1. April 2011 QIPP Digital and Technology Vision work stream – Phase 2 Online Preoperative Assessment Quick Win V1.1

2. Commercial in Confidence Contents  Scope & Vision  Benefits Summary  Intended Process  How would it be delivered  Stakeholders Engaged  Architecture  Implementation Costs Timeline 2

3. Scope & Vision 3

4. Commercial in Confidence Scope Preoperative assessment questionnaires are currently completed through a non-standard paper based system most often during a hospital or clinic visit in the presence of clinical staff. This is a time-consuming resource intensive process often completed too close to the surgical procedure to reallocate resources should a cancellation occur. Current  10m surgical procedures p.a.  Cancellation rate can be up to 20% for theatre slots where patient cannot be provided with anaesthetic based upon assessment. Scope  An online preoperative assessment service (providing a framework for the standardised capture of patient provided preoperative assessment data). This will allow the patient to pre-complete part of the pre-operative assessment online. Allow early triage of patients due to attend clinic Identify those patients that require further assessment in advance of the clinic Identify clinics that need to re-booked/cancelled in advance

5. Commercial in Confidence Online Preoperative Assessment: Scope & Vision A more efficient process of preoperative assessment focusing resources more effectively: From : Non-standard face to face preoperative assessment of a limited number of patients To: Online preoperative assessment questionnaires for all patients enabling focus of care to be on at-risk patients and improving efficiency A more efficient process of preoperative assessment focusing resources more effectively: From : Non-standard face to face preoperative assessment of a limited number of patients To: Online preoperative assessment questionnaires for all patients enabling focus of care to be on at-risk patients and improving efficiency Vision What is it? A nationally delivered online preoperative assessment service providing a standardised capture of patient provided preoperative assessment data prior to a hospital/clinic appointment, and the means to more efficiently manage theatre throughput Locally customised user experience (lightweight branding) preserving the relationship between patient and clinician and allowing relevant local content to be delivered to patients. Online preoperative assessment will ensure: An appropriate anaesthetist and surgeon can be allocated based on the patient's condition (maximising staff skills/mix) thus promoting patient safety Reduced waiting time / appointment duration within preoperative assessment clinics Reduced do not attend rates A nationally delivered online preoperative assessment service providing a standardised capture of patient provided preoperative assessment data prior to a hospital/clinic appointment, and the means to more efficiently manage theatre throughput Locally customised user experience (lightweight branding) preserving the relationship between patient and clinician and allowing relevant local content to be delivered to patients. Online preoperative assessment will ensure: An appropriate anaesthetist and surgeon can be allocated based on the patient's condition (maximising staff skills/mix) thus promoting patient safety Reduced waiting time / appointment duration within preoperative assessment clinics Reduced do not attend rates National Delivery 1.Information standards for the capture of data during preoperative assessment 2.Identity and Authentication component to provide basic authentication linked to patient appointment 3.Ability to produce targeted reports highlighting high-risk patients or those who require face-to-face or additional assessment 4.A national online pre-operative assessment site allowing patients to complete the assessments and clinicians to view them 1.Information standards for the capture of data during preoperative assessment 2.Identity and Authentication component to provide basic authentication linked to patient appointment 3.Ability to produce targeted reports highlighting high-risk patients or those who require face-to-face or additional assessment 4.A national online pre-operative assessment site allowing patients to complete the assessments and clinicians to view them Online completion of preoperative assessment questionnaire Leap In the Offer Identification of high-risk patients and motivation to optimise their health. High- risk patients are an extra burden on hospital resources. Optimising here saves money. Improved theatre efficiency: Those who can’t attend can be identified early and the vacated slots redeployed to other patients. Better communication between all parties: Patients, nurses, anaesthetists, surgeons, other clinicians, admin staff and hospital managers. Post-op patient feedback (e.g. patient view of service received). This assists in improving quality of care being delivered and is often missing from existing processes..

6. Benefits Summary

7. Commercial in Confidence Benefits  The Association of Anaesthetists of Great Britain and Ireland (AAGBI) has highlighted recent research by the Healthcare Commission (HCC) into the preoperative assessment process, concluding that improved Preoperative Assessment could dramatically increase the number of patients treated each year and reduce cancellation rates.  Addressing the inherent inefficiencies of current hospital systems through the implementation of a standardised online preoperative assessment the following potential benefits could be achieved: Reduced Do Not Attend Rates o Better communication between all parties: Patients, nurses, anaesthetists, surgeons, other clinicians, and admin staff and senior management o Improved theatre efficiency: Those who can’t come can be identified early and the vacated slots redeployed to other patients (some day surgery units currently exceed 20% cancellation rate) o Potential to treat more patients more quickly Maximising the Skills and Experience of Staff o Early identification of high-risk patients and motivation to optimise their health. High-risk patients are an extra burden on hospital resources. Optimising here saves money Streamlined Admin Process o Data is captured in a standard format in digital form reducing the overhead of rekeying and the cost of providing paper forms  Total Benefits of £65.83m could be realised from: Efficiency of collecting pre op data Reduced cancellations (current cancellation rate according to RCA is 20%) 7

