• Boards need to set conditions for teams to thrive which means looking at processes and governance and making sure they are always adding value and meeting the needs of users.
  • The most effective governance puts decision making in the hands of people who are best placed to act as they have the right skills, knowledge and context – all the while verifying that decision making is sound.
  • To speed up delivery, bring assurance into the team rather than a distant gateway board. Escalate to the board when risks are of strategic importance.
  • New types of governance, which brings teams and leaders together to see and discuss working software and report on issues, rather than comprehensive documentation, leads to richer understanding and dialogue.

Effective governance is critical to the delivery of safe, high-quality care. It can often be more difficult and complex in health than other sectors given the realities of information and clinical governance and the range of regulatory and national bodies involved. For boards, governance means obtaining assurance – confidence backed by sufficient evidence – that strategy is being delivered to meet the outcomes that have been agreed and risk is properly managed. 

However keeping up with papers submitted to the regular drum beat of a governing board can make it hard for directors to complete the vital triangulation process of comparing what they read and are told, with what they see for themselves, in order to check outcomes are being delivered.

It is equally hard to ensure risk management processes are proportionate so that teams have appropriate powers to act. Overly hierarchical structures can disempower teams. Existing forums used to make decisions can sometimes become distant, far removed from the reality of delivery. This can lead to teams feeling the pressure to deliver to deadlines, deliverables and documents, compromising their own focus, rather than on users and the outcomes they are seeking to achieve.

Boards of digital organisations are able to turn this around. They focus on empowering teams so that decision making is in the hands of people who are best placed to act as they have the right skills, knowledge and context – all the while verifying that decision making is sound. New types of governance are used to bring teams and leaders together to see working software and report on issues, rather than comprehensive documentation. This leads to richer understanding, dialogue and makes existing assurance processes more effective. Teams empowered in this way give people agency, passion, commitment and make your organisation a pleasure to work in.

A governance framework for the trust’s global digital exemplar (GDE) programme was established by the trust’s CIO in conjunction with the chief executive, who also acted as the executive sponsor. This sponsorship of the governance framework was key in that it provided authority to manage, challenge, and ensure project progression. At levels below the executive, clear intentions of the governance framework were set at an early stage which ensured there was no misunderstanding of the goals of the programme, which empowered teams to get on and deliver. Risk is now consistently managed and escalated through the framework.

South Tyneside and Sunderland NHS Foundation Trust    

For more on the above case study, see The Global Digital Exemplar blueprint, accessed online (requires log in): https://future.nhs.uk/GDEcommunity/view?objectId=15630768.


Key principles of good agile governance

Focus on outcomes, not deliverables

Digital strategies need to be more than shopping lists of technology against a list of dates. Board leaders need to understand and articulate the problems they want fixed and the outcomes they want to see, rather than place bets on a solution they have heard of. They must be both problem seekers and problem solvers, rather than simply recipients of information.  

The unit of delivery is the team

A team is in charge of how it delivers digital products and services. There’s no formal hierarchy within teams, even though they contain people from all levels of the organisation including board members. The service owner and team have the authority to make decisions and escalate (as well as deescalate) through an agreed and robust process. Good teams succeed when they have the right mix of skills, are empowered, and understand the outcome desired.

Assure as you go

Lengthy gateway approval processes designed by hierarchical organisations slow down agile delivery teams, by making them wait for decisions they are better placed to make themselves, and by interrupting the fast feedback loops that can enable a team to iterate and deliver value faster. A good digital team will have regular public check in points like showcases, and will be publishing information to enable people to see the quality and value they are creating. Assurance should be sought often not at ‘big bang’ stages.

Measure progress in different ways

Documenting is important but typically agile teams produce less long-form documentation, while still providing sufficient information to make robust decisions and provide proper assurance that risk is being managed effectively. Progress is recorded in user research notes, blog posts, weeknotes, test harnesses, release notes and verifiable metrics. Board members should get comfortable viewing prototypes and other more tangible examples of team progress.

More agile tools and techniques can be found in the GDS service manual.

Managing clinical and information governance

More than in other industries digital teams face the dual challenges of handling very sensitive patient data that occupies special categories under the relevant legislation, and delivering safe, quality clinical services. There is no doubt that the potential for harm from an error is greater in the delivery of digital healthcare services than elsewhere.

The application of good digital governance principles are no different in these areas. When clinical and information governance work best and meet their intended outcomes, the appropriately qualified specialist is within the team, empowered to make decisions within the risk management framework agreed by the board.

Including clinical safety and information governance, experts within the digital team have the added benefit of exposing them to new digital ways of working. There are very few official processes or governance arrangements that would not be improved by, for example, content design — the art and science of writing well for the internet.

The iterative processes at the heart of digital delivery are a powerful means of reducing both information and clinical governance risk, underlining the importance of moving beyond a reliance on gateway processes that are just not suitable for quick agile delivery.

The trust's chief transformation and information officer (CTIO) leads a small transformation team and a larger information management and technology team. Across the trust quality improvement methodology is embedded and transformation programmes are designed to strike a balance between care quality improvement and assurance on safety. This is done by ensuring enough people within the team "know how far to push things", while the CTIO pre briefs members of the board on points of contention before board meetings. This approach works for the trust and means the board has full confidence in the CTIO's teams. This approach has contributed to the current ICS-wide procurement of a shared care record in an ambitious 10 week window.

Derbyshire Community Health Services NHS Foundation Trust