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					                                       Southport and Ormskirk Hospital   NHS Trust




Southport and Ormskirk NHS Trust
Safe Discharge CQUIN Project
Programme Initiation Document




Prepared by: James Leighton
Version: Version 4.0
             th
Issue Date: 4 Jan 2011




Southport and Ormskirk NHS Trust                                          version4
                                   1
2         Purpose

The purpose of the Programme initiation document (PID) is to define the programme, to form a firm
basis for management and the assessment of overall success. Information included in the PID will
answer the following questions:

         What is the programme aiming to achieve?
         Why it is important to achieve it?
         Who will be involved and what are their responsibilities?
         How and when will it happen?

It is essential to obtain a clear view of the final objectives and outcome, as well as constraints and
assumptions that impact on those responsible for the project. This document outlines all of the
essentials to form a firm foundation for the project, including objectives, business benefits and risks,
quality expectations, scope and timeframes.

3     Project Background and Context

As part of the CQUIN commissioning programme Southport & Ormskirk NHS Trust have been set four
targets to improve the governance and communications with patient and primary care clinical staff
whenever a patient is discharged from the Trust. These are

1 All discharge summaries to be received in general practice within 24 hours of patients being
discharged from hospital as an in-patient

2 All discharge summaries must contain all the essential information to ensure a safe discharge by using
the approved electronic discharge summary from the clinical reference group minimum data set for
discharge summaries

3 Full discharge letters to be received in General practice within two weeks of patients being discharged
from hospital as an in-patient for medicine and surgery directorates

4 All patients ready to leave hospital will have all the necessary information and documentation

Failure to deliver on these targets presents the Trust with a risk to funding of approximately £352, 000.
Target number 4 is not within the scope of this programme.

3.1       Project approach

The programme will deliver on achieving the transmission of the discharge summary within 24 hours
and the discharge letter being sent out within 2 weeks. There will be two work streams within the
programme whose work will be overseen by the programme group.
                                                  st
The programme will complete its work by the 31 May 2011 when it will be wound up. The programme
will have three stages to its delivery.

Stage 1: Requirements Definition Stage

The primary output of this stage is this Project Initiation Document, which captures all of the information
required to begin the detailed specification of the programme outlined in the ‘Scope’ section of this
document.

Stage 2: Implementation stage

During this phase the key stakeholders in the development will strive to ensure delivery against agreed
timescales and standards.

Stage 3: Review Stage

During this phase the board will assess the impact of the safe discharge processes and make
recommendations on future delivery and sustainability


Southport and Ormskirk NHS Trust                                                                    version4
                                                   2
3.2 Maintenance and on-going support for safe discharge CQUIN

Please note that any maintenance and support required to sustain the safe discharge CQUIN targets
        st
after 31 March is not included in this programme.

It is recommended that this is planned and agreed in detail later in the programme once a detailed
understanding of the development is reached. The programme will be in a position to inform the Trust
on what will be required to continue to deliver the targets and will produce costings and
recommendations at the end of the programme.

4     Programme Definition

The programme will deliver –

      1. E-discharge tool will be on all wards of the Trust

      2. Each patient will have a complete discharge summary produced at the time of discharge

      3. That this summary will be able to be transmitted electronically to the relevant PCT/GP

      4. That 50% of discharge letters are received by GPs within two weeks of discharge by the end of
          March 2011

      5. Provide recommendations on sustaining the safe discharge CQUIN targets

4.2       Programme Objectives

          Achieve required communication standards to support a safe discharge
          Maintain the level of CQUIN funding associated with these targets


4.3       Scope

Discharge summaries
                                                                                      th
Currently the Trust provides a discharge summary that is posted to GPs. This is the 4 sheet of a
carbon copy pack. This only outlines what medicines the patient leaves the Trust with and is written by
the discharging medic.

This sheet is often amended by pharmacy and not all changes are communicated to the GP.

