Our most recent HTN Now panel discussion focused on the role of the CNIO in digital transformation, both now and in the future, considering its importance in driving digital transformation, and its value in linking digital with clinical operations. Our expert panellists, Sarah Hanbridge, CCIO at Leeds Teaching Hospitals (LTHT); Johanna Kelly, CNIO at Maidstone and Tunbridge Wells (MTW); and Rhian Bulmer, chief partnerships officer at Radar Healthcare; shared their experience and insight.
Sarah began by sharing her own journey to date, from working at Salford Royal Hospital in the late 1990s through to her current role at LTHT. “I was probably a digital nurse implementor back then, but didn’t really realise it, because digital was in its infancy – I left school with a typewriter, so it was quite a big transition to digital,” she considered, “but I’d always been passionate about people, process, and efficiency.”
Describing Salford as “very forward-thinking”, Sarah talked about the organisation’s implementation of an EHR in 2000, and the shock that accompanied leaving after 23 years and realising that “in other organisations, people were still predominantly on paper”. Up until then, every role she had held across clinical and operational remits had involved digital, according to Sarah, “so I was very lucky to be at the right organisation at the right time”.
Although keen to find a CNIO or CCIO role, a challenge she came up against was that most of the positions were medical, Sarah told us, “and I was having to knock on doors and ask where the nursing voice was – it didn’t really exist, and we were the main workforce developing the EHR”. After a stint working at Oldham focusing on digitising processes, she spotted a CCIO position advertised at The Christie, which turned out to be the first CCIO nursing position for the trust. “That was the true test of putting everything I’d learned into a new organisation, completely out of my comfort zone as I wasn’t a cancer specialist nurse,” she said, “and from there I went on to a regional CNIO role for the North West, before moving to the North East and my current role as CCIO at LTHT.”
Reflecting on her journey, Sarah said: “Sometimes I have to pinch myself and wonder how I got to this position! It’s the most rewarding job, because it encompasses patient safety, which I’m absolutely passionate about; making the best patient experience possible; and ensuring we’re meeting the patient outcomes. They’re my core values, and that’s why I came into the NHS, because my brother had a tragic accident and I watched nurses and doctors save his life – they were my role models, and I hope through my 30-odd years of nursing that I’ve achieved similar, and inspired those behind me.”
“When I first started my nursing journey I didn’t see myself going into digital either,” Johanna shared. “It’s definitely something that I organically fell into rather than my career pathway, which is something I’m really passionate about changing for our next generation of nurses, so they understand that the possibility exists for them to be a CNIO one day.” Starting out as a surgical nurse, her interest was initially in improvement projects and audits, she explained, “and I had the opportunity to set up a surgical assessment unit, which took me out of my bubble and made me see the bigger picture”.
Stepping outside of that bubble meant a chance to see the impact that was possible from different projects, Johanna considered, “and I enjoyed the whole experience of understanding the outcomes, collecting data, and so on”. Becoming a sepsis lead was an opportunity to get closer to patient safety, she continued. “Rolling out e-observations was the first real digital project within the trust, and it was so successful because it was implemented by nurses and midwives, for nurses and midwives; we understood the education and training element, and we could answer questions, because it wasn’t led by an IT training team.”
At that time, Johanna created a lead digital nurse role, she shared, “which I didn’t realise was a real job, but which I knew was needed – that led to me discovering this world and this community”. The role itself combined her passions for problem-solving with patient safety, improvement and education, she told us, “and from there I haven’t looked back – I moved to MTW three years ago to take on that next step in becoming a CNIO, and I feel that role was made for me”.
After starting her career as a technical author, she realised that writing step-by-step instructions for software “didn’t touch what was needed on the ground”, according to Rhian, prompting a move to working on the Choose and Book programme. “That was quite a dictatorial approach, it wasn’t partnership led, and it wasn’t working with clinical and operational teams,” she explained. “That informed my thoughts on health tech today – there’s brilliant tech out there, but it means nothing without the people to bring it to life in a way that ensures frontline teams can focus on caring for patients and service users.”