8. Commercial in Confidence Benefits case inputs  Based on elective admissions (impatient and day patient)  Uptake rate assumed to be 20% Best practice outside Health, but within Public Sector, for transactional consumer services are DVLA who have 51% adoption for online vehicle licensing and HMRC who have 67% online adoption rate for self assessment  Total Benefits of £65.83m arise from: Efficiency of collecting pre op data Reduced cancellations (current cancellation rate according to RCA is 20%)  Only savings over Face to Face Pre Operative assessments are considered; it is assumed that these are in general undertaken too close to the procedure to avoid cancellation  A saving in workload of 50% assumed on the basis that the online pre op data will need to be checked.  Reduction of up to 50% in cancellation rate (as cited by historical NHS Modernisation Agency information) for the online users. 8

9. Intended process

10. Commercial in Confidence Current Process: Typical Preoperative Assessment 10

11. Commercial in Confidence 11 Target Process Online Preoperative Assessment: Early identification of high-risk patients Opportunity to rebook early enough for theatre slots to be reused Better communication with patients Conventional Preoperative Assessment: Time-consuming resource intensive process Cancellation (following assessment) too late for reuse of theatre slots Equal time is spent with “fit and well” patients and those requiring greater attention Often co-morbities missed leading to late cancellations or subjecting patient to a higher risk

12. How would it be delivered

13. Commercial in Confidence Online Preoperative Assessment Delivery options  An integrated approach to delivering consistent and efficient Preoperative Assessment online: Develop a national Online Preoperative Assessment service providing functionality for the capture of preoperative assessment data based on a standardised question set. Support basic patient identification (through APIs) based on patient email address, and supplied password (generated by APIs). Basic configuration of the assessment forms at a local level to exclude or include pre- defined questions outside of the core set as approved by professional bodies (e.g. Royal College of Anaesthetists). Develop simple content distribution (links) for online learning material for patients completing assessments and for clinicians administrating and working with the system at the local level. 13

14. Commercial in Confidence 14 Delivery Options Release strategy  Release 1: pilot sites / feedback during use  Release 2: open to all Trusts Local v national delivery  Previous barriers at local level: cost & prioritisation  National service customised and managed at local level Pre-requisites  Minimum information set defined for preoperative assessment questionnaires  Clear business case for adoption by Trusts Deliverables for national team  Minimum Information Standard – for capture of preoperative assessment  National service including; assessment forms, reporting, administration

15. Stakeholders engaged

16. Commercial in Confidence Who wants it? – Key Stakeholders WhoRoleStatus / Support Peter MurphyNCL DHIDHighly supportive and contributing to proposition Has expressed interest in NHS Bristol being a pilot site Ranjit VermaChair Joint Informatics Committee RCoAHighly supportive and contributing to proposition Has expressed interest in NHS Derby being a pilot site Marie DignerActing Service Redesign and Implementation Manager, First Contact Services / Clinical Lead Outpatient Services Royal Bolton Hospital NHS Foundation Trust Proposition has been discussed and is very supportive. Has expressed interest in NHS Bolton becoming a pilot site as part of initial release. Stephanie LeonardPre-op team leader, Royal Bolton Hospital NHS Foundation Trust Proposition has been discussed and is very supportive. Richard ElliotConsultant Anaesthetist, Royal Derby Hospital Highly engaged and contributing to proposition. Consultant working closely with Ranjit Verma to produce preoperative question set. Kate RivettVice Chair,Patient Liaison Group (RCoA) Proposition presented to the Vice Chair of the Patient Liaison Group at the RCoA who was very supportive. Andrea SpyropoulosRoyal College of Nursing, Council President Proposition presented to President of the RCN Council who was very supportive. Opportunity to engage with RCN special interest groups for preoperative care and theatre nurses. 16

17. Architecture

18. Commercial in Confidence 18 High Level Business & Information Services

19. Commercial in Confidence 19 Architecture Components: Patient View ServiceFunctional Description Authenticate Authenticate patient based on single factor credentials created when patient is added to a clinical list. Preoperative Assessment Form Based on core question set (as configured by local site admin) presented through national functionality. Patient Feedback Form National API for collection of simple feedback questions with results emailed direct to the local level.API would be used at local level but would be provided nationally.

