south south-west hospital group - ehealth ireland · current system assessment was completed by...

South South-West Hospital Group

April 2016

ICT Plan and Operating Model

SSWHG | ICT plan and operating model 1

Criteria Name Date

Author EY - Paul Merry 24 February 2016

Draft reviewed by EY EY – Paul Duff/Jon Herries 26 February 2016

Draft full report reviewed by SSWHG SSWHG 29 March 2016

Updated by EY – Paul Duff/Jon Herries 1 April 2016

Final draft reviewed and issued by EY EY – Paul Duff/Jon Herries 21 April 2016

Final accepted by the SSWHG SSWHG 21 April 2016

Version Status Date Description of material changes

0.1 First draft report for discussion purposes 26 February 2016 First Draft for Discussion Purposes Only

0.2 Second draft report for Project Board comments 11 March 2016 Second Draft following feedback session with Sponsor

1.0 Final Draft report following feedback 1 April 2016 Miscellaneous updates to content and formatting

1.1 Final Report 8 April 2016 Miscellaneous updates to content and formatting

1.2

1.3

Revisions for Publishing

Final Agreed Version – CIO & CEO SSWHG

21 April 2016

25 April 2016

Miscellaneous updates to content and formatting

Miscellaneous updates to content and formatting

Foreword


Richard Corbridge - CIO

HSE and eHealth Ireland

Gerard O’Dwyer - CEO

South South West Hospital Group

Information and Technology has never been more important in delivering high quality, safe and cost-effective healthcare for the people of Ireland.

In a time where the amount of computing power on your wrist dwarfs that of the Apollo moon landings the public and our staff are expecting better service,

more quickly from our ICT teams than ever before.

In developing this plan the South South-West Hospital Group has identified three key themes which are critically important to delivering on the vision laid out

by eHealth Ireland:

Bringing improved population wellbeing, health service efficiencies and economic opportunity through the use of technology-enabled solutions

Our plan brings ICT into the frontline delivery of care and the business of health, making our ICT staff a part of solving patient and business issues while

attempting to leverage our current assets and spread the knowledge that ICT alone cannot make a difference to patient outcomes.

It is in this context that we have chosen to focus on establishing virtual teams and investing in Business Intelligence to leverage our existing skills knowledge

and infrastructure.

We are also interested in bringing together our clinical and business staff with ICT to build bridges between our clinical systems, to reduce re-work and gaps in

our clinical records.

Finally we are investigating how we can establish electronic support for managing our most important asset, the people that work for the South South West

Hospital Group.

SSWHG ICT Plan and Operating Model – Executive Summary

EY were engaged by the South-South West Hospital Group to assist with the completion of a group wide three year ICT plan

and supporting operating model. The work was completed during Q1 2016.

There are three themes that have been explored in the plan:

• Changing the role of ICT in SSWHG

• Business opportunities with an ICT solution

• Leveraging our assets

These themes will help SSWHG develop ICT and move executive and strategic conversations about ICT from managing risk

to enabling transformation and securing opportunities to deliver improvements in quality, patient safety and productivity.

Changing the Role of ICT

The operating model and delivery of the plan is larger than ICT itself. There is a need for the hospitals to incorporate ICT

within developments in care and for ICT to work in partnership with clinical and business teams. There is also a critical

interface with the OCIO which needs to be developed over the medium to long term. This is discussed in the need to

establish virtual teams which include resources from ICT, clinical and business teams within the hospitals.

Even with this new way of working, achieving the aims of the plan will require additional resources. This investment should

be seen as a key enabler of productivity and improvements in quality and patient safety.

There is a real need for governance, management and identification of priorities for ICT solutions as there will always be more

opportunities than available resources. A mechanism should be put in place to help drive this and to monitor these priorities

and projects on an ongoing basis.

Business Opportunities

During the planning process a number of ICT initiatives were identified as being a consistent priority for each of the hospitals

within the group. These include:

1. Enterprise Information Management – Providing better business intelligence to facilitate better decision making.

2. HR & E-Rostering – A group wide HR system that is linked in with an E-Rostering solution will reduce administrative

cost and improve control

3. Clinical Portal – In advance of the national Electronic Health Record project there is an opportunity to reduce multiple

logins and consolidate patient records to improve outcomes and productivity.

When deploying the limited resources at the groups disposal it is crucial that the correct opportunities are progressed. To

ensure only the best opportunities progress, Business Cases and Feasibility Studies should be completed for all major new

initiatives. Where appropriate, the focus should be put on leveraging existing systems and infrastructure before looking to

implement new systems.

Leveraging our Assets

SSWHG has a number of very experienced ICT resources who deliver services on a daily basis on a knife edge of

sustainability. This approach devalues these resources and reduces the organisation’s ownership of technology solutions.

The group also has a large amount of “shadow ICT” with clinical and administrative staff who have an interest or willingness

to help. These resources could be better engaged through the development of virtual teams.

The group is also in an enviable position of having one of the most complete application environments in the HSE. Many

people feel that this should deliver better information than other areas and help more with decisions. There is also a sense

that some consolidation and connection of existing applications could significantly improve the productivity of staff and

improve outcomes.

SSWHG | ICT plan and operating model

3

4

Page

Executive Summary 2

Section 1 Introduction and Overview 4

Section 2 Future State 14

- ICT Operating Model

- Governance

Section 3 Three Year ICT Plan 37

Appendices

Appendix A About the Assessment 45

Appendix B Opportunity Prioritisation 46

Appendix C Roadmap Activity Details 48

Contents

Section 1

Introduction and Overview

Introduction

Overview

EY were appointed by the South South-West Hospital Group in December 2015 to assist with the production of a group

wide three year ICT plan and supporting operating model. Prior to the commencement of this project a comprehensive

Current System Assessment was completed by members of the Group’s own ICT organisation and the Office of the CIO.

The resulting report identified a list of key risks and issues with ICT across the group, while also identifying the huge

potential ICT provides the group in helping to achieve its strategic objectives.

A number of other factors were also identified and influenced the creation of the ICT plan and operating model.

• National Context – A series of planned national initiatives that will impact the group.

• Patients – A need to build confidence in the services offered

• Staff – Issues with staff morale, capability and capacity across the group

To progress the creation of the ICT plan, a project team comprised of ICT, Business and Clinical representatives from across

the group was created. Workshops with the EY and SSWHG teams were held in January and February 2016. During January

2016 a series of hospital visits were conducted by the EY team to discuss with various stakeholders what their priorities were

from an ICT perspective. Meetings also took place with the relevant HSE and OCIO representatives to discuss the national

initiatives that will impact the group over the course of the three year ICT plan.

Key Deliverables

The following three deliverables were identified:

• New Operating Model for ICT

• New Governance arrangements

• Three year ICT Plan

Key Inputs to the ICT Plan

When compiling the ICT plan a number of factors and inputs needed to be considered (Figure 1).

ICT Operating Model

The ICT operating model supports the delivery of plans/strategy by describing how work gets prioritised, distributed, executed

and how change is managed.


SSWHG

ICT

Plan

National

Initiatives

Capability and

capacity

Em

ergi

ng h

ealth

and

ICT

tren

ds

Hospital priorities

ICT Plan

ICT Operating Model

How is work

Distributed?

How is work

Executed?

How is work

Prioritised?

How change is

Managed

Fig. 1 – ICT plan inputs

Fig. 2 – How the ICT plan is operationalised

Why Invest in Technology in Healthcare?

A key priority for the HSE is striking the appropriate balance between the financial challenges while providing an increased

focus on quality, safety, access and reform. These are the key themes of the HSE Service Plan 2016, guiding how health

services are to be delivered during 2016 and beyond. Longer term reform of the health services is critical and is now

underway with further integration of services, which places the patient at the centre of all the services that are delivered. This

integration is enabled through the ongoing work of the Integrated Care Programmes and emerging presence of the Hospital

Groups and Community Health Organisations (CHO’s).

Within this environment the South South-West Hospital Group is seeking to both enable change and drive efficiency. In

many industries, and increasingly in health, technology is seen as a critical enabler to achieving reform.

Technology to support better decision making

The use of Early Warning Scores has grown in recent years across many countries to improve the management of acutely

unwell patients. Unfortunately many of these systems are paper based and rely on manual observations to capture and analyse

the scores. Some hospitals in the UK and in the US have automated this information capture from patient monitoring (e.g.

HR, RR, BP, temp, Sats etc.) along with electronic capture of other clinical measures (e.g. GCS). The algorithm is then

managed electronically displaying on ward whiteboards, prompting patient reviews and alerting staff to deterioration.

Technology to improve Productivity

Seeking information in an outpatient situation is often slowed by multiple sign ins and access to medical records which is

required often per patient and per room. If we assume (Figure 4) a clinician sees 12 patients in a four hour clinic and is using

2 rooms with 30 seconds needed to sign in for documents, PACs and Labs for each patient this is costing 18 minutes of

productive time per session. Just changing to a single 30 second sign on, without changing any variables reduces this creates

enough time to add another appointment to the clinic.

Technology to improve patient safety and quality

Shared records between hospital and primary care intuitively make sense in an emergency situation. A patient presenting to

ED who has been to their GP on the same day would benefit if the GP could share their assessment and test results online

with the emergency department. This would also provide an opportunity to reduce the need for repeated testing in the

Emergency Department.