Rhian explained how Radar Healthcare was originally founded to address problems in social care, starting out as a compliance tool before going on to become a complete incident management system. “Paul and Lee, our founders, built this form methodology which could capture an incident but remain flexible and nuanced to meet the needs of a service or organisation,” she shared. “It could also map a business process behind that, so you could put a workflow engine in to sit behind that form and map those processes. That started to be used for incidents and events, collecting patient and staff feedback, and so on. The next logical step was to start to put in quality factors like audits, and for a long time that system was the jewel in Radar’s crown – that really got us to where we are now.”
From a supplier perspective, one of the biggest challenges is around being able to link in with other systems, Rhian said, and Radar Healthcare worked with Innovate UK to build an API adapter allowing information to be fed into their system, whether that’s on a transactional level to trigger individual incidents like in the case of an adverse medication error logged in an EPR system, which can then automatically start to populate an incident within Radar Healthcare’s system. “That means you don’t need to log into two different systems, it can be logged straight away. Equally important is the ability to make all of this information visible, so we’ve spent a lot of time on our data capabilities to feed into near-real-time dashboards granting those within an organisation a clear insight into what is happening.”
The final piece of the puzzle is ensuring that that data can work with other data lakes or other systems to allow the bidirectional flow of data, Rhian finished, “so you’re able to pull everything into one view and start to look at other things that add to your quality and safety”. Even with this in place, however, the tech remains a small part of what happens within health and care, she went on, “and it has to be a servant tool, something entirely secondary to getting the people, the process, and the systems right”.
Linking clinical and digital
Johanna talked about the role of the CNIO in linking clinical and digital, highlighting the importance of visibility, observing, and meeting with clinical teams on the ground, understanding challenges, identifying opportunities for optimisation, and getting suggestions from those on the shop floor. “They are living and breathing it, they’re going to come up with the best ideas,” she said, “so having those discussions, setting up working groups with the right people, and ensuring we have representation across the whole trust and all professions, really does help.”
The same can be said for developing a solution, Johanna continued, “because it’s important to have the right people in the room – it’s being an advocate for nurses, midwives and other healthcare professionals, but that is a team effort, and it’s important to know we’ve got the right technology and the right support for implementation or change”. A recent example at MTW has been the implementation of the automation of clinical vital signs into the EPR, she noted.
“We went live with our EPR around four years ago, and I think we failed to understand some of those tasks we do every day, like patient observations, and how that would change – without the right equipment and without understanding that workflow, us nurses reverted back to workarounds, which meant duplicating that work. We’ve worked on automatically bringing those vital signs done at the bedside straight into the EPR for the last two years.” Johanna’s team have worked out that it has saved about three minutes per observation, she shared, “which is around four hours a day to give back to nurses”.
“I’m methodology mad, and when I was at Salford I was taught QI methodology,” Sarah told us. “Using that QI methodology really set my stall, and using the pillars of practice in terms of research, education, leadership, clinical practice and clinical safety, I did a big piece of discovery work spending three months on the shop floor to understand the culture and digital maturity.” Doing that and spending time listening to staff from shop floor to board is key for a CCIO or CNIO role, especially when joining a new organisation, she considered. “I’ve come to the role with lots of clinical credibility, and I think I’ve been good at that governance structure and process, which is a critical thing.”
Looking at the problem statement and circling back to the QI methodology has helped, according to Sarah, “because it’s looking at what problem we’re trying to solve – it’s one thing having all of these systems, but at grassroots level, what is the actual benefit for the patient or to the workforce?” From being a staff nurse and seeing the data up close, identifying those trends and doing analysis, to seeing the beauty of technology and building those skills was “life changing”, she went on, “and I transitioned those skills into the Leeds model, and then spent time building relationships with the heads of nursing, ward managers, AHPs and midwives”.
In the beginning, the trust worked with a startup company, Sarah shared, to complete the What Good Looks Like benchmarking process, ultimately developing its vision and strategy. “We worked as a CCIO office with our organisation to build that strategy using our EHR as the spine, or the framework, but then really encapsulating the research, the education, the clinical safety, and the practice. It’s all about the continuous improvement cycle, because digital does not stay still, we’re on this constant treadmill, and sometimes we need to step off and reflect on what we’re doing to make sure we’re doing the right thing for patients at the right time.” That work was shortlisted for an award, she continued, “and we’ve also done phenomenal work around students, recently winning an award for student nurse placements”.
