Paperless or Paperlight?That is the question…

Presented by Hélène Somerville

Background

• September 2013 – initial discussions - Mobile Working

- Paperless Service.• GPs had been using SystmOne (S1) for several years.• Obvious choice… BUT it was not designed for SLT use!• Initially used for recording SLT face to face contacts and

admin contacts.• 3 different geographical areas operating 3 different S1

units. East & North Herts, West Herts and West Essex.

Process

• Numerous Meetings to map requirements onto S1.- Business change team- Senior Manager

- 2 x Clinicians • Processes need to be exact and comprehensive• Capture each step from referral to discharge.• Then replicated onto the system - S1.

Examples

•How will referrals come in?•How to send appointments out?•How to run a clinic?•What letters do we need?

A Light Bulb Moment

Paperless vs Paperlight is about way more than writing

up the case notes.

Referral process To Be Process: Register / Referral / Triage (Including Dysphagia)

Service: Children’s Speech & Language Therapy ServiceCreated By: Informatics – Sarah Brannen, Business Change Team

Date / Version / Page 17th Oct 2014 Version 2 Page 1 of 1

START OF PROCESS

Is child already registered on S1 with

the same referral reason?

Record Ethnicity & Smoking Status (Patient Profile) if relevant

Scan Paper Referral into child’s record if available

Contact Referrer to advise that child already referred for this

referral reasonScan referral into record and Task

Therapist to advise further information available

Is child Statemented?

END OF PROCESS

Speech, Language & Communication ReferralReason – Speech, Language & Communication(Routine)Referral Outcome - “Accepted”Referral Status - “Waiting for Care”Caseload – Triage SLCOR Dysphagia ReferralReferral Reason – Feeding & Swallowing(Routine)Referral Outcome - “Accepted”Referral Status - “Waiting for Care”Caseload – Triage Dysphagia

Referral received

Paper referral – Will require scanning into the S1 recordElectronic referral - Tasks must be accepted to report on inappropriate referrals)

Yes

Triage Team checks Triage SLC/Triage Dysphagia Caseload

Review New Referrals

Is Referral Accepted?

Add to appropriateWaiting for Assessment / PSN Dysphagia

CaseloadWaiting for Assessment Waiting List /

Dysphagia (Location) Waiting ListUpdate Waiting List Notes accordingly

Send Admin Discharge at New Referral Task to

End Referral using appropriate discharge Reason

& Print & send Discharge at Referral Letter

Task receivedCreate, print & send

Discharge at Referral Letter using appropriate Discharge Code

End Referral – using Discharge Reason

End Care if no further active referrals

Register (Re-register)Create New Referral In

Service Offered - “Statemented child – SLT in part 3”

Register/Re-registerCreate New Referral In

Service Offered – ‘Children’s SLT”

No

Yes

Complete “Child with Special Needs”

template, include date of Statement “Additional/Previous Record

Held” template with details of where Statement or any other paper records

are held

YesNo

Clinician Admin

Key

Ensure Date of Referral Column included on Caseload screen (as not sending Task) to be able to identify the new referrals

No

Task/Phone Dysphagia therapist to confirm New Referrals

Amend Status for Dysphagia referrals to Urgent if necessary

If further investigation required add patient to ‘Waiting for Action at Triage’ Waiting List, until further information received then move to Waiting for Assessment Waiting Lists as normal

Booking

Appointments

To Be Process: Book Appointment / Initial Assessment (CLINIC)

Service: Children’s Speech & Language Therapy ServiceCreated By: Informatics – Sarah Brannen - Business Change Team

Date / Version / Page 17th Oct 2014 Version 1 Page 1 of 1 LOGO???

START OF PROCESS

Send completed Service Questionnaire to AdminComplete Paediatric SLT Assessment & Diagnosis

Template Generate Screening Report.