Other uses are less obvious. Shared records could be used to help medicines reconciliation on admission to hospital. A GP

record as a source can lead to reduced medicines errors and therefore reduced length of stay. It can also be used in an

outpatient scenario where on referral a hospital clinician can check current medications and allergies, check investigations

undertaken by the GP and suggest treatment plans or provide advice based on this additional information.


Martin Carberry - How helpful are early warning scores? Nursing Times 15.01.14 / Vol 110 No 1/3 / www.nursingtimes.net

Reduced deaths from Cardiopulmonary arrests*

Reduced documentation

Increased accountability for assessment

Reduced interpretation error*

20 minute appointments with 1.5

minutes signing into three

systems

Same number of appointments

with single 30 sec sign into three

systems

12 minutes capacity

freed per session for additional

patient care

Fig. 4 Using technology to improve productivity

Fig. 3 – technology supporting better decision making

http://www.nursingtimes.net/

Current ICT Organisation

Observations

Throughout this engagement a number of observations were noted relating to the SSWHG ICT organisation. Many of these

observations helped to validate points that were previously captured in the Current Systems Assessment.

• During the hospital visits both Business and Clinical representatives spoke very highly of the ICT teams and

acknowledged the good work they are doing under difficult circumstances.

• Capacity issues – the ICT teams in each hospital are focused on 'keeping the lights on‘ with little capacity available

to support new ICT related initiatives

• No mechanism exists to agree and communicate ICT priorities at Hospital level. In addition, ICT is not fully

represented at the Group’s Leadership team. As a result, ICT lacks effective direction and coordination.

• There is a level of commonality across the group - similar pain points and frustrations across the group and similar

on-going initiatives.

• Many of the national projects, if successfully delivered, will by default address many of the group priorities.

• Some of the potential ICT initiatives (e.g. HR system and group-wide Portal) will require significant input from

Service and Clinical staff. It is not clear that the scale of this input is clearly understood or that it could be provided

without impacting existing patient services.

• Clinical staff have little visibility of future ICT initiatives.

• Mixed experiences across the group of national ICT initiatives – some successes, but also lots of frustration linked to

delays and lack of planning

• Post go-live support arrangements are not clearly understood.

• Risks noted in the Current Systems Assessment are still valid across the group (e.g., absence of Business Continuity

Plans for key systems, inconsistent Data Quality, on-call support arrangements for critical systems, etc.).

• Consistent security standards and business continuity procedures are not in place and adhered to across all systems

and functions.

• Lessons learned from previous projects are often not considered and taken into account when planning future

projects. Currently formal lessons learned exercises are rarely completed.

Transformational nature of initiatives often not recognised

In many instances change initiatives are viewed as being ICT led projects. The transformational nature and related impacts of

ICT system roll outs and changes are often not fully considered or recognised.

To address this issue there is a need for greater end user involvement (both Business and Clinical) throughout the systems

development lifecycle (Figure 5).

Currently, the challenges and difficulties associated with releasing staff to get involved in projects is often a roadblock to

making this happen.


Making sure the business

is ready for the solution

Making sure the solution

is ready for the business

Program

Business

8

Fig. 5 Connections required to build successful solutions

Current ICT Organisation (cont’d)

Capability and Capacity – Resourcing Realities

The current ICT function is made up of approximately 35 people with technical and non-technical backgrounds that support

day to day operations. The current ICT focus is very much on break/fix and business as usual support, and the majority of

resources do not have experience working in project delivery roles (Figure 6). There is currently a mix of inconsistent

reporting structures – some ICT resources report directly to the hospitals, while others report directly to the Office of the

CIO.

The current ICT resource profile clearly indicates capacity issues with significant dependencies on a small number of key

individuals. Given the current composition of the team, there is a lack of capacity to develop new large ICT projects.

Similarly the ability of Service and Clinical teams to support larger initiatives is challenged especially considering the number

of national projects that will require support. In order to address some of the capacity challenges, understanding how staff

could be better utilised is important.

The table below shows the breakdown of ICT resources in each hospital across the key activities.


► Lack of capacity to take on new large scale ICT initiatives

► Business Cases to be developed

► Support for national ICT projects

► Infrastructure upgrades

► Addressing risks identified in CSA (e.g.,

Business Continuity Plans for critical systems

etc.)

► Break/Fix activities

► Day-to-day operations

Hospital

Help Desk,

Break Fix

Technical and BAU Projects,

Service Management

Informatics,

Business Intelligence

Business

Projects

Total

WTE

CUH (including MGH and BGH) 2 6 1 2.5 11.5

UHW (including LOHK) 1.5 1.5 1 1 5

UHK* 2.5 2 0.5 1 6

MUH 2 1.5 0.5 1 5

STGH* 2 0.5 - 0.5 3

SIVUH 1 2 0.75 1 4.75

Total 11 13.5 3.75 7 35.25

Value Added to SSWHG

9

D. Large

projects

C. Enhancing

existing systems and infrastructure

B. Addressing

risks

A. ‘Keeping the lights on’

Fig. 6 Hierarchy of ICT activities

* Includes central HSE staff who provide services to Community Health Organisations Source: SSWHG Analysis: EY

Healthcare and Industry ICT Benchmarks

Expected Number of ICT staff for a similar sized organisation

This graph compares the expected number of ICT staff in a healthcare organisation and all industries to the current SSWHG

staffing levels. The yellow bars represent the Interquartile range. From the benchmark SSWHG has lower ICT staffing

numbers than 75% of businesses surveyed in all industries and healthcare

Expected Total ICT Budget for a similar sized organisation

This is an estimate of what the total expected ICT budget should be for an organisation with €705.7m in revenue. From the

chart, ICT investment in Healthcare is higher than industry in general.

This suggests that the annual operating budget (excluding capital) )for SSWHG ICT should be between €20 and €30m.


Source: EY and SSWHG Analysis: EY SSWHG

35.25 WTE

Median

99.2 WTE

Median

90.4 WTE

Median

€19.4m

Median

€25.2m

Source: EY Analysis: EY

EY undertakes regular surveys using clients and APQC benchmarking data to produce a number of standardised benchmarks for understanding key organisational processes and costs. Below are the ranges expected internationally for all

industries, healthcare providers standardised to an organisation with revenue of €705.7m*. Where available this has been overlaid with the SSWHG comparator.

* Source: SSWHG Operating Plan 2016

Proportion of Budget spent on deployment of ICT solutions for a similar sized organisation

This graph shows the proportion of budget spent on deploying ICT solutions. The estimate for SSWHG assumes that the

proportion of staff employed relating to business projects is highly associated with the investment in new solutions.

Based on more detailed knowledge of individuals in this category in SSWHG it is likely that the proportion of budget spent

on new solutions is a lot lower than this. If the assumption is that there is 1 WTE allocated to ICT management in each

hospital cluster (with STGH included with UHW), there is 2 WTE out of 35.25 deploying new ICT solutions which is 5.7%

of resource.


Healthcare and Industry ICT Benchmarks

Proportion of Data Managed Centrally for a similar sized organisation

This is an estimate of the amount of data managed centrally as opposed to by individual departments or individuals.

This is an indicator of how standardised data collection is and how pervasive enterprise systems are in the organisation.

There is no estimate for SSWHG, however based our conversations with you, the group is likely to have a low score in this and

means that data is less likely to be available and used to improve business performance.

Source: EY and SSWHG Analysis: EY

Median

10.0%

Median

14.0%

SSWHG

19.9%

Median

48.7%

Median

40%


IT Operation Model Framework - Overview

When looking at the current state, the existing ICT function in the group was evaluated against the framework below. The EY IT Operation Model Framework (Figure 7) goes beyond the “organisation structure” and considers what is needed using

different lenses (e.g. architecture, governance, and tools). Assessment against the framework provides a high level assessment of which dimensions are the most and least developed.


People

Capabilities

and

processes

Organisation

Org

anis

atio

n la

yer

Exec

utio

n la

yer

Res

ourc

e la

yer

► Establish a global framework for IT governance and

controls to support global governance and risk

management

► Physical locations of operations to optimise

performance

► Real estate and other facilities considerations

► The organising logic for business processes and IT

infrastructure

► Define the integration and standardisation

requirements of the firm’s operating model.

► Define the tools to enable IT activities

► Establish a global performance measurement

framework

► Deliver continuous improvement of IT service levels

► Structure the organisation to deliver value to the

business

► Define appropriate local, regional, global structures

including shared services and outsourcing

► Deliver IT services in a customer-centric manner, at the right service level and

price point

► Build an organisation of the right resources with the right skills in the

right locations

► Promote a global IT community

Fig. 7 EY IT Operating Model Framework

IT Operation Model Framework – SSWHG Assessment

Evaluation against the Framework

Each dimension of the IT Operation Model Framework was scored as per the table below (Figure 8). Overall the ICT function across the Group would

be seen as Under Developed when evaluated against the framework. The graph to the right outlines how each dimension is individually scored.


Level 5

Leading

Level 4

Advanced

Level 3

Comprehensive

Level 2

Emerging

Level 1

Underdeveloped

The organisation addresses this

challenge on an ad-hoc, or crisis

basis only; not a major area of

strength or investment

The organisation has a basic, or

fundamental, approach to

addressing the issues and concerns

in this area

The organisation has a formal plan

and/or approach to dealing with

the issues, problems and risks in

this challenge area

The organisation has a fairly

advanced, or sophisticated, level of

experience and expertise in dealing

with the issues and concerns in

this area

The organisation is a leader among

its peer group in this area, and

leverages leading practices to create

value, manage risks, and rationalise

costs

Graph: SSWHG ICT Maturity Assessment

Governance

Capabilities

& Processes

Performance

Measurement

OrganisationEnterprise

Architecture

People

Tools

5

1


EY ICT Maturity Framework

The Case for Change

Why Change ICT in SSWHG?

