Digital transformation can be challenging. For staff, it will involve changes to how they work. And many trust leaders feel ill-equipped to lead on digital; it is often seen as too complex and technical. Even within IT teams, digital transformation can be unfamiliar and uncomfortable territory for some. All this can contribute to fear and uncertainty about digital transformation. What does it mean for my job? What are the consequences if it goes wrong?
More trust is better than more controls
If you've had problems with digital delivery before, it can be tempting to implement more controls. But this can often make it even harder to deliver successful digital services. A common example of this is requiring all technology changes to be approved by a 'Change Advisory Board'. The intent behind mechanisms such as these is sound – a desire to make sure all technology changes are well considered and don't lead to system outages. Unfortunately, this type of control has shown to be negatively correlated with system stability while also slowing down delivery. Organisations with a modern approach to technology reduce risks by releasing software changes in small pieces multiple times a day, rather than storing up big changes for release once or twice a year. They also use techniques such as peer code review, automated testing and automated deployment to spot problems at a level of detail Change Advisory Boards are not able to.
Jez Humble coined the phrase 'risk management theatre' for controls such as these that are "imposed in a top-down way, which makes life painful for the innocent but can be circumvented by the guilty". In contrast, an adaptive risk management approach starts from a position of trust rather than suspicion, where "people work to detect problems through improving transparency and feedback, and solve them through improvisation and experimentation". This involves focusing on principles rather than rules and uses failure as a learning opportunity, rather than an opportunity to apportion blame. There are many parallels here with efforts to create a just, learning culture across the NHS to improve patient safety.
Trusts should think carefully about how to establish the right governance mechanisms that give boards and senior leaders the right level of oversight without getting in the way of digital teams. The National Audit Office's Governance for agile delivery and Government Digital Service's Governance principles for agile service delivery are useful guides.
Most of all, boards and senior leaders should ask for 'demos not memos'; using digital services for themselves (or shadowing staff as they use them), rather than reading papers about them. This helps to break down barriers and can give a real insight into how well things are working on the ground.
It is important that senior leaders take the opportunity to play with the product, especially if it is
coming from an established vendor – you wouldn't want to buy a car without a test drive and the same applies
to technology at your organisation.Executive Medical Director, Humber Teaching NHS Foundation Trust
It’s about being ambitious but not unrealistic. Don’t forget about the barriers, but do begin to think about how you might manage them and make them into speed bumps rather than roadblocks.
Interim Director of Improvement and Transformation at Cambridge University Hospitals NHS Foundation Trust
Work in the open
Successful digital transformation requires strong cross-functional collaboration and – increasingly – system-wide working. However, without care, digital can become another silo – technical jargon and different ways of working can be off-putting to those less familiar with the subject. Digital transformation can be worrying for some – and their concerns should be taken seriously. Again, demonstrating how digital will benefit staff, rather than add more complexity to their jobs, is critical. Communicating clearly, talking about what you've already delivered and sharing real stories from patients and clinicians are great ways to start breaking down these barriers.
At the heart of any transformation, it is all about improving patient experience and outcomes. In the NHS this is something that we all intuitively ‘get’. Throughout my career, I’ve spent a lot of time acting as a translator between technologists and clinicians. There is an opportunity for the shared language and common goals of quality improvement to help break down barriers and bring teams together.
Former Chief Nurse, NHS Digital Non-executive Director, Yorkshire Ambulance Service NHS Trust
Break down silos
Many trusts are realising that the best approach is to bring together different change initiatives; digital transformation working alongside system integration, quality improvement and practice development. This integrated way of working recognises that digital transformation is not a straightforward technical change, but rather an adaptive change that "involves substantial and long-lasting engagement between the leaders implementing the changes and the individuals on the front lines who are tasked with making them work".
Connect builders with users
It's important that those creating digital services – software developers, designers, data analysts, product managers – understand the needs of those who will use them. Unfortunately, there are often things that get in the way of this. Perhaps there are project managers or business analysts tasked with 'translating' between users and builders, passing requirements down the chain to builders (creating a 'feature factory'). Or maybe the builders are outside the organisation – supplier-side, perhaps even in another time zone. If a delivery team is not directly involved in research and problem exploration, or has little contact with users once a service is launched, this can be very disempowering for them and result in digital services that don’t meet user needs. Trusts should find ways to connect digital teams (and suppliers) directly with users and empower them to solve their pain points.
Key questions for boards:
- How frequently are digital teams able to release changes to digital services?
- How joined up are your digital transformation, system integration, quality improvement and practice development initiatives?
- How often do those actually building digital services have direct contact with users?
Case Study
Doing the hard yards of culture change at the Royal Free NHS Foundation Trust
This is all about patient care and all about what you are trying to get for patients. You start with that. Then you quite quickly go into how do we get clinical engagement. There is no point in undertaking digital transformation unless you are prepared to totally change the culture of your organisation.
Group Chief Executive, the Royal Free London NHS Foundation Trust
Context
Many leaders on the board had previous experience of implementing and deploying electronic patient records. The legacy across the Royal Free NHS Foundation Trust had left the trust with different editions of Cerner on each of its three main sites. In October 2021, the trust-wide version was deployed at the Royal Free Hospital, the last of its three sites. This latest implementation was done in partnership with West Hertfordshire Hospitals NHS Trust and yielded learnings on both sides from the collaboration.
Approach
Based on previous experience, the board understood that putting in a new system would expose clinical variation. Consequently, the trust invested a lot of resource and time in addressing these unwarranted variations and sought to avoid simply digitising existing varied processes. Work to reduce variation is continuing across the Royal Free, West Herts and the North Middlesex University Hospital NHS Trust, and starts with engaging clinical teams around their own data to devise the best pathways for their patients. Rich data produced by the trust-wide EPR now shows how pathways and systems are being used. This insight allows the trust to adapt and constantly improve to ensure the system enhances patient care, rather than distracts from it.
This is now beginning to have an impact on the quality of the trust's services, and is also starting to drive down costs. Having deployed Cerner across three large acute sites, the trust believes a successful EPR roll-out requires leaders to understand:
- The importance of scalability.
- Doing the hard work with system partners up front (as you will need to align sooner or later).
- Facilitating user interaction with the new system so ideas can be surfaced and then funnelled to the supplier during development.
- Considerable investment is needed to ensure clinical and operational teams have the training to use the rich functionality of a system and aren't relying on work arounds.
- Every team will need a champion – every service, ward and division will need someone who really appreciates what the impact on patients could be if a trust gets this right.