Centralisation of Trust Policies

1. Centralisation of Trust Policies Lynn Allan MSc MCLIP E-Resources Librarian Project received a commendation from the Sally Hernando Awards 2011-2012 for Organisational Initiative for good/best practice (SHALL, 2011)

2. Contents • Background to Project • A working solution • Current issues and future challenges

3. Background • Issues with Maternity & Neonatal Care • CQC (Care Quality Commission) and Monitor involved with investigating SUIs (serious untoward incidences) in 2009/2010 (KPMG, 2012, p4) • Monitor continued to oversee Trust and open further investigation in November 2011(Monitor, 2011) Monitor finds “governance processes and systems are inadequate and are below standard” (PriceWaterhouseCooper, 2012, p5)

4. Key Drivers • NHSLA (Litigation Authority) Risk Management Standards • at Level 2 - demonstrate procedures to respond to NICE guidance • for Level 3 – monitoring compliance • Trust Risk Register – failure to locate information on the intranet

5. Policies on the intranet So many different places to look! Which version is the correct one? But how do I find them? They are such a mess! I’m getting lost here! NHS not the only organisation that has problems with the intranet: More than half (52%) of respondents say they cannot find the information they are seeking using their own organization’s enterprise search facility within what most define as an acceptable amount of time (Mindmeter, 2011)

6. Trust attitude The intranet works fine Is there a problem? You just need to know the right place to look We don’t need a new system http://openclipart.org

7. What’s really needed • A single document management system to house all Trust policies • A single taxonomy required • A single team to manage revision control, including prompting editors • Strict version control required

8. How did library get involved? • Library Manager attended Integrated Risk sub-committee meeting • E-Resources Librarian also attended meeting involving IT, Clinical Audit and Marketing. • Senior Library Assistant key to cataloguing all policies consistently

9. A working solution Have you heard of the Library Management System (LMS) Heritage? Using in-house: Trust Savings of £25k

10. Piloting the project • Pharmacy was the first department to add their policies to Heritage. • Working with Pharmacy a project plan was implemented to identify: • key information required to add policies • a working process for adding policies • length of time required from policies being sent to library staff to them being available on Intranet • how to adapt Heritage to absorb Trust policies

11. Process • Policies sent to library with cover sheet and added to Heritage • Email confirmation sent to document author when policy added • From receipt of document to availability on catalogue can take 2 working days, or quicker if necessary • Revision date approaching – notification email sent to author • If no response from reminder then more pointed reminder sent out • Still no response? Policy removed from Heritage

12. Maternity Services In 2011 Monitor announced that UHMBT was in breach of terms to meet Foundation status in regards to Maternity Services. • Maternity Services were required to: • organise and update all policies • Make policies easier to find

13. Challenges • Continual approval and support from Senior Management • Gaining trust from departments • Difficulty getting IT on board Policies continue to be in two places and staff do not know where to find them • Intranet editors no longer working for department • Problems opening policies on some machines • Some users are unhappy with the change • How many policies are there? • Terminology – what do we call Heritage?

14. Going forward • Getting continual approval from senior management • Continue to publicise the new document storage model • Surgical Division policies are next in line to be added • Working in partnership with IT to improve the intranet

15. Thank you for listeningAny Question? Lynn Allan E-Resources Librarian University Hospitals of Morecambe Bay NHS Foundation Trust Lynn.Allan@mbht.nhs.uk

16. References KPMG (2012) Learning and implications from University Hospitals of Morecambe Bay NHS Foundation Trust: London: Monitor http://www.monitor-nhsft.gov.uk/sites/default/files/Morecambe%20Bay%20Report%2026%20June%202012.pdf (Accessed: 2 July 2012) MindMeter (2011) Mind the search gap Available at: http://www.smartlogic.com/home/knowledge-zone/white-papers/1600-mindmetre-research-report-sponsored-by-smartlogic (Accessed: 19 June 2012) Monitor (2011) Monitor intervenes at University Hospitals of Morecambe Bay NHS Foundation Trust Available at: http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/latest-press-releases/press-release-archive/2011/monitor-intervene (Accessed: 19 June 2012) NHS Litigation Authority (2011) NHSLA Risk Management Standards 2012-2013 Available at: http://www.nhsla.com/NR/rdonlyres/6CBDEB8A-9F39-4A44-B04C-2865FD89C683/0/NHSLARiskManagementStandards201213.pdf(Accessed: 26 May 2012) PriceWaterhouseCooper (2012) Formal Interventions:  University Hospitals of Morecambe Bay NHS Foundation Trust Governance Review. London: Monitor. Available at: http://www.monitor-nhsft.gov.uk/about-nhs-foundation-trusts/regulatory-action/formal-interventions.  (Accessed: 25 June 2012) SHALL (2011) Organisational Innovation Submissionshttp://www.libraryservices.nhs.uk/wiki/Innovations.2011-12-Organisational-Innovations-Submissions.ashx (Accessed 20 June 2012)