As has been mentioned earlier in this report, ICT in the group is not operating as effectively as it could. To date, the full

potential of the groups ICT function has not been realised. It could be said that ICT is viewed as a “necessary evil” by some

areas of the group. The risks linked with ICT are usually to the forefront of peoples minds when they think about ICT. In

contrast, the opportunities and the potential benefits ICT might help deliver are often secondary.

Opportunities

Renewed focus on and investment in ICT will offer the Group many opportunities to improve the services offered, including:

• Improved decision making through better business intelligence.

• Improved systems and applications to help clinicians deliver safer and higher quality patient care while improving

productivity.

Risks

The Current Systems Assessment identified a series of ICT related risks that are directly attributable to a lack of focus on and

investment in ICT across the group. It is important that these risks are addressed and provisions are put in place to ensure

similar issues do not arise again in the future.

• Staff Capacity and Capability - All hospitals, from both an ICT and Business perspective, have reported that ICT

staffing levels are not sufficient to support the Knowledge and Information requirements of their hospital.

• NIMIS - It is a National priority of the HSE that NIMIS is implemented in all hospitals. This System has been

implemented in UHW, STGH, UHK, SIVUH and KOP and is scheduled for CUH, MUH, MGH and BGH.

However, a number of significant issues have arisen with this proposal and these are the subject of discussions

between the relevant parties.

• Regional Lab Systems - All hospitals reported concerns around their regional Lab System.

• Business Continuity Plans – Hospitals report that not every system has an agreed and tested Business Continuity

Plan. Where they do exist there is variability in terms of completeness and level of testing.

• On Call Support for Critical Systems - System owners have reported that for many critical systems full support is

not available outside of normal office hours. Where Vendor support is available on a 24/7 hour basis matching

support is not always available on the HSE side.

• Regional Patient Numbering - The SSWHG has a common PAS across all its hospitals (iPM) and in all but four

hospitals there is a common regional identifier supporting safer and more efficient patient care.

• Hospital Billing Systems - Five hospitals (CUH, MGH, BGH, SIVUH and UHK) in the Group utilise the Keogh

Billing System. This System is currently unsupported as the Supplier is no longer in business.

• Structured Support and Service Level Agreements (SLA) - All hospitals have identified the need for a more

structured and formal approach to both infrastructure and applications support.

• Data Quality - Concern was raised about the level of data quality within the Group. Recent data migration exercises

revealed issues with data quality (e.g. patient duplicates).

Of course all change, be it ICT change or non-ICT change, gives rise to risk. As a result it is vital that robust risk

identification and risk management processes are in place and adhered to.


14

Legend: CUH MUH SIVUH UHW LOHK STG UHK BGH MGH All

Current Application Landscape Below is a high level overview of some of the core applications supporting the day to day operations across the group


Order Comms

Medicines Management

Corporate/Business Functions

Theatre Management

Patient Administration System (PAS) PACS/RIS – Radiology and Imaging Laboratory System

Cancer

Lantis iPM

Specialty Systems

ICU

Cardiology

Renal

Clinical Documents

iCM

G2

General Ledger Keogh UniPay QPulse

CA

ClinicScript

Maternity

Tech Services

iPM iPM

iPM

iPM

iPM

iPM

iPM iPM

iPM

Maternity

ClinicChemo

iPM JAC

Renal UniPay Keogh

Sage

Oracle

E-Financials

SQL Server

QPulse

Intelligo

Endoraad

Cliniscript iPM

Dawnac

Clinochemo

Agfa

Agfa

NIMIS

NIMIS

NIMIS

NIMIS NIMIS

Agfa

Agfa

ClincChemo

Cliniscript

Claimsure

Intelligo

Megapay

EIS

Crystal Reports

Diabetic

Audiology

INOR

iCM

iCM

iCM

DART Lab

Ordering

ClinicChemo

Dendrite EI Trax

Endoraad

Vascubase

Histology

Audiology (NOAH)

Diabetic (DRS)

General Ledger

Core Payroll & Travel

QPulse

Claimsure

QPulse

Helix

Claimsure

Aran (financial)

Audiology Infection Ctrl (iCNet)

Cardiology

Colposcopy (IRISOFT)

Telepath

NetAcquire

iLAB

iLAB

iLAB

iLAB

Apex

Apex

Apex

Apex

Blood Track

15

Integration underway

HIPE

Healthlink

Section 2

Future State

Introduction

A clear view of the future state for the group is critical for success. The previous section provided an assessment of the current

state and the following section has the plan for achieving the future state. This section is a discussion about and

recommendations for the future state.

New Role for ICT

The historic role of ICT and the operating approach needs to change to a more business focused approach with formalised

processes, governance and with a genuine partnership which changes the role the business has in ICT (no longer just the

customer).

This means the plan needs to consider the broader context of improving the quality, safety and effectiveness of health and

social care services. This necessarily means that the aim of this plan is not to undertake “ICT projects”. Examples of how this

role might change include:

• allowing for adequate Clinical, Business and Service input into building new systems and improving existing systems

• ensure ICT systems are designed to reduce duplicate entry and to make patient care more clinical and cost effective

• Information is collected, analysed, and utilised to support clinicians and the business make good decisions for

patients and the population

• ICT considers the needs of patients, all health professions and non-regulated staff

• Relationships, Information and resources are readily available to identify and drive innovation in clinical and business

practice

An ICT organisation in this context could then conform to the design principles in the following figure. These focus ICT on

becoming an enabler and a technical resource rather than a silo or gatekeeper.

Role of Third Parties and Partners

A critical opportunity for consideration is how the hospital group and ICT can leverage the skills, experience and resources

offered by primary (UCC) and other academic partners and CSR (Corporate Social Responsibility – eg. Google’s 20% time

for employees to work on their own projects with charities or public good organisations) partners to achieve these design

principles and the plan. They could be used across the board in the development of solutions (eg. Informatics, Health

Economics and information technology and application development).

Identifying and delivering opportunities

While the hospitals continue to be under pressure as a result of the changes in the past 6 years, digital solutions can be seen

as an enabler to improving productivity and helping the business to do more with less. However achieving this will necessitate

investment in the short-term in order to realise the benefits.

This requirement means that ICT processes, people and governance need to be able to respond to the business and clinical

needs and build trust in their new role in the coming years. This plan describes the key changes in how ICT can be re-

organised to respond to this.


ICT Design Principles

1. Patient care and safety at the heart of all solutions

2. Providing flexible access to a single version of the truth

3. Collaboration between hospitals, business, clinical and ICT to deliver solutions

with defined benefits

4. Technical leadership to support business and clinical owners of technology

solutions

Group Priorities

In developing the plan, a key component of the requirement was to understand not just how the ICT organisation must

change, but to identify some initiatives where this new way of working could be established and tested.

In visiting the hospitals in the group these three priorities were identified:

• Enterprise Information Management

• Human Resources and E-rostering

• Clinical Portal

Enterprise Information Management

This can be described as “Business Intelligence”, “Reporting”, “Analytics” or “Health Informatics”. Essentially the opportunity

is to collect data which is more complete and reliable, use this data to drive decisions and use gaps in our data to drive

decisions about what to change and what other data to collect.

The potential deliverables from this type of project include:

• Better quality information

• Agreed, standardised reporting

• Dashboards

• Analytical tools

• Working with primary (UCC) and other academic partners to develop staff and improve recruitment and retention

• Better decision making

Human Resources and e-Rostering

This request came up in every hospital we visited, from managing annual and sick leave, to keeping an up to date register of

employees, knowing who and what training staff had received and being able to plan staffing for a hospital were issues

identified. Given that in healthcare 70-80% of spending is usually associated with human resource, managing this effectively is

critical to fiscal responsibility.

Clinical Portal

From a clinical perspective there was a sense provided of the disparate, disconnected and duplicatory clinical applications. The

opportunity discussed and described by clinicians includes:

• Single sign on for all clinical systems

• Single patient search function

• Unified patient summary interface

• Single Clinical Data repository

• Single Order Comms for labs, referrals and radiology

Development Approach

In developing these initiatives there is an opportunity for ICT to act in it’s new role defining the business needs, supporting

them to understand the possible solutions and delivering a tool which lets the business improve the quality, safety and

efficiency of the care that they deliver.


Section 2.1

ICT operating model

Implementing a new ICT operating model for the group should be seen as an iterative process. It will take time to fully

implement. It is critical that this new operating model is a part of the entire organisation. Historically ICT have been the

owners for many systems that have been implemented, which leaves clinicians and the business unable to affect change and

with no ownership or commitment to maintaining or improving existing systems. This also leads to cynicism about the value

of improvements or new systems.

In the new model a partnership between ICT and the rest of the organisation will ensure that the systems which are

developed, implemented and operated are valuable to clinicians and the business, ICTs role will be as a technical partner

rather than owner of the systems, inputs or outputs.

An ICT Operating Model for the group will specify how ICT work gets prioritised, distributed and executed within the

group. More specifically the ICT Operating model should aspire to achieve the principles outlined in the table below. These

are critical to resolving the issue identified above.