The Trust has purchased an e-discharge tool which will provide a comprehensive discharge summary in
line with minimum data set requirements as set out by the North Mersey HIS. This is to be piloted on
three wards. This summary is however not able to be transmitted to GPs.

The Trust had no plans to roll this out across the Trust before this programme was put in place.

Discharge letters

The delivery of discharge letters has never been audited to assess the length of time from discharge to
delivery. As a prelude to the work of this programme two audits were undertaken for patients
discharged in May and August.

These showed a Trust compliance range of 34% to 38%, with medicine having a range of 10%-14% and
surgery having a range of 57% - 64%.



4.3.1      Potential exclusions from scope

No ward areas are to be excluded from the safe discharge CQUIN programme of work.



Southport and Ormskirk NHS Trust                                                                   version4
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4.4 Assumptions


This PID and associated project plan is based around a number of key assumptions which are detailed
as follows.


Ref.      Assumption Description

1         Programme steering group to be established

                                     th
2         PID to be approved by 17 December 2010
          That the project work for discharge summaries will commence only when the pilot has been
3
          completed, reviewed and signed off.
4         That the supporting IT infrastructure is deployed on the ward areas before March 2011
                                                                               th
5         That the interface to allow onward transmission is in place by 11 March 2011
          That each CBU will be responsible for consultation with stakeholders on the work of the
6
          programme
7         That Pharmacy will identify suitable staff to undertake the training of clinical staff
          That funding will be available to undertake the work of the programme as outlined in the
8
          project plan and PID
                                                                               st
9         That the programme will be wound up upon completion on the 31 May 2011



4.6    Constraints

       1. Time constraints on project manager and programme board
       2. Costs of programme
       3. Change management processes


4.7    Interfaces

This section outlines relationships with other projects in the programme and identifies the wider context
of the project with reference to external dependencies/prerequisites/third party suppliers. The external
organisations /third parties this project interfaces with are as follows:-

Key Third Party Dependencies



Third Party
                   Key External Dependencies



Ascribe
                   Supplier of e-discharge tool

Medisec            Supplier of document management tool

NHS Sefton         Commissioning PCT

NHS Central
                   Commissioning PCT
Lancashire

NM HIS             Logistics for Health informatics across economy



Southport and Ormskirk NHS Trust                                                                   version4
                                                    4
5       Programme Organisation Structure

The roles, responsibilities, job definitions and lines of authority outlined in this section represent the
people involved in directing the project, day-to-day management of the project, team management, and
the work to create the products.


5.1        The Programme Board

On the Programme Board the senior responsible officer (SRO) is the key decision maker, with advice &
commitments from others. To ensure effective decision making, the programme board should consist of
people with appropriate skills and influence to ensure successful delivery of the programme.

The Programme Board manages by exception to ensure minimum demands on members’ time while
enabling them to fulfil their responsibilities to the programme.

5.1.1       Overview of Programme Board Responsibilities

           Provide overall direction and management.
           Accountable for success of project
           Programme ‘voice’ to outside world – disseminate information from and convey external
            information to project.
           Approves all major plans and authorises changes and major deviations outside of plan.
           Ensures required resources are available.
           ‘Ownership’ of the identified risks (i.e. monitors the risks and keeps the project manager
            informed).
           Ultimate escalation point for key unresolved project issues which have not been able to be
            resolved through the normal process of dialogue and investigation between interested parties.
           Assurance that the development meets acceptance criteria.



5.1.2       Project Board Roles

                                                                                       Reporting to
Role                                 Job Description
SRO                S Finnegan        Ultimately responsible for programme and          Trust Board, F&P and
                                     business assurance with support from              cabinet
                                     programme manager (i.e. that the programme
                                     is on target to deliver the expected business
                                     benefits); ensures a business focussed
                                     approach to the projects; ‘owns’ any business
                                     case; links to corporate management. Ensure
                                     technical elements are clearly and completely
                                     defined; ensure programme is fit for purpose.
                                     Main liaison between Programme board and
                                     Trust board.
                                     Control risks.
                                     Ensure constraints are being observed.
                                     Ensure the right people are involved and
                                     informed.
Programme          J Leighton        Ensure requirements are clearly & completely      Programme board, F&P
manager                              defined; ensure delivery of the programme is      and
                                     fit for purpose; monitor that the solution will   cabinet
                                     meet Trust needs within any constraints
                                     identified; that the programme provides
                                     expected benefits, .




