Virtual wards are here to stay. In guidance released earlier this year, NHS England and NHS Improvement set an ambitious target for Integrated Care Systems (ICS) to deliver up to 24,000 virtual ward beds by December 2023. But, targets and funding are only one piece of the puzzle. As recently explored in an article for HSJ, we must look beyond procurement in order to realise the ambition and truly succeed in harnessing technology to solve some of the NHS’s greatest challenges. But how can we turn intention into action? And what steps do we need to take to make virtual wards a reality?
We invited an expert panel to join us live on 5th December 2022, to discuss the key considerations to ensure that virtual wards are set up for success.
Watch the webinar on-demand here, or keep reading for a high-level summary of the event.
Panel members:
- Harpreet Sood, VP, Primary Care & Clinical Partnerships, Huma (Chair)
- Terry Deeny, Global Clinical Director, Operations and Strategy, Huma
- Esther Clift, Consultant Frailty Practitioner and Professional Advisor to NHS England
- Tara Sood, National Clinical Lead NHSEI Same Day Emergency Care
How can you get senior clinical management endorsement for a virtual wards project?
Do: Ensure you have the full endorsement and participation of senior management and clinical leaders
Don't: Think that you can get started without one or the other and bring them onboard at a later stage.
COVID-19 was probably the first time that many trusts had experienced virtual wards. The urgency created by the pandemic allowed many of us to ‘cut through the red tape’ and scale and implement digital solutions quicker. The once-in-a-lifetime nature of the pandemic really shook us out of the apathy that often suffocates these kind of transformation projects. Now we know the benefits, the NHS is looking to explore other areas that these models can work, and many organisations are facing challenges in getting these projects off the ground. While we all recognise the urgent need for remote and digital care, the urgency we saw in the pandemic is not a factor in these second-generation virtual ward projects, which means getting senior clinical management endorsement can be a struggle.
Virtual wards can present a really significant change to the way things are done, meaning the initiative is likely to encounter some resistance . That’s why it's really important to have senior hospital management and senior clinicians working hand in glove on a project like this and giving it their full endorsement.If you don't have buy-in from senior clinicians, it's going to be an uphill struggle from day one.
“If a clinical lead doesn't declare themselves, or it's not obvious within the organisation who this person is, I really think the clock should stop on the project until that person has been identified.” - Dr Terry Deeny, Global Clinical Director, Operations and Strategy, Huma
It’s also important to remember that change has to happen from within, and that means that you’ll need to enable everybody to work at the top of their capabilities to develop that workforce. Multi-professional leadership is fundamental to lead the change. In order to get full buy-in and ensure that virtual wards are a success, and integrated care approach will help make sure that everybody is working together as functionally as possible.
It’s also important not to forget about the patients themselves. The overall goal of virtual wards is to improve outcomes for patients and improve their experience. It's incredibly compelling to include a patients point of view and experience.
“Our allies in this space are the patients themselves. They are the profound advocates for this way of working. Finding patients who are your advocates, and who are going to tell you how it is is a real game changer.” - Esther Clift, Consultant Frailty Practitioner and Professional Advisor to NHS England
How can you build the right team to deliver efficient, successful and sustainable virtual ward services with a clear governance process?
Do: Form a core project team and create a governance structure within which they can work efficiently
Don’t: Forget to inform and consult other teams and departments that will likely be impacted or whose help you will need
Some of the senior personnel and departments that need to be involved when planning a virtual ward include:
- Chief Executive Officer
- Transformation Leads
- Chief Clinical Information Officers (CCIOs)
- Chief Nursing Information Officers (CNIOs)
- Lead consultants and clinical nurse specialists for the services implementing the virtual wards
But, don’t forget about the other key players that you’ll need to get involved too. Consider:
- Data protection teams
- Patient advocacy groups
- Patient communication team
- Community nursing and social care teams
- Pharmacists
- Therapists
- Business insights team
- Electrical and Biomedical Engineering teams
Even if you're not quite sure how some of these teams are going to be involved, it's useful to make them aware of the process early because at some point you may need their help or find that your work crosses over into their field of expertise. It’s better to involve a lot of people early and then bring them back in as you need to as you work through the process.
It’s also important to put in place a governance process for the project. There are a lot of decisions to be made in setting up a virtual ward, so having a decision making forum will be beneficial. Adding your virtual wards project to part of your clinical governance comittee’s regular agenda is a good step, or you could set up a seperate meeting to focus solely on virtual ward issues.
How can you set the right goals and objectives for your virtual ward?
Do: Set an evidence-based end-goal for your ward
Don’t: Focus too much on service design goals
When we start conversations with clients about designing an RPM project we often see them jumping straight in to trying to tackle the details of project design like frequency of monitoring or which devices to use.
But before that it’s important to stop and ask yourself “What is the point of this project? Why are we doing it at all?”