ICT Operating Model


ICT Operating Model Enterprise Information Management Applications/Infrastructure

Vision and Strategy

Staff and Structure

• ICT should have initiatives that are aligned to the group and hospitals strategies and plans and deliver benefits that are of value to the organisation

• There should be regular assessment and review of new opportunities with the business and clinicians to ensure the best ideas are implemented quickly

• As described above there is a need for ICT to work in a more collaborative way with clinicians and the business, this will mean more cross-functional working and more ownership of the solutions from business and clinical leaders.

• Existing staff should also be engaged to undertake work which is more valuable to patients, clinicians and the business.

Process

Governance and Monitoring

• A standard way of undertaking work, engaging with stakeholders and managing systems and data will improve confidence in ICT and will allow ICT to assume it’s new role

• Keeping processes simple will allow the business and clinicians to engage and manage expectations while delivering the most important priorities.

• ICT should work with the organisation to build compelling cases for the use of technology but shouldn’t be responsible for owning or deciding on the solution.

• ICT should regularly report progress and priorities at a group executive level to ensure visibility and early and informed decision-making

Fig. 8 Components of an ICT Operating Model

The process below is an example of one of the processes mentioned on the previous page. It will allow the group to make, sponsor, and enforce ICT decisions. This process includes a built in governance and escalation/monitoring approach where monthly

meetings with the Hospital Group and HSE allow prioritisation issues and solutions to be discussed.

Opportunity Identification and Prioritisation Process


Captured using a group-

wide issues list

All issues/initiatives are discussed and ranked for priority

Solved within business as usual

break fix

30 min weekly meeting to review these

with clinicians

Added to planning list

Portfolio summary shows above the

line (can do) and below the line -

need additional resource to deliver

Not seen as a organisational priority

Monthly presentation to Hospital

Group

Monthly discussion with

HSE

ICT Issues

Business

Issues


Fig. 9 Opportunity Identification and Prioritisation Process

Governance Forums



Governance forum Responsibilities Suggested members

Monthly Prioritisation Meeting (Hospital Level)

• Identify new additions to the priority list based on prioritisation principles

• If required, update and reprioritise open issues and initiatives

• Identify issues that can be solved using established break/fix channel

• Identify issues/opportunities that may require a project to be initiated to

address

• Issues that require more than 4 weeks of staffing resource (or equivalent cash

cost) should be included for discussion.

• Hospital ICT Manager

• Hospital ICT teams

• Business and/or clinical

representation

Monthly Prioritisation Meeting (Group Level)

• Agree new additions to the priority list based on prioritisation principles

• If required, update and reprioritise open issues and initiatives

• Identify issues/opportunities that may require a project to be initiated to

address

• Identify issues/initiatives that need to be flagged to HSE

• SSWHG ICT Director

• Hospital ICT Managers

• Clinical and business

representation

• Programme Manager

Monthly discussion with OCIO/National Acute Hospitals

• Provide an update on issues and initiatives

• Identify issues for HSE management

• Flag resource requirements/constraints

• SSWHG ICT Director

• Relevant HSE representation

• Hospital ICT Managers

• Clinical Rep/CCIO

• HBS rep

• SSWHG Business Rep

Monthly presentation to Group Exec

• Provide an update on ICT projects (based on agreed prioritisation

principles) and initiatives

• Receive insight into new initiatives or changes in prioritisation

• Group ICT Director

• Clinical Rep/CCIO

• HBS rep

• SSWHG Executive

Clear governance structures are required to ensure the opportunity identification & prioritisation process is effective. The

table to the right details the forums required to make the process work. Additional meetings may not be required, it

should be possible to cover the necessary content at existing standing meetings.

To support the process a mechanism to help prioritise opportunities and initiatives is required. The mechanism should

take the emotion out of scoring and prioritising initiatives and it should ensure initiatives are not prioritised on a “who

shouts loudest” basis. The type of criteria that could be considered include:

• Strategic alignment

• Benefits

• Costs

• Impact on stakeholders

• Time sensitivity

• Political sensitivity

These can then be mapped against a matrix or consolidated into a score or weighted score and reported regularly as

shown in Figure 10.

Sample prioritisation matrix:

Ease of implementation

Hig

h Lo

w

High Low

Project 1 Project 2

Project 3 Project 4

Stra

tegi

c va

lue

Fig. 10

Project and Portfolio Management Process



It is critical that once projects are prioritised and up and running that they are effectively monitored and tracked. A dashboard to track the portfolio of inflight projects across the group would be of benefit. The effectiveness of any such dashboard will be

driven by quality and timely information coming from the project teams. There is a real need to ensure projects get planned and estimated correctly and the resource requirements (business/clinical/ICT) are understood up front. At the end of projects,

formal lessons learned exercises should be conducted and the outputs should be documented.

Project activity

documented and reported

on a fortnightly basis

PIDs are completed to provide a

summary description of the

project

Business case and project plan completed

when cash investment or more than 4

person weeks of effort is involved.

Project approved at

Hospital

Project approved at

Group

Project reviewed at

Group

Project complete

Business Cases needs to consider:

• Business resources required

• On-going management costs and resources

• Whether this is a group project

• What are the benefits

• Consider technical feasibility

• Risk identification and mitigation (checklist against lessons learnt)

1 2

3

4

5

Project Initiation Document needs to consider:

• Vision

• Scope

• Key Stakeholders

• Roles and Responsibilities

• Risks

• Value Proposition

Regular Project Reporting should cover:

• Overall status

• Key risks and issues

• Progress against milestones

• Key activities completed

• Key upcoming activities

• Progress against budget

Fig. 11 Project and Portfolio Management Process

Depending on size further

approvals may be required eg.

HSE, DoH or DEPR

Business Cases Helping to make the right investments

What is a Business Case?

A business case captures the reasoning for initiating a project or task. It is often presented in a well-structured written

document, but may also sometimes come in the form of a short verbal argument or presentation. The logic of the business

case is that, whenever resources such as money or effort are consumed, they should be in support of a specific business need.

A compelling business case adequately captures both the quantifiable and non-quantifiable characteristics of a proposed project.

Business cases can range from comprehensive and highly structured, as required by formal project management methodologies,

to informal and brief. It is important SSWHG settles on a level of detail that is adequate for all stakeholders who will be

required to sign up to and approve a business case. It is worth considering that as the risk and cost associated with a project

increases, the more detail and approval will be required (the Public Spending Code provides guidance on these requirements).

The information in a formal business case could include:

• The background of the project

• The expected business benefits

• The options considered (with reasons for rejecting or carrying forward each option)

• A feasibility study – Considering other ongoing initiatives in the organisation an honest assessment should be made

about how likely the project is to be successful. Attention should be given to the lessons learned from previous

similar projects

• An assessment of the expected costs, resources required and timelines of the project

• A gap analysis and the expected risks

Consideration should also be given to the option of doing nothing including the costs and risks of inactivity. From this

information, the justification for the project is derived.

Business Cases that aren’t approved

Not all business cases should be approved. If the idea is good, the benefits outweigh the costs and risks and the project is

aligned to the organisations strategic direction and there is capacity to deliver it the business case should proceed. However

even this doesn’t guarantee the organisation should proceed. There will always be more ideas than capacity, so the ability to

weigh the merits and say no to some ideas is as valuable as the ones which are approved.

Business, Clinical and ICT Collaboration

The business case for a project or initiative should not be created in isolation by business, clinical or ICT resources. It is

important it is a collaborative effort and all parties input into the process as required.

Lessons Learned

It is important that lessons from previous projects are considered during the compilation of the business case. If a lesson is

relevant to the initiative that is being evaluated an assessment should be made as to what provisions will be put in place

during the project to reduce the risk of the same issue happening again. The table (Figure 12) below details an example of

what this might look like.



Lesson Description What will be different this time

Choosing an ICT solution

The ICT solution selected should be appropriate to the needs being addressed and its requirements fully factored into the implementation plan.

► Business/clinical resources will have a greater involvement in the selection of the solution.

► A full suite of business requirements will be captured and signed off before selecting the new system.

Fig. 12 – Example Lesson and mitigation to be included in business case

ICT Organisation Core processes linked to capability areas

Core Processes for Development

The table to the right outlines the core ICT processes that are required to identify, define, modify, and enforce the activities

that will enable the effective and efficient delivery of ICT services for SSWHG. Ultimately helping to ensure the ICT function

supports in the provision of quality patient care. Likely process owners are also identified in the table.