Apply relevant Tier Care Plan(s) if appropriate & Perform

If any other paper documents/assessments completed – record location using Additional/Previous Record Held template OR send to admin to Scan into record

‘Report to be Sent’ Task to Admin team for distribution of Screening report

Remove from Waiting for Assessment Waiting List

Add to appropriate Intervention (Waiting) List Update Waiting List Notes accordingly

Assign to Caseload

Is furtherAssessment/Intervention required?

End Tier Care Plan (s) if applied End Referral using Discharge

Reason &End Care if no further active

referralsIf Appropriate (DNA)

Create Discharge Summary/Letter & Task Admin to distribute

END OF PROCESS

‘Initial Appointment Letter to be sent’ Task received

Create, print & send Initial Appointment in Clinic Letter from Waiting List Actions

Update Waiting List Notes as appropriate

Patient contacts within 3 weeks?

Book Appointment into appropriate slot in Therapist’s Staff Diary.

Update Waiting List Notes accordingly

Patient attends

Clinician Admin

Key

Therapist Reviews Waiting for Assessment Waiting List

Books required number of Textual Appointments using Appointment Templates & Presets in Staff

Diary. Sends ‘Initial Appointment Letter to be sent’ Task to admin detailing Waiting List, Number of patients to

be invited and details of Textual appointments

Yes

Questionnaire receivedScan into record - shredRecord/Check Ethnicity

(Patient Profile)Record Consent

‘Report to be Sent’ Task received- Print &

Distribute ReportSend ‘SLT Report to

be Read’ Task to appropriate HV Group in

CUS unit

No

Create Discharge Letter/Summary – using appropriate Discharge Code End Referral –

using Discharge reason

End Care if no further active

referralsTask Admin to print & send Discharge Letter/Summary

Yes

Patient cancels appointment

Attempt to Rebook appointment for child cancelling

AND/OR Update Waiting List notes

accordingly.Review Waiting

List to allocate free appointment to

alternative child (Use Priority & Therapist’s

Initials to identify)

Following review of record, Discharge

patient?

Initial Appointment to be Sent Task to Admin to rebook

Appointment

Yes

No

No

Yes

Yes

Create & send No

Response LetterUpdate

Waiting List Notes

Following review of record,

Discharge patient ?

No

Task Admin to send another Appointment

No

Task ReceivedPrint & send

Discharge Summary/Letter

Task receivedPrint & send Discharge Summary/

Letter

Therapist may book appointments with Dysphagia patients direct to ensure seen within required timescales

Record DNAUpdate

Waiting List Notes

Yes

No

Task Therapist to advise

No Contact Made

Top Tips

• Protected project time: - one staff member seconded as full time role.

• Experience of the system. • Visit locations to see in action.• Co-ordinate training and going live.

- staff can put learning straight into practice.• Check software requirements and compatibility

with any new computers.• Get used to the new vocabulary – semantics.

Clinical vs Non Clinical Contacts

• Record and capture data for Audit: Staff activity, waiting times,

Specialist versus Universal working

Research: Reporting co-existing diagnosis

Outcomes: Adapted the East Kent Outcome System. Called a Questionnaire just to confuse us...all part of

adapting our needs into an existing system.

Letters and Reports Come From The Process

• Letters circulated from central hubs - three hubs with the relevant admin address and telephone number.

• Move to mobile working means many clinics not manned during the day - To avoid messages being left on answerphones,

letters only have the admin telephone numbers • Patients can therefore always speak to a person. • Task from S1 (like an email) then sent to therapist with the

message.• Less personal approach for letters versus less unanswered calls.

Text Messages

• Text Reminder two days before a clinic/home visit when in electronic ledger/diary.

• No text reminder for school visits.• Text can be sent at appointment booking via

electronic ledgers/diary.• Possibility of confusion.• Reduces DNAs.