Southport and Ormskirk NHS Trust                                                                       version4
                                                     5
Role                                        Job description                             Reporting to

Board             K Monaghan                CBU representative
member
Board             T Rawlings                CBU representative
member
Board             E Hoban                   CBU representative
member
Board             G Mathers                 NHS Central Lancashire representative
member
Board             P Shillcock               NHS Sefton representative
member
Board             Dr Biswas                 GP representative
member
Board             Dr G Butcher              Clinical representative
member

Board             F1 /F2 Surgery            Clinical representative TBC
member

Board             Dr H Gibson               Clinical representative
member

Board             Dr T McBride              Clinical representative Paediatric
member

Board             Dr Niall Leonard          GP representative
member

Board             J Williams                Pharmacy representative
member


6      Communication Plan

Information requirements/methods/frequencies for all interested parties. Identify all stakeholders,
including those outside the project team and agree mutual information needs.


                                                                        Frequency of    Method of
Interested                                                              Communicati     Communication
party             Info Required                      Info Provider      on
All               Current programme activities       Programme          Weekly          Status report
stakeholders                                         manager

All               Changes or updates to project      Programme          As required.    Post updates to
stakeholders      plan/schedule                      manager                            extranet & notify by
                                                                                        email


Meeting           Contact reports/minutes            Meeting            After all       Email
participants                                         organiser          meetings

Programme         Highlight report                   Programme          Monthly         Meeting
board                                                board /
                                                     Programme
                                                     manager




Southport and Ormskirk NHS Trust                                                                      version4
                                                    7
All                 Programme review:                 Programme        Monthly              Report
                    accomplishments & status,         manager
                    issues, risks, assumptions,
                    changes, planned activities for
                    coming weeks, planned
                    movements for team
                    members.

7       Delivery Plan

The delivery plan outlines the activities that are to be undertaken to ensure delivery of the programme
on time and within budget.

Delivery of the work required to deliver the safe discharge CQUIN target will be managed through
organised programme board and review meetings. The board will have assurance system to detect
issues and risks and plan to eliminate and minimise impact as early as possible.

7.2         Responsibilities

Programme Manager

          Plan and organise the board / review ensuring that appropriate members are involved and that
           they understand their responsibilities.
          Check the correct information is ready for review.
          Control the review procedures ensuring they achieve their aims.
          Determine the review outcome with the board and ensure actions and required results are
           agreed.
          Keep relevant people informed of delivery review status.
          Plan to overcome any project issues raised.

Project Board

          Set the success criteria within the programme.
          Sign off follow up list of actions and ensure that errors are fully understood and resolved
           satisfactorily.
          Identify delivery resources.
          Monitor delivery progress against the plan.

8       Initial Project Plan

The project plan outlines how and when the project activities will occur. (See appendix 1)

8.1       Timeframe Estimates An estimated delivery period will be outlined once the pilot has
          been completed.

8.1.1      Phased Delivery Plan

This section outlines the plans for phasing delivery of the full scope of features and functionality outlined
in this document.

Outlined below is an overview plan of the main activities, milestones and stages for the stage 1 and 2
delivery streams



                    Stage 1 Milestones

                    PID agreed                                                   10 12 10

                    Project plan agreed                                          17 12 10




Southport and Ormskirk NHS Trust                                                                     version4
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                                                                                  th
                   Programme board meetings agreed                              10     Jan 11

                                                                                  th
                   Trainer capacity identified                                  10 Jan 11

                                                                                  th
                   Increased IT Capacity roll out                               17 Jan 11

                                                                                  th
                   Ascribe interface deployed                                   28 Feb 11




9     Project Controls


9.1    Tolerances and Exception Procedure

Tolerances are the permissible deviation above and below the programmes plan’s estimate of time and
cost without escalating the deviation to the next level of management.