The core processes should be mapped and owners assigned to ensure that there is no ambiguity with ownership. A well

constructed process map is a powerful tool that can contribute towards key business, clinical, strategic and operational benefits

such as:

• Reduced operating costs

• Increased quality

• Increased productivity

• Improved patient care

• Work simplification

In addition, process maps can help:

• Establish a baseline in order to validate improvement and justify change or expenditure

• Protect SSWHG from the risk of losing knowledge capital by capturing and documenting critical current-state

processes

• Prepare SSWHG to make the transition into system requirements analysis because they describe how functions

would interact with a system to complete an activity step



Processes Description/purpose of process Process Owner

Patient Care and Safety

Management

• End to end service delivery processes tailored to the patient pathway • SSWHG leadership team

Enterprise Architecture

Planning and Governance

• Define and maintain the overall Enterprise Architecture and

governance framework for ICT across the Group

• ICT Director

• Enterprise Architect

Information Management • End to end data flow for consistent information across the Hospital

Group

• Business Intelligence and analytics


• Clinical/Business Analyst

Clinical and Business Demand

Management

• Consistently Identify and capture ICT demand from Clinicians and

Business stakeholders

• CMIO

• Clinical/Business Analyst

Supplier Management • Consistent governance process for suppliers to ensure SSWHG

maximises value from all suppliers

• ICT Director

• Service Management and Operations

Lead

Service Management (Including

Security, Risk Management)

• Ongoing focus on ICT optimal service levels, while ensuring adequate

business continuity measures are in place

• Application portfolio management (including licensing and contracts)

• Service Management and Operations

Lead

Innovation Management • A clear and concise approach to capture and encourage innovation

across the Group

• ICT Director


Project and Programme

Management (including

prioritisation)

• End to end management of a programme or project through

initiation, planning, execution, control, and close

• Programme or project prioritisation to deliver committed portfolio of

programmes or projects within agreed timelines


Change Management • Ensure that all ICT changes are controlled, and implemented with

minimum disruption to patient care and safety


Knowledge Management • Consistent ICT knowledge management framework

• Staff capability development using the ‘70/20/10’ learning and

development model


• HR

Starting with the simple processes described on the previous pages along with the

governance roles described will begin to cement the new ICT role in the organisation

and build trust in the change. This is likely to require additional resource to deliver

Recommendation

ICT Organisation Virtual teams – core activities by skill set

Virtual teams linked to capability areas

SSWHG need to consider focusing In-house ICT functions on core capabilities and high-vale skills. Creating virtual teams will

help build capability in these areas and increase knowledge sharing across the group.

The group should look to build up capability in the six areas in figure 13. A number of virtual teams should be created to

cover off each of area. A virtual team for each area may not be required. Each virtual team should have an assigned lead and

all members of the ICT function should belong to one or more teams. Considering the capacity issues across the groups ICT

function it may be prudent to initially set up an Enterprise Information Management virtual team as EIM capability already

exists across the group.

What is a virtual team?

A virtual team is a team that operates across time, space, organisational boundaries and has its links strengthened by the use

of communication technology.

A virtual team is not a project team it is a permanent structure and as such it will identify opportunities to be undertaken and

provide organisation knowledge and expertise in the identified domain. It will also have responsibility for defining the

approach, processes, procedures and technical documentation within the domain.

What would success look like?

The teams are engaged in interdependent tasks – i.e., are truly teams and not just groups of independent workers.

26



Enterprise Architecture

Strategy/Planning

Chief Clinical

Information Officer Programme Management PMO, Planning, and Administration

Service Management & Operations

• Clinical and Business pipeline

identification

• Clinical ICT Requirements

management

• Clinical and Business impact

management

• Stakeholder relationship

management (Clinicians)

• Data governance

• Project delivery and change

management

• Application Portfolio management

• ICT process development and

management

• Supplier/vendor relationship

management

• Day to day service operations and

support (incl. hardware)

• Performance management (internal

& external)

• Service and Operational Level

Agreements (including contracts &

licenses)

• Security, Quality control, and

business continuity

• Bio-technical Services

Clinical/Business Analysis

• ICT Project feasibility assessment,

scoping, and rationale

• Clinical/Business requirement

documentation

• Requirements analysis and

refinement

• High level functional design

• Business Intelligence

• Support CIO with development and

maintenance of ICT Plan

• Business & Information Architecture

• Application Architecture

• ICT roadmap, principles, standards,

and policies

• Reporting on progress for

management insights and decision-

making

• Overall administration of all

documentation & maintenance of

project management tools

Fig. 13 – ICT functions that could become virtual teams

Virtual Teams Start with Enterprise Information Management

Given that current ICT resources are operating at capacity, it is prudent to start by creating a virtual team for Business

Intelligence (Figure 14). This will embed the “virtual” way of working across the group. Assuming this model is successful,

additional virtual teams can then be put in place. By nature these virtual teams will also include people from the business and

so could be thought of in the case of Business Intelligence by including finance, operations, administrative and clinical people

who would use or produce business intelligence or develop reporting, or develop standardised benchmarking or tools for

accessing information.

Staff Capability and Development

The establishment of virtual teams is the first step to identifying the staff skills and experience required in the organisation.

In completing a PID and business case for establishing the first virtual team there is an ability to set out what is required to

achieve the aims in the business case. A business case is useful in this instance to ensure expectations are explicit and to build

trust. There is unlikely to be significant investment required.

Staff could then self-identify as interested in response to organisational communications or through identification due to a

current role or existing participation in related fields. It is important that participation is largely open to encourage business

participation and for building trust.

This group could then work to undertake an online skills assessment would let the organisation assess the current and required

skills and any skills gap. Training options can be identified from this and is linked to the role that primary (UCC) and other

academic partners and CSR partners can play. There may be an ability to exchange internship or experiential learning roles for

students for places on programmes. There may also be mentorship available from CSR partners to support development of

skills.

The next step would be to identify projects, policies and processes, approaches and technology to delivering EIM within the

group. If this is successful there may be a need to change some peoples roles. In this instance any change will follow due

process with employees, their representatives and Human Resources.


UHK SIVUH CUH, BGH

& MGH

UHW,

LOHK &

STGH

MUH

Business Intelligence

1. Identify lead and cross-functional team

from hospitals including non-ICT staff

and how the costs are apportioned between

members

2. Consider role of UCC, Health Innovation

Hub (IHI) and primary (UCC) and other

academic partners

3. Develop PID

2016 2017

UHK SIVUH CUH, BGH

& MGH

UHW,

LOHK &

STGH

MUH

Next virtual team

1. Identify lead and cross-functional team from

hospitals including non-ICT staff and how

the costs are apportioned between members

2. Consider role of UCC, Health Innovation

Hub (IHI) and primary (UCC) and other

academic partners

3. Develop PID


Fig. 14 Establishment of Virtual Teams

Starting with a single virtual team will reduce staff anxiety and stress by identifying those who are

interested, manage risk and provide a proof of concept for internal and external stakeholders without

significant investment. This will then provide a basis for staff development opportunities in the future.

Recommendation

The diagram below (Figure 15) shows how the virtual teams should be aligned across the group. The required reporting structures are also shown. Achieving the structure below may take a number of years and extra resources will be required.

Alignment of Virtual Teams End state



HSE - CIO

SSWHG eHealth Director Hospital CEOs*

HSE DG

Virtual Teams

Includes a lead and self-identified alignment from ICT

and organisation

SSWHG CEO

HSE Director Acute Hospitals

* Voluntary Hospitals accountable via SLA

UHK SIVUH CUH, BGH

and MGH

UHW, LOHK

and STGH

MUH

Enterprise Architecture Strategy/Planning

Chief Clinical Information Officer

Programme Management

PMO, Planning, and Administration

Service Management & Operations

Clinical/Business Analysis

Management Direct Report

Provides professional or

technical support & leadership

The Group ICT Lead should collaborate with the

hospitals to

provide leadership and ownership of the Virtual

Team structure

For discussion

Recommendation

Fig. 15 – Proposed SSWHG ICT Structure

Section 2.2


EIM is an integrated discipline for structuring, describing and governing information assets across organisational and technological boundaries to improve efficiency, promoting transparency and enabling business insight.

The following principles should be used to shape the EIM initiative:

1. Consider the required information from a patient pathway perspective. This ensures all information relevant to patient outcomes and service delivery is collected. This provides a concrete understanding of volume, flow and outcomes, while minimising

non-useful information collection.

2. Providing information in a tailored manner for users within and outside the Hospital Group (enabling an ‘activity-based' view of quality and cost), while enforcing data governance policies and standards to ensure quality, accuracy and security of the

data.

The figure below shows how the information from a patient pathway is linked together, linked to key stakeholders and performance.

Introduction



Unique Patient Identifier

Patients National Bodies & Regulators (eg. HSE,

HIQA) Administrative staff Social Care Clinical Staff Third Parties (Researchers)

Primary Care Diagnosis After Care Referral Treatment End of Life Care

► Detection ► Prevention ► Referral to treat ► Primary management

► Elective Care ► Emergency Care ► Medical Assessment unit ► Women and Children

► Radiology ► Pathology ► Cardiac care ► Cancer

► Care plans ► Surgery ► Complex Long term conditions

► Discharge plans ► Rehab

► Palliative care

KPIs

The objective of any EIM initiative should be to provide better business intelligence to enable better decision making

Fig. 16 – Conceptual framework for EIM

SSWHG needs quality data, not only at the point of service delivery but also to support effective decision making. Feedback from many stakeholders highlighted issues with

consistency in reporting, access to data and tools for reporting and the quality of data as issues.

The diagram below (Figure 17) shows how this hierarchy of intelligence is developed, with supporting technology providing a standard set of methodologies. Upon these

relationships conversations can be built to explore information. This exploration of data will drive a willingness to improve the quality of data. With regular conversations about high

quality data coming from sources that are captured and reported in a consistent and immediate way decisions that can improve the quality and safety of care along with productivity

can be made and implemented more quickly.

Clinical/Business Insights (Improved Outcomes)



Quality data

Changes in business processes need to be reflected in reporting

through the use of Master Data Management.

This means ongoing conversations about how changes in the business

are reflected in reporting. The ability to document these changes and

reflect them in reporting builds confidence in the reporting, and

reporting remains current and coherent through changes in service

delivery.

Relationships

Regular conversations occur between ICT, clinicians and the business

to identify issues with service delivery and clinical practice and how

these result in information inaccuracies. These issues are logged to

ensure that they will be actioned or become part of the ICT planning

process.

This process ensures that clinicians can see issues that they identify

are being rectified and reduces the need to develop additional or

alternative data collection processes.

Measurement culture

The ability to measure progress on patient outcomes and safety

becomes an expected part of Business as Usual.

