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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
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Issue Date: 4 Jan 2011
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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.
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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
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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
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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
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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.
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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
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2 PID to be approved by 17 December 2010
That the project work for discharge summaries will commence only when the pilot has been
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completed, reviewed and signed off.
4 That the supporting IT infrastructure is deployed on the ward areas before March 2011
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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
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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
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project plan and PID
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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
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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, .
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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
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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
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Programme board meetings agreed 10 Jan 11
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Trainer capacity identified 10 Jan 11
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Increased IT Capacity roll out 17 Jan 11
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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.
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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.
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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
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Appendix 1
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Appendix 2
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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
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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.
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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.
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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.
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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___________
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