The key thing is to never make assumptions and always to ask questions, Sarah said. “Be curious and also be a bit of a positive disruptor – sometimes I’ve not been popular, but that’s part of being a good CCIO or CNIO, and sometimes you have to have broad shoulders and take that on the chin. The role is fantastic, but there are downsides, and sometimes I don’t think we fully appreciate some of that, and I think we should give ourselves a big pat on the back, because we do a really challenging job of bridging the technical world, translating that back to the shop floor. It needs to be transparent so staff understand the ask, because it’s the people on the shop floor who do the doing, not us, and that’s good leadership.”
“I think the most interesting thing that both Johanna and Sarah have mentioned is getting the culture right,” said Rhian, “and it’s almost like that iceberg concept, where there is so much under the surface. For example, within patient safety we see the full culture piece around being able to speak up for safety, disrupting the hierarchies that used to exist, getting a good reporting culture. Incident reporting has always existed as a negative, but it can be really positive in terms of learning, and it’s also about starting to report excellence.” Radar Healthcare often does “a bit of reverse innovation”, she continued, “looking to other territories to try and roll things out to prove the tech piece, like our work in the Emirates, where we work across the whole of the health service as their incident reporting system, linking in with different systems to give them that total view of what they need around quality and safety”.
What is done well in the Emirates that would be brilliant if it was rolled out in the NHS is that reporting of excellence, Rhian told us, “because you can learn just as much from reporting excellence as you can from looking at adverse events; but it’s again getting the culture right to be able to do that”. In the future, getting that right will be key to ensuring people feel free to speak up about things that happen, she said, knowing their feedback will be acted upon. “Feeding back to the shop floor is so essential, as if our staff know why we’re asking for certain information and the impact it will have, it won’t be as difficult to get them on board, and to ask them to do it when they’re already busy.”
Harnessing data to promote patient safety
LTHT’s homegrown EPR contains lots of data, and there’s a lot of potential, Sarah stated. “You have to be strategic and think outside of the box, especially when you don’t have any money, which speaks for all NHS organisations now. We’ve had to look at optimisation and think differently, so about 12 months ago we brought a PhD student in to work with us, her name is Gwen and she’s phenomenal. She’s been doing some background research in terms of what data we’re collecting, and how we can be using that data as actionable information to enhance patient outcomes and experience.”
LTHT has done “significant work” around maternity services in this regard, according to Sarah, but there are opportunities to look to other things like tissue viability and CQC key lines of enquiry, interrogating data use to inform practice. “I’m an evidence-based trained nurse,” she said, “and we need to do more of that triangulation to figure out what the research and data is telling us, looking at what we can do with our data. Over the last six months I’ve been working really closely with the chief nurse, corporate team and the professional standards team, because we’re in the process of doing our nursing accreditation system. We’ve never had one at Leeds before, and although I’ve completed that process twice in two different organisations, I’ve never digitalised it.”
That has involved taking a closer look at what data is collected and why, Sarah explained, “as I don’t want to waste our staff’s time collecting data that won’t be beneficial to the patient or the workforce”. It’s been transformative, she said, “as we’ve really checked and challenged each other’s knowledge and expertise, and I’ve brought the right people into the conversations”. The patient lens has also been pivotal, she went on, as the trust is also developing a patient portal. “It’s been an amazing piece of work, and we’re nearly at the end of it, so hopefully we can share the blueprint for that with other organisations soon.” This work underpins quality assurance, and Sarah hopes it will eventually help empower patients to take more responsibility for their own health, reporting symptoms earlier, and having an impact on patient outcomes.