All initiatives have key deliverables and measures to assess success.

Standard reporting methodologies

Standard approaches to reporting and validating information mean that conversations between parts of the business are underpinned by an agreed understanding of the problem and performance being discussed.

Supporting technology

Easy to use, fast and reliable infrastructure supports real time reporting, with easy to update changes to Master Data within the data warehouse.

SSWHG should include people within the EIM workstream who

understand business and clinical processes and can implement

change in service delivery

Recommendation

Fig. 17 – Proposed approach to development of EIM

Data Quality and Master Data Management

Safe and reliable healthcare depends heavily on the access to and use of quality data. This is not only important for quality

clinical care, but also for continuing care, research, activity-based financing and strategic planning. This can be assessed in the

following dimensions.

Master Data Management is the process by which the meaning of data collected is captured and managed by the organisation.

This critical role allows continuity in reporting when changes have been made to systems. This also enables standardised

reporting methodologies.

The first activity to be undertaken is to identify the configurable options within systems along with what the current choices

are. This will then provide an ability to track changes over time.

An example of Master Data Management (Figure 19) in a hospital context is hospital beds and occupancy. Documenting the

number of and name of wards, the number of physical bed spaces in the ward, the number of beds open (equipped) and the

number of resourced (ie. with nurses available to care for a patient in that space) are all different measures which can be

reported differently depending on who asks the question and why. The table below shows how this would be captured.



Data

Quality

Accurate

How closely the data correctly captures

what it was designed to capture.

Valid

Data is collected in accordance with

any rules or definitions applicable for

that type of information.

Timely

Data is collected within a reasonable

time period after the activity that it

measures and is available when it is

required and as often as it is required.

Reliable

Data that is collected consistently over

time and reflects the true facts.

Relevant

Data that meets the needs of the

information users.

Legible

Data that the intended users will find

easy to read and understand.

Complete

Data that has all those items required

to measure the intended activity or

event.

SSWHG in development of the EIM initiative should develop some KPIs which reflect these

components of data quality.

Recommendation

CodeUID CategoryCode Ward BedNumber

0001 WARDBED ICU 1

CodeUID UpdateUID PreviousStatus Date Comment

0001 0001 Closed 1/3/2016 16:00 MRSA cleaning

0001 0001 Open 1/2/2016 16:00 ICU opened

SSWHG in development of the EIM initiative should establish a MDM repository and policies

and processes for control and change of these variables

Recommendation Fig. 18 – Elements of Data Quality

Fig. 19 – Master Data Management example

Data Protection

As part of any EIM initiative SSWHG need to develop and implement clear and consistent data policies and procedures on

data quality for staff that are based on legislation and standards set out by governing bodies. This can be achieved with

adherence to the HSE’s ‘Information Classification & Handling Policy’.

This will become more important as more information is available electronically and is able to be shared, there are a number

of elements to effective data protection, some of them reactionary and some pro-active. These include:

• Proactive audit

• Investigation

• Controls over Access

• Policy for Access to information

In meetings with hospitals there were discussions about a lack of audit and a lack of adherence to policy in this space which

were seen to be due to accessibility of systems.



Information

classification Description Examples

Public Information that is available to the general public and is intended for distribution outside SSWHG Health Care Group

► Patient/Client brochures ► Staff Brochures ► News or media releases ► Pamphlets ► Advertisements ► Web content ► Job postings ► Public Health Information

Internal Information that is intended for internal distribution among SSWHG staff, contractors, agency staff, and authorised 3rd parties

► Internal telephone directory ► Internal policies & procedures (excluding those published on

the web) ► User manuals ► Training manuals and documentation ► Staff newsletters & magazines ► Inter-office memorandums (depending on the content) ► Business continuity plans

Confidential Information which is protected by national and international legislation or regulations

► Patient/client/staff personal information ► Patient /client/staff medical records ► Unpublished medical research ► Financial information/budgetary reports ► Service plans/service performance monitoring

Restricted Highly sensitive confidential information that would seriously and adversely impact SSWHG, the HSE, patients, staff, and any business partners

► Patient/client/staff sensitive personal information (i.e., mental health status, HIV status, STD/STI status etc.)

► Childcare/adoption information ► Social work information ► Disability services information ► Unpublished financial reports

SSWHG should consider how changes to applications and reporting environments can

improve access to and control of data to ensure compliance with data protection policy

Recommendation

Potential Application - Patient Flow



Hospital

Social Care

Primary Care

Current System View

Future System View

T0

The screenshot to the right shows a tool EY uses to analyse patient flow in an emergency department using information from multiple sources Benefits of this include:

• Visualisation of the patient space and flow in a schematic manner

• Ability to run different simulations with changed flow assumptions

• Continuity and temporality of records leads to understanding in a whole system cause and effect

• Also helps to remove and reduce bottle necks in patient flow.

The diagram below shows how activity within an Emergency Department might be modelled using multiple currently unconnected datasets. Accurate and easy to access business intelligence will help to facilitate better decision making, planning and forecasting. This solution can also lead to improvements in patient outcomes through reducing bottlenecks and waiting times. The realisation of any such solution will rely on accurate and timely data.

Fig. 20 - EY adapted version of Simul8

Section 2.3

Applications/ Infrastructure

Introduction The existing landscape is a result of ICT capabilities that support individual hospital operations. The target landscape will

allow SSWHG to build new features, store additional patient data, interface to other applications and locations while still

maintaining a cohesive architecture that supports continued growth (Figure 21).

To realise the target state it is vital the correct application and infrastructure decisions are made. From the current state

assessment there are a number of areas where collaboration is planned and could provide a consolidated platform with more

features.

Key areas for development and consolidation include:

• Consolidation coherence of iPMS instances

• Implementation of National Maternity System

• National Lab system implementation – MedLIS

• National Chemotherapy system

• SAP Finance System

• SAP HR System and e-rostering tool

Gaps in consolidation:

• Radiology (split between NIMIS and Agfa)

• Order Comms

• Clinical Documentation



• Consistent platforms and interfaces for end to end delivery of patient care

• More accurate data and readily available information due to automation

• Operational efficiency leading to reduced cost and overheads as a result of automation and consistent

approach for core processes

• Simplification of Data Structure

• Simplification of Application landscape

• End to end visibility of Core patient data

• Improved governance due to clear visibility and ownership of core applications

• Managing new requirements in the proposed landscape will become a straightforward integration in a fully

consolidated environment

• Improved branding due to consistent look and feel of core applications

• Faster development turnaround time for future innovative solutions

Standardised systems and tools across all hospitals to automate processes and enhance visibility and usability

of core information supporting patient care and safety.

Targeted Consolidation of Application Architecture

Development of a Clinical Portal

Development of a Hospital Group HR and e-Rostering tool

Fig. 21 – Framework for developing a standardised application landscape

In developing an ICT operating environment for the future there is a need to think about how the application and infrastructure will work together most effectively. Realistically in a healthcare environment there will always be multiple applications for

managing patient care and other functions. In order to maximise the benefits of technology there is a need to develop interfaces between systems, while reducing the complexity of these interfaces to avoid cascade type consequences from development (Figure

22). The following principles should be followed when considering the implementation of new applications or infrastructure.

1. Where appropriate, the focus should be on consolidating and standardising on existing systems before looking to implement new ones

2. A systems architecture that supports a patient care pathway will help enable the concept of 'Activity-based Costing‘. This ensures all applications are relevant to patient outcomes and service delivery and will provide a concrete understanding of

volume, flow and outcomes, improving productivity and outcomes.

3. Development of a consistent provider and professional identifier linked to all systems will reduce duplication and manual workarounds for systems.

4. Assessing the productivity benefits of improvements will allow increased demand to be managed without increased staffing.

5. Consider the domino effect in changes to systems. Generally changes to the infrastructure and the PAS have the largest flow through effects and should be approached with caution and be delivered ahead of new functionality further down the

cascade.

Principles that Underpin Applications/Infrastructure



System

infrastructure

Core

applications

Shared identity – patients, providers, professionals

Security – Authentication and single sign on, privacy and consent, auditing

PAS

(Enterprise Master Patient Index, appointments, waiting list, billing,

Inpatient/Outpatient activities management and reporting)

Additional/Optional Systems supporting collaborative care

Labs PACs EPR/Order

Comms Theatres and ITU

Clinical

Documents Cancer

eReferrals

HR,

pay

roll

and

Fina

nce

Clin

ical/B

usin

ess In

telli

genc

e Medication

Management

Hardware, software, connectivity, database, and support services

HIPE

Fig. 22 – Conceptual Application Framework

Integration Engine

Potential Application - Shared Care Planning


ICT Operating Model

Goals Activities Outcomes

Web-based tools are under development that work for sub-sets of the population with long term conditions (diabetes, heart failure etc.). Similar to the ED modelling tool mentioned previously, tools to help with shared care planning will rely on accurate and timely data.

• These patients benefit from coordinated care between hospitals and the community.

• The tool allows a patient and any clinician to develop goals, care plans, with identified tasks and owners which are then pushed to hospital and primary care systems.

• This means all the required providers can work together, see each other’s work with the patient and reduce duplication.

Primary Care

Hospitals

Fig. 23 – example CCM care planning tool

Enterprise Information Management Applications/Infrastructure

Section 3

Three Year ICT Plan

Introduction

Three year ICT plan

An ICT plan in this context will help SSWHG to identify which ICT projects will allow the business part of the organisation

attain strategic objectives. It will also enable ICT to forecast the technology requirements needed to meet those goals.