If there are indications at any point that that the project is going to deviate outside of the tolerances
agreed, an Exception Report will be created and the exception will be raised to the programme board.
Project risks and issues will be closely monitored by the programme manager to ensure potential
deviation is observed and reported as early as possible.

Specific time & cost tolerances are to be defined by the programme board.

9.2    Change Management Procedures

It is anticipated that changes may be requested to the scope of the programme outlined in this
document. It must be borne in mind that the schedule for delivery is extremely tight and that there is no
room for slippage. Change requests may impact upon both the delivery date and the budget.

All requests for changes must first be raised immediately as project issues to the programme manager,
who will log the issue, these will then be reviewed and, if approved, a completed change request form
will be forwarded to the SRO. The SRO will carry out an impact assessment, review and if it is agreed
then that the change will be beneficial to the programme and business outcome, the programme
manager will plan the change into the schedule.




Southport and Ormskirk NHS Trust                                                                   version4
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9.3      Risk Management

Risks identified by the programme board other third parties will be retained in a centralised risk log and
ownership for risk mitigation / reduction will be initially assigned by the programme manager and then
reassigned if necessary by the programme board.

Identified risks will initially be analysed in terms of impact and likelihood of occurring by SRO during risk
resolution meetings. Risks where mitigation /reduction is being blocked will be raised in the programme
issue log and escalated to the project board for resolution.


9.4    Issue Management

Issues identified by programme manager and other parties will be logged in a centralised issues log
along with change requests. The ownership for issues resolution will be initially assigned by the
programme manager and then reassigned if necessary by the project board.

Identified issues will initially be analysed in terms of impact (High /Medium /Low) during an issue
resolution meeting. Issues where resolution is being blocked will be escalated to the SRO and if this has
no effect then depending on urgency and severity issues will be escalated to the project board for
revised ownership and eventual resolution.


9.5    Risk & Issue Escalation Procedure

Stage 1 Project team escalate via Risk & Issue procedure to the relevant Project Manager

Stage 2 Project Manager escalates Risk /Issues to programme manager.

Stage 3 If stage 1 is an external related risk / issue then it will be identified in a log sent with the weekly
report and escalated to programme manager.

Stage 4 If stage 3 fails to achieve resolution / mitigation then the risk / issue will be escalated to the
Programme Board.

Fast Track The relevant project manager does have the right to fast track this process and escalate
risks /issues to the programme board in high impact urgent situations where the minimum of delay is
essential for timely /cost effective delivery of the programme.


9.6    Managing project portfolios

The production of status reports by the Programme Manager and issued to the programme board along
with any exception reports if project tolerances look likely to be breached should give the programme
board transparency as to the progress of delivering a specified project stage.

This should allow the project board to give the Programme Manager effective / focused and informed
steer. With the approval of the programme board re-planning and estimating of the next stage in the
delivery will be carried out before the current stage is complete. This plan will need to be signed off by
the programme board before the next stage can be initiated.

10    Initial Risk Analysis

Project teams need to work closely to meet the time-critical delivery requirement for this programme.
The following list presents an initial summary of the concerns that could affect the schedule of this
project and outlines what mitigation should be carried out.




Southport and Ormskirk NHS Trust                                                                       version4
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                                    Key to Severity and
Key to Risk Types                   Likelihood                 Key to Owners
B – Business                        H – High
P – Project                         M – Medium
T – Technical                       L – Low
S – Security
C - Content/Creative




10.1 Initial Risk Analysis

Please see appendix 2




11          Benefits to be realised


Patients:
            1. A better discharge process implemented to ensure that onward care is delivered in a safer
            more informed way.

For the trust:
          1. A better discharge process implemented to ensure that receiving clinicians are better
               informed so that onward care is delivered in a safer more informed way.
          2. That all Safe discharge CQUIN targets are delivered.