Setting Objectives To Be Process: School Visits (Setting Objectives / Recording Outcomes)

Service: Children’s Speech & Language Therapy ServiceCreated By: Informatics – Business Change Team

Date / Version / Page 31st Oct 2014 Version 1 Page 1 of 1

Clinician Admin

Key

END OF PROCESS

START OF PROCESS

Start of Term/Treatment (when appropriate)Review Tier Care Plan (s) as appropriate & add

alternative(s) & if required & PerformComplete Therapy Plan Objectives

Questionnaire - Save as Final VersionCreate SLT Objectives Therapy Plan in

Communications & Letters - Save as Final Version

Complete Paed SLT SOAP Progress/Paediatric SLT Assessment & Diagnosis templates as

appropriateIf any other Paper documents completed – record location using Additional/Previous Record Held Template OR send to admin to Scan into recordTask sent to Admin to Print & send copy of SLT

Objectives Therapy Plan to Parents/Carers

Child on School Intervention Waiting List has Appointment(s) booked

Approaching End of Term/TreatmentComplete SLT Therapy Plan Outcomes Questionnaire – Save as Final VersionCreate SLT Outcomes Therapy Plan in

Communications & Letters – Save as Final Version

Task Admin to Print & Send copy of SLT Outcomes Therapy Plan to Parents/Carers

Task received Print and send SLT Objectives/

Outcomes Therapy Plan to Parents/Carers

Therapist attends meeting with SENCo

Further intervention

required

Add to appropriate Schools Intervention Waiting List OR

Update Waiting List Notes accordinglyCheck on appropriate Caseload

Yes

No

End Tier Care Plan(s) Create Discharge Summary/

Letter if appropriate End Referral using appropriate

Discharge Reason End Care if no further active

referralsTask Admin to Print & send Discharge Letter/Summary

Task receivedPrint & Send Discharge

Summary/Letter

‘On-going’ Face to Face TherapyUse Paed SLT Progress (SOAP) Notes

Template to record contactsReview Tier Care Plan(s) as appropriate and add

alternative(s) & if required & Perform

Care Plans will need to be Performed when applied.

Therapy Blocks To Be Process: Therapy Blocks

Service: Children’s Speech & Language Therapy ServiceCreated By: Informatics – Business Change Team

Date / Version / Page 18th Nov 2014 Version 1 Page 1 of 1

Clinician

Admin

Key

START OF PROCESS

Therapist reviews appropriate Intervention (Waiting) List and amends required number of slots to Therapy Blocks

Send Appointment Letter to be Sent Task to Admin detailing Patients to be booked and appointment details

Task received Therapy Appointment Letters created & sent

Update Therapy Intervention Waiting List Notes accordingly

Patient contacts within

3 weeks?

Book (Assign Patient) block of Appointments – Therapy Blocks

Review/add Tier Care Plan(s) & PerformComplete Paed SLT Progress (SOAP) Notes Template OR Paediatric SLT Assessment &

Diagnosis Template as necessaryReview/set SLT Objectives/Outcomes

Questionnaire if appropriate – create appropriate SLT Therapy Plans

Generate SLT Progress Report if requiredReport to be Sent Task sent to Admin Team for

distribution

Task receivedSend ‘SLT Report to be Read’ Task

to appropriate Health Visitor

Group in CUS unitDistribute Report

accordingly

Add to appropriate Intervention Waiting List or update Waiting List Notes accordingly.

Check Caseload

END OF PROCESS

Complete SLT Outcomes Questionnaire & Therapy Plan

(save Final Versions)End Tier Care Plan(s)

End Referral using appropriate Discharge Reason &

End Care if no further active referrals

Create Discharge Letter/ Summary if appropriate

Task Admin to print & send Discharge Letter/summary

Yes

Patient cancels Appointment?

Task Therapist to advise Patient

cancelled and slot now available for

rebooking

Patient attends?Following review

of Record Discharge Patient?

No

Send No Response

Letter Update

Waiting List Notes

Task Admin to rebook

appointment

Yes

Letter includes only Dates not specific times of appointments

Task Admin to rebook

appointment with alternative

patients names

No

Record DNA & Update Waiting

List Notes

At the End of Block is further

Intervention required?

Admin picks from Waiting List or does Therapist confirm names??

Task received Print & send Discharge

Letter/Summary

No

Yes

Yes

Yes

Patient responds?