Planning considerations

To create a group level plan a number of different perspectives needed to be considered and understood (Figure 24):

• National initiatives – The series of national projects that are scheduled to be rolled out within the group over the

three year period

• Hospital priorities – The pain points and priorities that each hospital in the group has. Consideration also needed to

be given to what projects are inflight across the group

• Emerging health and ICT trends – Emerging ICT trends in the health space (e.g. Business Intelligence and

informatics)

• Capability and capacity – The resources (ICT & Service/Clinical) available to work on initiatives over the three year

period. The skill sets and capability of the resource pool also needed to be considered.

Planning Context

This plan is by nature directional. This means further work is required to develop many of these initiatives. This should be

undertaken through a process of defining the project or programme (e.g. PID), then development of a benefit and cost

assessment (e.g. Business Case) before the plan can be delivered.

There is also a need to consider this plan in the broader context of improving the quality, safety and effectiveness of health

and social care services. This necessarily means that the projects in this plan are not necessarily “ICT projects”. This means

that while the hospitals continue to be under pressure as a result of the changes in the past 6 years, digital solutions can be

seen as an enabler to improving productivity and helping the business to do more with less. However achieving this will

necessitate investment in the short-term in order to realise the benefits.

In order to achieve these benefits, the historic role of ICT and the operating approach needs to change to a more business

focused approach with formalised processes, governance and with a genuine partnership which changes the role the

business has in ICT (no longer just the customer). Another approach the group needs to consider is how they will leverage

the skills, experience and resources offered by primary (UCC) and other academic partners and CSR partners. They could

be used across the board in the development of solutions (eg. Informatics, Health Economics and information technology

and application development).


SSWHG

ICT

Plan

National

Initiatives

Capability and

capacity

Em

ergi

ng h

ealth

and

ICT

tren

ds

Hospital priorities

Fig. 24 – ICT Plan Inputs

40

Indicative scale

High: 10 people Local priorities

Medium: 5 people National priorities

Low: 1 person Group priorities

Future ICT Priorities Indicative timings and sizings


Business

Clinical

Resource

Local

ICT Resource Projects

2016 2017 2018 2019

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

H M HR System and E-Rostering

H M Enterprise Information Management

H M Clinical Portal

H M MedLIS (Medical Laboratory Information System)

M M MN-CMS (Maternal and New-born Clinical Management System)

M M eReferrals (Hospital PAS integration/workflow)

H M IHI (Individual Health Identifier)

M L EBTS (Electronic Blood Tracking System)

L L INOR (Irish National Orthopaedic Register)

L L IPMS PAS (Extension of SSWHG instance to include Kerry)

L L ERS (Endoscopy Reporting System)

L L SATIS (Standardised Assessment Tool Information System)

L L RIMD and Endoscopes Track and Trace

M M MOCIS (Medical Oncology Clinical Information System)

M L ePharmacy

M L SAP Finance (HBS)

M M Replacement Billing system

M L Lab migration MUH

M L Activity Based Funding

L L Sharing radiology images between hospitals

M M Ophthalmology specialty system

L M ICT infrastructure (steady state)

L H Help-Desk/Break Fix

Resourcing Forecasts

Indicative ICT resources required by category

The graph above indicates that some additional ICT resources may be required to support the successful implementation of

the scheduled national ICT projects through to the end of 2017.

If Business Cases are approved for additional group-wide ICT projects, then further ICT resources would be required.

Indicative Service/Clinical resources required by category

The graph above indicates that considerable Service/Clinical input is required, with significantly more resources required than

ICT.

The CCIO role and other identified project roles within the Hospital Group fit naturally within this as do identifying and

formalising 'shadow ICT' roles which are normally associated with Business Intelligence.


Assumptions:

1. Resourcing forecasts above are indicative only and for high level decision making purposes only.

2. Assumes national ICT initiatives will continue to be supported by central HSE ICT teams.

Ongoing ICT Governance

Ongoing Portfolio planning & Prioritisation

Ongoing Processes and Systems Training and Delivery

SSWHG ICT Roadmap


2016 2017 2018 2019

Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2

Short Term Medium Term

► Key ICT roles filled and first virtual team created

► Full ICT governance structure in place

► Governance-related processes in progress

► Draft prioritised portfolio of applications for development and implementation

► Business cases/ feasibility studies created and approved/rejected for EHR Portal/HR

and E-Rostering, EIM projects

► All Core Process designed and implemented

► Portal, EIM E-Rostering projects underway (dependant on business case approval)

► BCPs in place for some critical systems

► All BAU/Ongoing projects completed (or de-prioritised)

► Enterprise Information Management initiative underway

► Work underway to identify the next tranche of opportunities to be assessed

ICT Operating Model and Governance


BAU and National Support

Applications/ Infrastructure

Key milestones ► Projects under way – pending business case approval

► Operating model fully embedded

► Better able to develop and deploy further large scale projects using the new ICT Operating model

► Next tranche of applications for development underway

► BAU state (including training and adherence to core processes)

Application/Infrastructure Workstream

Portfolio planning & Prioritisation

Programme Management, Change Management and Benefits Tracking

Data/Information Workstream

Operating Model Workstream

Virtual Team established

HR & E-Rostering

Rqmts, Design and Build Test Deploy

Clinical Portal

Rqmts, Design, & Build Deploy BAU Transition

Establish Core Processes

Test


BAU Transition Deploy Test Analysis, design & build

Business Case decision

point

Local Project and infrastructure Development

Continued delivery of Business as Usual Services

Rqmts, Design & Build Test BAU Transition 1. Core HR Staff Management Modules

2. E-Rostering and Payroll link

Bridging Resource – National Project Support

2 1 3

Governance, Portfolio and Project Development

Bridging Resource - Governance, Portfolio and Project Development

1 3 2

Long Term

Deploy

Business case*

Business case

Business case

The activities identified have been described in the following roadmap. Further detail about these activities are described in Appendix C.

* Underway with HBS

Key Risks The table below details the key risks to successfully implementing the plan.

44

# Risk Mitigation Likelihood Impact

1 Buy-in is not achieved within the group or

further afield Strong executive sponsorship is required L H

2 ICT in the group continues to lack

coordination and direction.

ICT should be given the required representation ‘at

the top table’ within the group M H

3

A lack of trust and collaboration amongst the

hospitals in the group impacts the

implementation of the ICT plan and operating

model

Group and hospital management need to agree a

way of sharing costs and benefits with written and

agreed commitments

L H

4 Implementation of the initiatives in the plan

lose direction and ultimately fail

Clearly defined change and portfolio management

processes are required to support key initiatives M M

5

Initiatives are not adequately resourced and

business/clinical resource requirements are not

identified upfront

Initiatives need to be adequately resourced with

both ICT and clinical/business resources. Capability

in addition to capacity also needs to be considered

L M

6 Initiatives that are implemented do not deliver

benefit to the group

It is essential that robust business cases and

feasibility studies are completed for all potential new

initiatives

L M

45

The development of a plan is the beginning of the process. Significant differences can be made to progress the plan in the short term with a small amount of investment and commitment from the hospitals and group to implement the following steps.

Short Term (0-6 months)

• Validate and sign off SSWHG ICT plan and operating model with key stakeholders (both locally and

nationally)

• Appoint the group ICT Lead to ensure momentum is not lost and to maintain focus

• Explore role of primary (UCC) and other academic partners and CSR partners

• Begin to put operating model and governance structures in place (i.e. clinical and business roles with in ICT,

opportunity identification & prioritisation process with a prioritisation tool and ongoing portfolio and

programme management)

• Complete HR Business Case (already underway with HBS)

• Build out robust business cases for initiatives that have been prioritised (e.g., EHR Portal, e-Rostering, EIM)

Medium Term (6-12 months)

• If BC successful begin implementation of HR project

• Depending on success of business case establish project to implement new ICT virtual team for Health

Analytics/EIM. Ensure the team has both Business/Clinical and ICT representation

• Begin to map and agree remaining ICT related processes across the group

Long Term (12 months+)

• Build out other virtual teams if model is successful

• Embed processes across the organisation

Next Steps

Appendices

Appendix A: Project Organisation and Membership

Name Roles Position

Sponsorship

Mr G O Dwyer Co-Sponsor Group CEO

Mr Richard Corbridge Co-Sponsor Chief Information Officer

Project board

Mr Gerard O Callaghan Chairman Group COO

Mr Seamus Butler Member ICT Delivery Director, Acute Hospitals, OCIO

Mr Tony McNamara Member CEO, CUH

Mr Richard Dooley Member CEO, UHW

Mr TJ O Connor Member GM, TGH

Ms Sandra Daly Member CEO, MUH

Ms Mary Burke Member A/GM, STGH

Ms Helen Donovan Member CEO, SIVUH

Ms Jackie Daly Member Hospital Manager, BGH

Ms Michelle Roche Member Hospital Manager, MGH

Mr Mike O Regan Member Information Services Manager, CUH

Mr Gerard O Riordan Member Project Lead, OCIO

Project team

Mr Jason Kenny Member CUH, COO

Ms Breda Kavanagh Member UHW, COO

Ms Maria Godley Member UHK, Operations Manager

Mr Maurice Spillane Member MUH, Chief Financial Officer

Ms Maura Grogan Member STGH, Haemovigilance Co-ordinator

Mr Mike O Regan Member CUH, Information Services Manager

Mr Peter Roche Member UHW, Information Services Manager

Mr Pat O Driscoll Member UHK, IT Manager, HSE South Kerry, OCIO

Mr Peter O Callaghan Member MUH, ICT Manager

Mr Ronan O Connell Member SIVUH, IT & Management Services Manager

Mr Gerard O Riordan Member Project Lead, OCIO

Carmel Murphy Group Admin SSWHG SSWHG | ICT plan and operating model 47

The following is a list of the SSWHG stakeholders who contributed to the review. There is also a general acknowledgement to all the staff in all Group Hospitals, from all disciplines for their participation in information gathering meetings and to the Group

leadership for their active engagement. To also be acknowledged is the input from the OCIO, in particular the CIO and the head of Acute Delivery as well as providing project resources for the exercise.