For the receiving clinicians
         1. They will be better informed on the patient’s admission allowing them to be better able to
         provide the required level of care




Southport and Ormskirk NHS Trust                                                                  version4
                                                   11
Appendix 1




Southport and Ormskirk NHS Trust        version4
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Appendix 2




Southport and Ormskirk NHS Trust        version4
                                   13
                                                                                                                                       Southport & Ormskirk Hospital NHS Trust
                                                                                                                                                  Risk Assessment



                                                                                                                                                                                                                                                                     Risk Matrix
     Ward/Department Pharmacy                                                                                                       Subject of Assessment Ascribe Electronic Prescribing                                                                   Severity (s)       Likelihood
                                                                                                                                            e.g. activity/work area/equipment/patient
                                                                                                                                                                                                                                                           A – Insignificant   A – almost certain
                                                                                                                                                                                                                                                           B – Minor           B – Likely
                                                                                                                                                                                                                                                           C Moderate          C – Possible
     Assessment Date ______________________ Review Date ________________________                                                                                                                                                                           D – Major           D – Unlikely
                                                                                                                                                                                                                                                           E – Catastrophic    E - Rare

          HAZARD                                                                                                                   Actions/controls previously taken to                                                           Describe additional measures that
                                        (refer to risk matrix)
                                                                 Likelihood (l)
                                                                 Severity (s) &
                                                                                  (without controls/actions)




                                                                                                                                                                                (With Control/actions)
                                                                                                                                                                                                         Level of Risk (R1)




                                                                                                                                                                                                                                                                               Responsible
                                                                                                                                                                                                                                                                               Person


                                                                                                                                                                                                                                                                                             Completed
                                                                                                                                                                                                                                                                                             Date
                                                                                                               Level of Risk (R)
                                                                                                                                               reduce risk                                                                               would reduce risk.
                                                                                                                                                                                                                                     Include costs where known




1. Computer software –                     C/B                                                H                                      1. Limited number of trained staff                                                             1. Ascribe to stream line
   Difficult to use leading to                                                                                                          on hand to assist with used                                                                    software.
   possible mistakes.                                                                                                                   problems.
                                                                                                                                     2. Limited In-house training being
                                                                                                                                                                                                                                    2. Employ/identify extra
                                                                                                                                        provided to end users.                                                                         staff to provide help &
                                                                                                                                     3. Information/feedback is provided                                                               support to system
                                                                                                                                        to ascribe user group regards all                                                              users prior to full role
                                                                                                                                        software issues.                                                                               out of project.
                                                                                                                                     4. System Manager to streamline
                                                                                                                                        drug templates
2. Shortage of appropriately               C/B                                                H                                      1. Back-up and support being                                                                   1. Back-up and support
   trained staff to assist when                                                                                                         provided by Ascribe as part of                                                                 can be provided by
   end users have problems.                                                                                                             pilot project.
                                                                                                                                     2. Temporary support being
                                                                                                                                                                                                                                       Ascribe for an annual
                                                                                                                                        provided by Pharmacy staff for                                                                 cost.
                                                                                                                                        pilot.                                                                                      2. Employ/identify extra
                                                                                                                                                                                                                                       staff to provide help &
                                                                                                                                                                                                                                       support to system



     Southport and Ormskirk NHS Trust                                                                                                                                       version4                                          1
         HAZARD                                                                                                                   Actions/controls previously taken to                                                           Describe additional measures that




                                       (refer to risk matrix)
                                                                Likelihood (l)
                                                                Severity (s) &
                                                                                 (without controls/actions)




                                                                                                                                                                               (With Control/actions)
                                                                                                                                                                                                        Level of Risk (R1)




                                                                                                                                                                                                                                                                     Responsible
                                                                                                                                                                                                                                                                     Person


                                                                                                                                                                                                                                                                                   Completed
                                                                                                                                                                                                                                                                                   Date
                                                                                                              Level of Risk (R)
                                                                                                                                              reduce risk                                                                               would reduce risk.
                                                                                                                                                                                                                                    Include costs where known




                                                                                                                                                                                                                                       users prior to full role
                                                                                                                                                                                                                                       out of project.