No

Yes

No

No

Task Therapist to advise No Contact

made

Patient attends next

appointment?

Yes

No

Checklist for Appointments and/or Admin Time• Check child’s address and telephone number.• Add ethnicity if not recorded.• Update consent template.• Initial assessment- complete paediatric SLT assess and

diagnosis notes.• Therapy/review/Drop in- complete SOAP notes.• Care plan- create or check.• After initial assessment – remove from waiting list,

amend caseload and add to intervention list.• Intervention list – amend notes/waiting since and due

date.

Checklist for Appointments and/or Admin Time• Set new objectives (programme).• Complete outcomes for previous objectives.• Write report.• Task admin group to circulate report, programme and

outcomes• Add information to Children’s ongoing diagnosis

template if appropriate e.g. type of cleft• Add details to groups and relationships (e.g. family

members, professionals)• Add reminder if required e.g. safety issues in home,

dog at property.

Benefits• Shared Access to information from involved

services(subject to parental agreement).• Access to alerts: Safeguarding issues, domestic abuse

etc.• Joined up working with local SLTs - one shared set of

notes.• Use of admin staff to deal with all initial queries.• Use of admin for circulation of reports.• Reports and letters templates save time. • Child’s information automatically populates – safer

record.

Benefits

• Drop-in - admin can check if child previously known. - quick access to alerts, HV information. - Can email advice to parents.

• Able to stay in one place to do reports/programmes.• Can complete everything on the day.• Don’t have to go back to clinic to print – task admin.

Benefits

• Reduces SLT admin time – quicker to send task• Standardised formats/templates across the

service• Don’t’ have to carry big files around• Safer transfer of care to colleagues – no case

notes in internal post!

Benefits

• Everything attached to patient record - Tasks from the patient record can check. - Assessments scanned on.- Objectives.- Outcomes.

• Increased Flexibility - Able to access patient information from any location.- Flexibility to work from home, school, other base.

Benefits

• User messaging – - Can message SLT who is logged onto S1 - Can see if staff on annual leave

• Intervention lists for each team- Better information sharing and transparency

• No need to keep end of the month records as all the information there.

• Can see who has breached time constraints as names go red.

• Can collect information on conditions e.g. SLI caseload, Down’s Syndrome.

Challenges

• Reliant on internet access –“dead” spots in the Hertfordshire countryside.

• Time taken to “fireup” the laptop and enter the many passwords and security cards to get onto S1.

• Speed of typing! • Trying to type and simultaneously keep the child from

joining in on the laptop.• Transcription - still allowed to do with pen and paper

but difficult to do with lap top open as well for reasons given above. I need another pair of hands!

Challenges

• Unable to merge the 3 S1 units - I have 3 ledgers!• Took time initially to move all my patients into units.• Only current patients on S1. • Review & cleft clinic only patients discharged & re-

registered each time they are seen.- Extra admin for me.- Potential for loosing them to follow up.

• Can take time for letters, assessments to be scanned on.• Keeping all the information in your head once you are

typing in the SOAP notes as can’t get out of this box and in again.

Challenges

• Maintaining eye contact during consultations whilst typing.

• Reading long reports on screen.• These last two do seem to be a bit age specific

but not exclusively so…..

The Clinical Tree

Paperless or Paperlight?

• Our service is paperlight - much to our relief!• Large documents such as Statements or EHC Plans,

Large booklet assessments such as the ACE are NOT scanned in but kept in manila folders

• We can also keep a paper copy of the questionnaire (i.e. our current targets) so that we can refer to it during therapy sessions and e.g. for my role copies of the GOS.SP.ASS.

How are we doing?

• Just over 6 months in we are slowly getting used to doing everything via our laptops.

• Finding out new things you can do on S1 all the time.

• Not sure the typing is getting quicker.• But probably most importantly we wouldn’t

go back to paper records.

What about the future?

• Looking at the possibility of using Skype as has been trialled by an adult service within our Trust

• Using the intervention lists to find children with similar needs and seeing in groups

• Closer links with GPs.

Any Questions?

Thank you for listening.