Theatre Mgt.

Appendix B - Opportunity Prioritisation


Busin

ess/

Clin

ical B

enef

it

Ease of implementation High

EHR

HR & E-Rostering

BMS

ICT Training

Clinical Audit

Messaging

ICT Infrastructure

Single Sign on

EIM

Digital Dictation Clinical Documents

Order Comms e-referrals

Portal EHR

48

Appendix B - Priorities and Indicative Sizings


Rank Projects

Business Clinical

Resource

Local

ICT Resource Comment

1 Portal H M

2 Enterprise Information Management H M

3 HR System and E-Rostering M M

4 IPMS PAS (Extension of SSWHG instance to include Kerry) L L

5 MN-CMS (Maternal and New-born Clinical Management System) M M

6 MedLIS (Medical Laboratory Information System) M M Contracts have been signed in relation to this.

7 Replacement Billing system M M

8 Lab migration MUH M L

9 Sharing radiology images between hospitals L L

10 eReferrals (Hospital PAS integration/workflow) M M

11 IHI (Individual Health Identifier) H M

12 EBTS (Electronic Blood Tracking System) M L

13 ERS (Endoscopy Reporting System) L L

14 SATIS (Standardised Assessment Tool Information System) L L

15 Activity Based Funding M L

16 MOCIS (Medical Oncology Clinical Information System) M M

17 ePharmacy M L

18 SAP Finance (HBS) M L

19 INOR (Irish National Orthopaedic Register) L L

19 RIMD and Endoscopes Track and Trace L L

20 Ophthalmology specialty system M M

Appendix C: Roadmap Activities Detail


Area Implementation activity Activity description Dependencies Opportunities to consider

ICT Operating Model Key ICT roles and virtual teams

► Appoint SSWHG ICT Director (with a seat on the Leadership table)

► Agree alignment and interface with HSE’s ICT vision

► Appoint individual/shared roles/virtual teams for the following:

► Enterprise Architect

► Clinical/Business Analysis

► Chief Medical Information Officer

► Programme Management

► Service Management and Operations

► PMO, Planning, and administration

► Clear definition of HSE alignment

► National and local buy in to establish new ICT organisation

► Clear outline and communication of ICT vision from leadership team

► Recruitment of key roles must be aligned with clinical and business activities (i.e., core ICT roles must be filled before activities such as finalising core processes, EIM, and Portal implementation)

► ICT team must have the required level of experience and profile required to drive through transformational change

► Internal recruitment to fill identified roles (pending capability assessment)

► Potential to share roles across core functions (e.g., Programme Management and PMO function)

► Potential to leverage existing expertise within the HSE (e.g., role profiles)

► Aligning the ICT Director role with key clinical and business skills instead sole ICT focus

Governance ► Draw up and agree terms of reference for each governance forum with relevant stakeholders both locally and nationally

► Assign owner and members to each governance forums

► Benchmark and analyse current performance with leading health practice ICT functions

► Sign off and buy in from the clinical and business stakeholders

► Maintaining progress by conducting frequent status updates, and resolving issues and mitigating risks on a regular basis

► Ensuring ongoing alignment across all governance forums to maximise outputs, while avoiding duplication of effort

► Rationalising and re-defining some existing governance forums

► National involvement in defining terms of reference will ensure ongoing buy in

Ongoing processes and systems training

► Ongoing knowledge management approach via on-the-job learning, coaching, and formal training

► Consistent approach for introducing new processes and systems into the live service

► Perform ongoing change management within SSWHG and national leadership to ensure continuous buy-in

► Ensuring change management implications are factored into the timelines and sequencing of all ICT initiatives

► Documentation of core process and systems related changes to form part of all ICT initiatives

► Flexible communication and access to new change initiatives (e.g., staff portal, email, mobile etc.)

Appendix C: Roadmap Activities Detail (cont’d)



ICT Operating Model

Establish core processes

► Conduct detailed design across all ICT areas by detailing from level 2 to task level for impacted stakeholders

► Identify areas of integration across ICT function both locally and at national level

► Clear definition of how clinical and business requirements are gathered, analysed, prioritised, and implemented

► Define all data/information required to support the core processes

► Align ICT processes with clinical and business processes

► End to end process definition for patient care and safety. Adherence to consistency across the Group

► Sign off and buy in from the clinical and business stakeholders

► Collaborative approach to process definition (i.e., inputs required from clinical, business, and ICT stakeholders)

► Ensure consistencies for core ICT processes across entire group

► Clearly defined approach for continuous process improvement

► Ensuring all ICT initiatives are aligned to clinical and business initiatives that enable patient care and safety

► Leveraging the best existing processes across each hospital will reduce re-work (pending detailed analysis)

► Leveraging internal and national resources for process definition (with support from external expertise as appropriate)

Analysis/ consolidation roadmap

Assess current state using a deep dive to understand:

► KPI and dataset requirements

► Reporting approach

► Internal management and dashboard reporting

► MDM approaches between hospitals

► Staff providing the service and their capabilities and experience

► Data sources and technology supporting them

► Issues with current data sources and reporting

► End to end process definition for patient care and safety. Adherence to consistency across the Group

► Availability of staff to discuss current approach

► ICT Governance and key roles to support the development of this road map and to resource plans

► IT-CMF approach is a capabilities based assessment

► The new national CIO is previously from a analytics/health informatics background so could be a good ally

► The organisation will understand at a high level the current provenance, currency and quality of the information produced and the associated risk with this

► This will inform how the organisation currently measures their performance, will establish a set of future state requirements and a plan for achieving these

► This process will also highlight key gaps in clinical and business applications which when linked to the risk will provide some guidance on prioritising opportunities

Enterprise Information

Management




Enterprise Information

Management

Establish Enterprise Information Management

Standards, policies and controls

► Standard approaches to measuring KPIs and producing datasets are developed and available to provide assurance about data integrity

► Development of a regular process for updating and maintaining these Operating Procedures

► Operating procedures establish the approach for management of Data Quality

Master and Meta Data management

► Master dataset is established which provides a technical means for managing and describing business changes in the information

Business analytics enablement

► Roles are established to support routine report development, build and establish relationships with the business and clinicians

► Routine reporting is automated as far as possible

► Gaps in business critical information are identified for clinical and business system development

► ICT governance and key roles to support the development of this road map and to resource plans

► Identified reporting standards

► Single datawarehouse

► MDM solution

► Business analytics roles which include relationship and performance management components

► The information that is collected is useful to more than just SSWHG. There could be an opportunity for investment from education and research providers or even medical devices or pharmaceutical companies

► There may be a way to utilise a managed service in this area, which would reduce risk around recruitment and retention of these key skills




Applications/ Infra-

structure

Portfolio planning and prioritisation

Assess current state using a deep dive to understand:

► Portal/HR and E-Rostering solution decision

► Current deliverables and implications of a Portal solution

► Strategic benefits planned as a result of Portal solution

► Risks and dependencies in delivery

► Fit of current solutions with planned future state

► HSE support (including financial)

► Availability of staff to support prioritisation exercise

► ICT Governance and key roles to support the development of this road map and to resource plans

► IT-CMF approach is a capabilities based assessment

► The organisation will understand at a high level the current landscape of development and deployment, allowing the organisation to make informed prioritisation decisions and critically understand key dependencies

► This process will also highlight key gaps in clinical and business applications which when linked to the risk will provide some guidance on prioritising opportunities

Portal System Work with HSE to understand:

► Business case

► Procurement process

► Requirements and development

► Testing

► Deployment

Solution could include:

► Single sign on

► Universal search

► Order comms

► Clinical documents

► Digital dictation

► Clinical audit

► Bed management

► Availability of SSWHG staff (IT and Business) to support project over implementation period

► It is critical to have completed the portfolio planning and prioritisation along with the Enterprise Information consolidation and roadmap. This will inform the organisation in where the current gaps are, how critical these are and whether they need to be filled using this solution

► Implementation of the IT Operating Model

► Resourcing model i.e., in-house, national, and external resources

► Considerations need to be given to how the infrastructure will provide for multiple hospitals

► Consideration should be given for how the solution can be shared with other providers (e.g., Primary Care)

► Benchmarking against other Hospitals both nationally and internationally to leverage best practices

► Utilise the existing resourcing framework




Applications/ Infra-

structure

HR and E-Rostering

Work with HSE to understand:

► Business Case

► Procurement process

► Requirements and development

► Testing

► Deployment

► Availability of SSWHG staff (IT and Business) to support project over implementation period

► It is critical to have completed the portfolio planning and prioritisation along with the Enterprise Information consolidation and roadmap. This will inform the organisation in where the current gaps are, how critical these are and whether they need to be filled using this solution

► Resourcing model i.e., in-house, national, and external resources

► Utilise the existing framework for e-rostering

Blank Page