3. Inadequate training                    C/B                                                H                                    1. Limited In-house training being                                                               1. Identify training
   provided to end users.                                                                                                         provided to end users                                                                               resources to provide
                                                                                                                                                                                                                                      on-going training to
                                                                                                                                                                                                                                      existing & new staff.
                                                                                                                                                                                                                                   2. Provide training on
                                                                                                                                                                                                                                      electronic prescribing
                                                                                                                                                                                                                                      at Doctors clinical
                                                                                                                                                                                                                                      induction.
4. Depending on number of                 C/B                                                H                                        1. Trained staff on hand to assist                                                           1. Ascribe to stream line
   drugs used/required                                                                                                                   until full role out of project.                                                              software.
   Doctors’ taking                                                                                                                    2. Limited in-house training
   approximately 30 minutes to                                                                                                           provided to all end users for
                                                                                                                                                                                                                                   2. Identify training
   complete TTO’s making                                                                                                                 pilot.                                                                                       resources to provide
   them reluctant to use                                                                                                                                                                                                              on-going training to
   system.                                                                                                                                                                                                                            existing & new staff.
                                                                                                                                                                                                                                   3. Provide training on
                                                                                                                                                                                                                                      electronic prescribing
                                                                                                                                                                                                                                      at Doctors clinical
                                                                                                                                                                                                                                      induction.



    Southport and Ormskirk NHS Trust                                                                                                                                       version4                                          2
          HAZARD                                                                                                                   Actions/controls previously taken to                                                          Describe additional measures that




                                        (refer to risk matrix)
                                                                 Likelihood (l)
                                                                 Severity (s) &
                                                                                  (without controls/actions)




                                                                                                                                                                               (With Control/actions)
                                                                                                                                                                                                        Level of Risk (R1)




                                                                                                                                                                                                                                                                     Responsible
                                                                                                                                                                                                                                                                     Person


                                                                                                                                                                                                                                                                                   Completed
                                                                                                                                                                                                                                                                                   Date
                                                                                                               Level of Risk (R)
                                                                                                                                               reduce risk                                                                              would reduce risk.
                                                                                                                                                                                                                                    Include costs where known




5. Ascribe system discharge                                                                                                                                                                                                        1. Approval to be
   summary being used in-                                                                                                                                                                                                             confirmed by Trust
   place of full discharge letter
   without formal Trust
                                                                                                                                                                                                                                      Board before
   approval.                                                                                                                                                                                                                          discharge summary
                                                                                                                                                                                                                                      can be used in place
                                                                                                                                                                                                                                      of full discharge letter.
6. House Officers are                                                                                                                1. Some registrars are reviewing                                                              1. Ensure all discharge
   completing summary                                                                                                                   completed discharge letters.                                                                  letters are checked by
   discharge letters.                                                                                                                2. Audit of quality of electronic
                                                                                                                                        discharge currently in progress.
                                                                                                                                                                                                                                      SHO OR registrar.

7. Extended dispensing and                 E/D                                                H                                                                                                                                    1. Ascribe to stream line
   clinical checking time                                                                                                                                                                                                             software, which will
   putting pressure on
   dispensary staff – with a
                                                                                                                                                                                                                                      save some time.
   potential to make mistakes.                                                                                                                                                                                                     2. Stop afternoon ward
                                                                                                                                                                                                                                      rounds.
                                                                                                                                                                                                                                   3. Additional Pharmacy
                                                                                                                                                                                                                                      staff.