MTW is in a similar situation as far as data, Johanna shared, “and we’ve really been trying to utilise some of that data and understand it a bit more”. Whilst working with the nurses, she realised there was a problem with documentation and the transition from paper to digital, with finding information and understanding compliance at ward level being challenging. Last year the trust started to collate the core documentation compliance into a dashboard, “which feels like giving the data back to the owners of that data so they can understand and use it themselves to their benefit”. The dashboard offers high-level oversight with the ability to drill down to patient level to understand the compliance for documentation, according to Johanna, “and I know some of our wards literally go around and share that, letting everyone know the things that are outstanding, whereas before they would have had to go through every single patient’s documentation on the system”.
Taking that time-consuming work away and providing this insight has helped with changing mindsets, Johanna explained. “It brought nurses on board with the EPR system and enabled them to see that they could potentially do a lot with it, and now we’re working on other projects following the same concept, trying to push that information back to our clinicians so they have got that visibility and understanding. They can then use that data to their own benefit, because that’s what it’s about, giving that back, so people can utilise it and do it themselves.”
“There’s a statement that always sticks with me, although I’m not sure on the source,” Rhian said, “which is to stop letting other people measure you, and measure yourself – we should be exposing the data for people to be able to measure themselves, because people want to do that.” This approach also prevents the poor culture which can accompany a top-down approach, she went on, “and our culture should be about giving people the tools they need to be able to make their improvements, about opportunities to showcase positive achievements, and learning from each other”.
The future of the CNIO role
Sarah shared some advice for anyone looking at becoming a CNIO in the future, noting that roles are still quite limited and opportunities might not be there within some organisations. “My advice would be to shadow someone, perhaps even from a different organisation,” she said, “as I’ve seen a lot of people do that, both at Leeds and other organisations, so they can spend a day in the life of the CNIO or CCIO – I’m a qualified teacher, as well, so I’m all for the education bit.” Mentorship and coaching can also play a part, she continued, “but it depends where you are on your journey, because I’ve seen really experienced nurses want to change career direction and come into digital, and for them it’s more of the mentoring rather than coaching about leadership”.
Workforce planning is “a bit of a downfall” in the NHS, Sarah considered, “and looking back at my time in nursing, it was always about who was going to replace me as ward manager when I left, so we always had somebody behind us who we were investing time in, and I think one of my legacies is investing in people and giving them opportunities”. Building your community, and attending seminars and events are also integral. “That was something I learned doing the Florence Nightingale digital programme – I’d been in the Salford bubble, but when I came out of it I realised there was a wealth of digital knowledge and experience I could tap into elsewhere.”
Finding the job description, highlighting the parts you can already do and then thinking strategically about how to get the exposure needed to work on the rest is beneficial, Sarah recommended. “It doesn’t matter if you have no digital experience – I wasn’t digital, I’m a nurse who loves patients and people, and although the tech is interesting, it’s not the pinnacle for me. Understand who you are and what you can bring to the role, because every CNIO or CCIO has different skillsets, and that’s what makes the NHS what it is.”
In the next ten years, Sarah shared hopes that the CNIO and CCIO roles would be phased out, “which is controversial, but it should be ingrained in business as usual, and I’d love to see a CNIO or a CCIO in a chief nurse position at the helm of running an organisation, that can really challenge with that digital expertise and experience”.
Johanna also recommended network building and seeking opportunities for anyone looking to get into a CNIO role. “I wouldn’t even have gone for this CNIO role if I didn’t have great supporters around me who believed in me,” she said, “and that might be your own personal network, but also building a network of like-minded people is important. I’m part of the National Digital Decision Making Council, and they have been pivotal in supporting and encouraging me.” There are also regional groups, Johanna shared, “so seeking those out and joining them, pushing yourself out of your comfort zone is integral”.
Recently completing a Digital Health Leadership course as part of the NHS Academy has helped Johanna validate herself within her CNIO role, she told us, “because I sometimes do underestimate myself, and in hindsight I already knew a lot of it, so I underestimated the amount I knew and my own leadership skills”. On Sarah’s point about the future of the CNIO role, Johanna said: “That’s a really good point, although I think it will take longer than ten years. We’re all at such different places, and some trusts still don’t have an EPR. I suppose it’s thinking now about providing everyone with those tools and skills to be agile and to be forever moving forward, because that optimisation journey is forever.”
We’d like to thank our panellists for sharing their insight and experience with us on this topic.