If you have a clear overarching goal for the project that can be easily communicated to the key stakeholders it will help to buy into your vision, and it will help to answer the many service design questions that come along. It really is worth taking as long as it takes to get clear on this issue. The more clearly defined this is the better.
One way we help clients to define their goals for the project is to introduce the idea of evidence generation early to agree on what it is that you’re hoping to change and how you’re going to measure it that change.
We guide this conversation using an evaluation framework that covers
Different types of evidence generation
- Clinical outcomes
- Patient experience
- Capacity and operational outcomes including workforce impact
It’s important to think about all of these domains of evidence generation, not just clinical outcomes, because any new service needs to be evaluated in a holistic way.
Which patients make good candidates for virtual wards?
Do: Measure something that reliably heralds deterioration in a patient’s condition
Don’t: Use a cohort that is too well, therefore unlikely to need acute hosptial services anyway
It may sound obvious but if you want to reduce use of acute hospital services, you need to enrol patients who are risk of needing to use the hospital.
One of the main reasons that many RPM (Remote Patient Monitoring) projects fail to reduce use of acute hospital services is that clinicians (completely understandably) have a tendency to enrol patients who are quite well or uncomplicated, so are less likely to attend hospital anyway.
One way to solve this problem could be to proactively monitor higher risk patient groups before they become unwell or at the first sign of trouble e.g. Heart failure patients frequently ‘bounce back’ into hospital if their medications are adjusted during an in-patient stay and they go home without a sufficient period of monitoring on the new dose. Monitoring these patients in the post discharge period could reduce their readmission rate.
Once you have identified a disease and patient cohort to monitor, it is important to make sure you are measuring something that reliably predicts deterioration in a patient's condition in time for appropriate action to be taken. Identifying these measures and thresholds is a task for the project’s senior clinical leads.
Another element is in choosing the type of patients that are likely to engage with your system. On a practical level, you’ll need to consider whether a patient can physically manage the kit themselves (for example using blood pressure cuffs) or whether they have someone who can assist with it. You also need to consider their cognitive capability to manage the uploading of data. For somebody who's got a cognitive impairment who can't take on a new piece of learning, it is a really complex key piece of kit, and of course, that’s a challenge.
“We do have a feature in our platform (Huma) where patients are able to add a helper, which is a kind of a nice way to get around any challenges with digital literacy. At the onboarding point, somebody else can be invited to input data on the patient's behalf.” - Dr Terry Deeny, Global Clinical Director, Operations and Strategy, Huma
How can you configure technology and write Standard Operating Procedures (SOP)?
Do: Use simple processes and technology
Don’t: Forget about a clear escalation and governance process
A well-functioning remote patient monitoring system relies on two key components. The first is timely data entry - the patient needs to enter the right data at the right time. The second is making sure that the providers are taking appropriate and timely action when concerning episodes occurred.
To ensure you capture timely data entry you need to consider the following:
- Designing a process that is simple to follow
- Use devices that are simple for the patient (or nominated individual) to use
It’s also important to remember that the right patients, while not physically in a hospital bed, may be very sick and otherwise have been in hospital, so we need to select them very carefully. So when it comes to monitoring them, the governance around that needs to be tight, particularly around escalation.
“It's important that the people who are monitoring those patients remotely know where to write their notes, that you've got a clear governance process around that. So that if a patient does deteriorate and comes in, the technical information is available to the clinicians.” - Tara Sood, National Clinical Lead NHSEI Same Day Emergency Care
Two-way communication is essential in monitoring and escalating patients. Whether it’s by phone, through an app like Huma or a dedicated email address, frequent data monitoring is essential. Alongside that, you need fast decision-making and action. So that means everybody involved in the process has clear roles and responsibilities and they've agreed on an escalation pathway well ahead of time.
Executing the launch and iterating the design
Do: Take time to check, and double-check everything before you launch
Don’t: Expect that it’ll be perfect first-time and forget to plan for iterations
The planning and preparation phase can take a long time so, naturally, there may be a desire to just launch and get going. but launching in a chaotic environment can be detrimental to the success of your project. Create a checklist for go-live, including:
- Make sure your technology and operations work fully
- Ensure you’ve communicated with patients
- Ensure everyone is trained on the platform
- Build a plan for iterations and adaptions based on feedback
Ensuring you build in time to iterate and adapt your virtual ward SOP and service design is crucial. It's really important to continue to engage with the original team that was built to implement your virtual ward and use them to help implement feedback. You're likely going to need to iterate, change parts of the technology, change parts of the SOP and make sure that it's serving its purpose.
“We're building the plane while we're flying it all the time. We're changing what we're doing, we have to be agile. But I think, absolutely clear communication and collaboration are really, really important to help this plane to fly. And I think we're all a very, very exciting journey with this.” - Tara Sood, National Clinical Lead NHSEI Same Day Emergency Care
Watch the webinar on-demand, here.