     Southport and Ormskirk NHS Trust                                                                                                                                      version4                                          3
         HAZARD                                                                                                                   Actions/controls previously taken to                                                                Describe additional measures that




                                       (refer to risk matrix)
                                                                Likelihood (l)
                                                                Severity (s) &
                                                                                 (without controls/actions)




                                                                                                                                                                                    (With Control/actions)
                                                                                                                                                                                                             Level of Risk (R1)




                                                                                                                                                                                                                                                                          Responsible
                                                                                                                                                                                                                                                                          Person


                                                                                                                                                                                                                                                                                        Completed
                                                                                                                                                                                                                                                                                        Date
                                                                                                              Level of Risk (R)
                                                                                                                                              reduce risk                                                                                    would reduce risk.
                                                                                                                                                                                                                                         Include costs where known




8. Paper prescription forms                                                                                                                                                                                                             1. Remove all access to
   are being used when                                                                                                                                                                                                                     paper prescriptions.
   doctors feel under pressure
   to see patients, alongside
   the ascribe system will
   cause confusion.
9. Pharmacy staff are required            C/B                                                H                                    1. Doctors must use ‘out of hours’ facility                                                     1. Ascribe to stream line
   to re-check clinically all                                                                                                     to avoid prescriptions being held at the                                                        software, which will save
   amended prescriptions                                                                                                          Pharmacy clinical check stage
   received on the ascribe                                                                                                        preventing discharge.
                                                                                                                                                                                                                                  some time.
   system causing a delay in                                                                                                                                                                                                      2. Additional Pharmacy staff.
   dispatch and extra work
   load.

10. Drug chart required before            B/C                                                M                                        1. Screen checked on a regular
    dispatch of prescriptions.                                                                                                           basis to ensure medicines
                                                                                                                                         requirements have arrived.


11. IT Systems on some wards                                                                                                                                                                                                            1. Terminal server and
    old and unable to cope with                                                                                                                                                                                                            hardware links should
    ascribe software.
                                                                                                                                                                                                                                           be provided to all
                                                                                                                                                                                                                                           areas before ascribe
                                                                                                                                                                                                                                           project role out begins.




    Southport and Ormskirk NHS Trust                                                                                                                                            version4                                          4
          HAZARD                                                                                                                   Actions/controls previously taken to                                                           Describe additional measures that




                                        (refer to risk matrix)
                                                                 Likelihood (l)
                                                                 Severity (s) &
                                                                                  (without controls/actions)




                                                                                                                                                                                (With Control/actions)
                                                                                                                                                                                                         Level of Risk (R1)




                                                                                                                                                                                                                                                                      Responsible
                                                                                                                                                                                                                                                                      Person


                                                                                                                                                                                                                                                                                    Completed
                                                                                                                                                                                                                                                                                    Date
                                                                                                               Level of Risk (R)
                                                                                                                                               reduce risk                                                                               would reduce risk.
                                                                                                                                                                                                                                     Include costs where known




12. Changing of Doctors                                                                                                            1. Provide limited training to Doctors                                                           1. Identify training
    rotation during pilot and role                                                                                                 prior to change of rotation.                                                                         resources to provide
    out. Untrained staff will be
    located to areas using e-
                                                                                                                                                                                                                                        on-going training to
    discharge.                                                                                                                                                                                                                          existing & new staff.
                                                                                                                                                                                                                                    2. Provide training on
                                                                                                                                                                                                                                        electronic prescribing
                                                                                                                                                                                                                                        at Doctors clinical
                                                                                                                                                                                                                                        induction.
13. If Doctors do not discharge                                                                                                                                                                                                     1. Identify training
    the patient on the Ascribe                                                                                                                                                                                                          resources to provide
    system documentation can
    not be printed off when
                                                                                                                                                                                                                                        on-going training to
    medical staff are not                                                                                                                                                                                                               existing & new staff.
    present, as on-call medical                                                                                                                                                                                                     2. Provide training on
    team may not be trained on                                                                                                                                                                                                      electronic prescribing at
    Ascribe.                                                                                                                                                                                                                        Doctors clinical induction

     Signature(s):
     Assessor _____________________ Date __________________ Head of Department________________________ Date ____________
     Risk Lead __________________Date ________________ Executive Director _______________________Date___________




     Southport and Ormskirk NHS Trust                                                                                                                                       version4                                          5

				
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