- The transition to a digital organisation impacts on all aspects of the trust - from its leadership and operating model, to how projects are managed and financed.
- Boards need to be as comfortable with the core concepts and ways of working as their teams.
- Boards are responsible for establishing senior specialist digital leadership within the trust particularly from the clinical workforce to ensure effective clinical engagement.
- Boards also need to provide the space for a multidisciplinary approach to flourish - ensuring that services are designed with all of digital, operations, and clinical viewpoints represented.
Digitally-minded organisations operate differently to IT driven ones, and can feel quite different as well. The key litmus tests of a digital organisation include:
- Leadership: digital and technology is viewed at the board level with the same importance as finance or quality and is seen as a core enabler to the organisation's goals.
- Approach to developing new services: digital teams are inherently agile in their approach, testing with users and iterating solutions. They favour outcomes over outputs.
- Finances: digital organisations fund teams not technology, adopt blended funding models (combining revenue and capital) and factor in life cycle costs.
- Operating model: digital organisations are characterised by small pieces, loosely joined in a flat network, with professional skills united through communities of practice.
- User centricity: above all, digital organisations are user-centred, investing in deeply understanding user needs. They have the humility to never assume they have the right answer.
When digital teams need to scale up, the delivery team itself does not get bigger. Rather once your minimum viable team has delivered something visibly and you need to do more, you then build another team (rather than make the existing team bigger). And the cycle continues.
Digital leadership roles
In the NHS, the key triumvirate of digital leadership roles is a CDO or CIO, a chief clinical information officer (CCIO) and a chief nursing officer (CNIO). For some, there's a subtle difference between the CIO and the increasingly popular CDO or CDIOs within the trust sector. For example, the latter is an increasingly external-facing role.
Clinical ownership of the digital agenda is vital. CCIOs and CNIOs act as the bridge between digital and front-line clinicians. They tend to perform two important roles: engaging the clinical community and winning hearts and minds, while at the same time combining their knowledge of patient care, digital ways of working and change management to drive service transformation.
CCIOs and CNIOs often emphasise how their roles require the appropriate authority and resources to fulfil their potential. In order to strengthen and deepen this clinical leadership, trusts are increasingly identifying multiple digital champions across their digital teams. For more on clinical leadership, please see the 2016 Wachter Review.
Clinical ownership of digital is key to the success of any implementation. Derbyshire learned this after their electronic prescribing programme stalled. A chief clinical information officer with a strong and experienced clinical background and excellent people skills was recruited to listen, feedback, and challenge clinical views of the programme. The programme was then redesigned and relaunched successfully. At Bolton the trust has appointed a multidisciplinary team approach with several CCIOs and CNIOs who are from diverse professions including an acute medical physician, ophthalmologist, dietitian, occupational therapist, senior nurse, radiologists and an operational business management champion. They all act as digital champions across the trust to represent the diverse population of staff.
Some trusts have taken the decision to appoint a CDO/CIO to their board. Others have not. Either way, boards must not lose sight of their collective responsibility for the digital agenda. Executive and non-executive directors reach decisions as a unitary board, which requires them to have access to specialist expertise. In turn, CDOs/CIOs must be able to access and influence board thinking, regardless of their own board status.
This all points to the kind of experience a CDO/CIO needs. The best candidates are not necessarily those who have cut their teeth in digitally native organisations. They will likely be of the internet era but will also understand what preceded it, and will have experience of changing organisations operating with significant amounts of technology and human legacy. They will also have a good working knowledge of the technology of the internet, they should espouse the working practices outlined earlier in the guide - user-centred, open, agile, empowering. Any newly appointed CDO/CIO should have a clear vision for how an organisation can change and shouldn't be afraid of asking the difficult questions.
The two trusts share a CDIO who sits on both boards. Like other executive directors, the CDIO has collective responsibility across both of the trust’s activities. This includes digital as a portfolio accountability but also wider corporate director responsibility for other areas with other directors including quality, safety, finance and performance. The CDIO role requires the technical skills of a digital expert but also more general leadership skills. Working at board level exposes the CDIO to the problems and challenges faced by all executives. The CDIO has regular sessions and updates with executives and board members which helps ensure the board is engaged and supportive of the digital agenda.
In some trusts the role of technology and transformation has been combined. This speaks to the need to place technology as a core enabler, at the heart of any changes to the trust's operating model. When there are multiple roles with potentially overlapping territories, accountability for leading the digital team and its programmes do need complete clarity. It is equally dangerous to hire a CDO/CIO and hope that will be enough to make the transformation work: all board members need to take collective responsibility for digital transformation.
Bridging silos
In addition to ensuring different disciplines come together within a digital team, there is also a crucial task of ensuring that the team is connected to operational and clinical teams across the organisation. In a traditional arrangement there are typically silos between technically defined IT teams, clinical teams and ops or the IT vs transformation function. To harness the full potential of digital NHS trusts must bring these teams together around shared outcomes of improving services. Integrating digital specialists, operations managers and clinicians can begin to establish new operating models. To be a success this also needs collective board leadership and modelling.
The digital and information directorate has developed a flexible approach, both in terms of how they work and who they work for. This has enabled them to work at greater pace and reflect changing competency requirements in the digital world. They aim to assemble teams from a fusion of operational/clinical, digital and information departments based on the competencies required. This differs from a project-team based approach which tends to focus on specific roles rather than competencies. The approach allows for a true codesign and cocreation, and proved particularly successful during the launch of the trust's single point of access. Since then they have adopted the use of fusion teams whenever delivering new services or capabilities to the trust.
Synergies are required at the board table too. Transformation requires engagement of the whole board and particularly from medical and nursing directors, the director of workforce, and the chief operating officer, roles that can traditionally be distant from the digital agenda. It can't be simply delegated to the CDO/CIO.
The trust’s medical director will lead the new £108m electronic patient record (EPR) programme as part of efforts to engage the wider organisation in the digital agenda. In addition to this the board has appointed a new executive director of transformation, innovation and digital. They will focus on joining up the trust’s organisational change programme that includes the EPR, a new hospital and the wider quality improvement work, while also educating the wider trust about what transformation really involves.