For digital transformation to be successful, trusts should have a strong conviction of what they want to achieve by investing in digital. Without a clear goal – closely aligned to trust and system strategy – there's a risk that you'll make things more 'digital' but not necessarily better for patients and staff. This is true even for 'foundational' investments such as implementing an EPR: it's important to define the benefits these will deliver for staff and patients – reduced adverse events, improved flow, better adherence to prescribing guidelines – not just the technical milestones.
Digital can help trusts achieve the triple aim of better health, better care, lower cost. Boards should be clear on the benefits they plan to realise by investing in digital: perhaps reduced prescribing errors, improved scheduling or better communications across departmental and organisational boundaries. If the primary aim is improved data collection or achieving cost savings, this will be hard to realise without delivering – first and foremost – real, tangible benefits for patients, service users and staff. Improved data and efficiency can be a valuable by-product of digital transformation, but these are hard to achieve without widespread adoption of digital services. Trusts should design for adoption, building services that are genuinely useful for patients and staff – pull rather than push.
Be honest about benefits, even when it's uncomfortable
Trusts should avoid becoming hostage to unrealistic business cases. As HM Treasury makes clear in their guide to optimism bias, "there is a demonstrated, systematic, tendency for project appraisers to be overly optimistic". And there are incentives for both project promoters and approvers to inflate potential benefits, in order to get projects approved and to justify budget plans. This can result in one-sided business cases that set out the upside of an investment without assessing the downside: perhaps a decrease in pressure in one part of the trust will increase pressure elsewhere, offsetting any potential benefit. For example, some trusts have reported how electronic prescribing, while reducing certain prescribing errors, creates entirely new ones.
The reality is that not all digital expenditure will have a positive return on investment in purely financial terms. Trusts shouldn't shy away from this; it's better to set out an honest business case than create unrealistic expectations. And although it may be embarrassing or uncomfortable to admit where your trust hasn't been able to deliver the benefits promised by previous digital initiatives, it will help your organisation make better investment decisions in future if you are able to reflect on and learn from this.
Set specific goals and make progress visible
Often, business cases focus on output metrics like costs rather than controllable input metrics like adoption rates, error rates and wait times. This can make it hard to understand the specific aims of digital investment, and provide unclear direction for delivery teams. Boards should demand business cases that contain both a clear, concise set of input goals alongside the estimated financial impact.
It's also important to break these goals out of business case documents (which soon become stale) and turn them into a living tool to help guide delivery decisions and measure benefits. Making these goals easy to grasp and highly visible is a great way to focus minds across delivery teams, decision makers and partners. Boards should ask for weekly or monthly reporting on these goals from their digital teams, providing a more meaningful way to verify whether things are on track than a traditional project status report.
Key questions for boards:
- What's the primary aim of your digital investments?
- Are your digital transformation business cases realistic, given the risk of optimism bias and challenge of realising benefits?
- Can you clearly articulate the impact your digital investments will have on staff and patients?
Case Study
Making clear to users what change means at Central London Community Healthcare NHS Trust (CLCH)
Over the course of the pandemic we’ve seen a real mindset shift about the possibilities of digital. And virtual wards are a great example of this change. As a member of the board a critical part of my role is to communicate to colleagues the art of the possible.
Director of Improvement
Context
Central London Community Healthcare took the decision to invest in virtual wards as part of their response to the COVID-19 pandemic. As an organisation that works across four different integrated care systems (ICSs) this involved taking different approaches in different areas which has led to the development of a range of successful virtual ward implementations.
Approach
The success of this approach was due to a number of factors:
Despite a lack of significant evidence available, the trust took the view that there was a sufficient case to invest in virtual wards both because of the strategic importance of digitally enabled services and because of the importance of learning from developing these new services. For example, in some areas this meant taking financial risk to pilot services with partners ahead of securing funding from commissioners.
The implementation of new digital ways of working and virtual wards would not have been possible without a mindset shift across the organisation. The real difference now is that staff across the trust and the system are comfortable with what it is possible to do with technology and understand what it means for them. This increased confidence has contributed to a wider culture of service innovation at the trust. Since the deployment of virtual wards, the trust's medical director chairs a new "80/20 group" to explore the ways of turning other clinician-led innovations that are "80 per cent of the way there" into reality.
Clinical leadership has also been vital. This has involved clinical leaders thinking about how better care can be provided for patients using technology, rather than compartmentalising ideas as separate 'digital' projects. Another key part of this has been making the change feel real and exciting for clinicians. Patient stories and videos were used to highlight to staff the positive impact of the programme on patients (one video explained the impact on those able to be discharged home earlier). And discussions at business meetings focused on what it meant for clinicians.