20. Commercial in Confidence 20 Architecture Components: Clinical Staff View ServiceFunctional Description Authenticate Authenticate clinician based on user access details managed at the local level but using a national configuration service. View Clinical List View a clinical list based on Anaesthetist / Surgeon and specified date. This would show all patients for the specified clinician on the selected day highlighting any high risk patients or cancellations. View Patient Assessment View an individual patient’s assessment form. View Patient Report Customisable report highlighting high risk patients. Parameters would include appointment date range, surgeon/anaesthetist responsible, date questionnaire sent.

21. Commercial in Confidence 21 Architecture Components: Admin Local Level ServiceFunctional Description Authenticate Authenticate clinician based on user access details managed at the local level but using a national configuration service. Customise User Interface Apply lightweight branding to the user experience by uploading logos, contact details, and customising text based content on landing pages. Manage Content Links Add links to local content for inclusion at set places throughout the site as governed by site templates. For example, adding links to patient guidance to be available when entering an online preoperative assessment. Configure Questionnaire Configure questions relevant to the clinical setting. Add Patient to ListAdd a patient to a clinical list in preparation for anaesthesia. This would trigger a patient being sent an email requesting completion of a preoperative assessment questionnaire.

22. Commercial in Confidence 22 Architecture Components: Admin National Level ServiceFunctional Description Authenticate Authenticate national site manager / super user. Manage Local Access Configure access permissions and local admin user accounts. Manage (upload) Information Standard Ability to upload changes to the preoperative assessment question set (information standard).

23. Commercial in Confidence Service Directory: National Service NameFunctional descriptionInformation processed Developed or reused Source Preoperative Assessment Questionnaires Standard question set for online preoperative assessment Patient entered assessment answers DevelopedQuestion sets driven by Information Standard as accredited by RCoA Clinician InterfaceAllows clinicians to add new PreOp assessment accounts and to access reporting. Developed Questionnaire Administration Configuration of question sets for use in local websites Question preferences for local websites Developed National Management Interface For the management of clinician level access and local website ‘registration’ with the service. Developed Authentication APIBasic authentication (username / password). Also, APIs to create and manage patient assessment accounts and clinician access. User account definitions and authentication requests / responses Developed ReportingReports highlighting at risk / high- risk patients. Rules based reporting based on completed preoperative assessment questionnaires DevelopedReports defined based on pilot site and RCoA input. Patient Feedback API Accept simple feedback form data for management reporting Simple feedback form data Developed Local Content Linking Ability for local content managers to add links to local content within the preoperative assessment screens. NoneDevelopedLocal content for patients and clinicians using the system. Could be links to elearning or key guidance / content. 23

24. Implementation

25. Commercial in Confidence 25 Implementation Roadmap  Release Roadmap  Release 1 – National Pre-Op Service ability for patients to provide pre-op assessments. Assumptions o Clinic List created manually o Clinician to view pre-ops (tactical – through generic mailbox), (strategic – log on to view reports) o Username and Password for Identity Management (due to f2f confirmation in clinic) Options: o Tactical – Sending of pre-ops to generic mailbox (tactical) o Strategic – Ability for clinicians to log-on to view reports.  Future Releases Potential integration with clinical systems to allow population of the clinic list electronically.

26. Commercial in Confidence Implementation Approach  Initial effort estimate across Analysis, Design, Implementation, Integration, UAT and Deployment. Development of national framework – 350 man days  Initial ROM Cost for National Framework over 5 years = £1.7m  Includes Upfront Development of National Site and Ongoing Hardware, Hosting and Technical Support for 5 years.  Implementation Timeline across Analysis, Design, Implementation, Integration, UAT and Deployment Initial estimate to be validated of the implementation timeline is 14 weeks from contract award Assumption – that 3 FTE would be required during the development period (Project Mgmt, Tech Arch, Business Analysis and Assurance) Assumption – that existing core information set used and not awaiting RCoA agreed information set  Stakeholder Agreement Strong clinical support thus far (Joint Informatics Committee). 3 pilot sites engaged – Derby, Bristol, Bolton 26

27. Commercial in Confidence Implementation Plan (High Level) 27 Clarify requirements create product backlog Product backlog signoff Sprint 1 Design and Build Demo review and re-prioritisation Sprint 2 Design and Build Demo review and re-prioritisation Sprint 3 Design and Build Demo review and re-prioritisation Pilot system launch Pilot user coaching Capture lessons learned and plan national release Enhancements for national release National roll-out planning Activities July 2011Aug 2011Sept 2011Apr 2011May 2011June 2011 Pilot Pre-rollout