Knowledge Matters Volume 8, Issue 3

Volume 8 Issue 3 August 2014 Welcome to Knowledge Matters Welcome to the August (well, -ish) special holiday edition of Knowledge Matters!

This month we have an update on the Friends and Family Test from Samantha Riley, Director of Insights at NHS England, and its forthcoming major rollout across GP practices, mental and community health services, dental practices, patient transport services, day cases and outpatients (phew!).

We also have a fairly topical Analysis Ancient and Modern around improvements in treatment of the injured up to the Great War, an update from the Association of Professional Healthcare Analysts and an interesting article on the Bayesian Approach in statistics from one of our new team members, Trishna.

For those looking to build their knowledge of using R, a handy free tool for statistical analysis much in use in academia and statistics, I would strongly recommend looking at the News section for details of a free course being run by edX. I’m off to relax by the pool with a cheeky cocktail now so cheers and see you next edition!

Simon

Inside This Issue : Making Connections - FFT

2

Skills Builder

6

Analysis Ancient and Modern

4

Ask an Analyst

8

Making Connections - AphA

5

News

10

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2 The Friends and Family Test is coming to a place near you SOON

By Samantha Riley, Director of Insight, NHS England Hello Knowledge Matters readers. I’m hoping that most of you are aware of the Friends and Family Test (FFT), that it is coming to a place near you very soon and also that you are starting to hear about the significant benefits that it is bringing to both staff and patients. There have already been 3 million responses received to the FFT – that compares to 65,000 responses per year from the annual inpatient survey. Anyway, just in case you aren’t familiar with FFT, let’s start with some basics…….

So, the Friends and Family Test is a feedback tool which supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience that can be used to improve services. All patients should have the opportunity to provide feedback through the FFT at any time. The important thing to stress here is that ALL patients should be provided with the opportunity regardless of their needs – children need to be communicated with in a different way to someone who has hearing loss. It is important that steps are taken to ensure that all patients are given a voice.

Approximately a quarter of the recently published guidance is dedicated to providing advice on how to make the FFT more inclusive, allowing people of all ages and from all parts of our community to provide feedback.

The FFT was introduced to inpatients and A&E in April 2013 and to maternity services in October 2013. FFT is now being rolled out to all NHS services to the timetable below: st

 GP practices from 1 December 2014 st

 Community and mental health services from 1 January 2015 st

 Dental practices, patient transport services, day cases and outpatients from 1 April 2015

Clearly there are big differences in how care is delivered in different settings and we have given a lot of thought to how FFT is now approached to ensure that it works for patients and NHS staff. A review was undertaken to look at what had worked well in inpatients and A&E and what could have been better. In addition, a number of ‘pathfinder’ sites tested FFT in a range of new settings and provided evidence on which approaches worked best. The review documents can be accessed here : http://www.england.nhs.uk/ ourwork/pe/fft/fft-test-review/ Key findings from the review were as follows:

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The FFT has made a positive impact on the NHS, with 78 per cent of trusts saying it had increased the emphasis on patient experience in their trust; The FFT was also seen to have an important role in driving local service improvements, as well as boosting staff morale when positive comments are received.

The net promoter score was not easily understood and, as a result, the FFT will move to a more transparent presentation of the data which both patients and staff will find easier to understand and use. As a result of this we are changing the way in which FFT data will be presented.

On 21st July, the long awaited guidance on how to implement the Friends and Family Test in all care settings was published. This marked a really important step in ensuring that every patient will have the opportunity to provide feedback on the services they have received, enabling the public to make better informed choices about the services they use. The introduction of FFT to all settings also means providers will be able to design care services based on the feedback and around the needs of patients.

The new guidance mirrors the format of the Participation Guidance which was published by NHS England last autumn and which received very good feedback from the NHS and key stakeholders. The new guidance is interactive and contains advice, videos, supporting materials and case studies. I hope that the interactive nature of the guidance helps to bring FFT alive for people and that the videos (which I highly recommend) help describe the benefits experienced by both patients and staff.

The guidance can be accessed here http://www.england.nhs.uk/wp-content/ uploads/2014/07/fft-imp-guid-14.pdf If you have any queries on the guidance or would like to provide feedback you can email england.friendsandfamilytest@nhs.net or phone 0113 824 9494. For those of you using twitter, we use #nhsfft to mark any relevant tweets.

The last thing to say for now is that the first set of results for staff FFT will be published towards the end of next month. As always the data will be available on the NHS England statistics page and on NHS Choices. More about staff FFT next time!

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Analysis Ancient & Modern It is generally acknowledged that the Great War was one of the most costly conflicts in history in terms of human life. But throughout history war has generally provided at least one small up-side in the form of innovations in medical treatment.

World War One was no exception, but the impact was perhaps more evident than in previous conflicts.

Take a look at the chart on the right. The proportion of deaths due to disease rather than combat practically reverses compared to relatively contemporaneous conflicts (although of course we should bear in mind a range of caveats such as the theatre of war, where hotter climates abroad were likely to give rise to nasty diseases that British soldiers at any rate were unlikely to have encountered before). So why did we see this apparent reversal happen?

World War One had a direct impact on a range of medical innovations which would have affected this figure. Blood storage and transfusion is a famous example but advances were made also made in wound care. The incidence of trench foot and obviously the impact of wounds from combat led to significant changes in how wounds were initially treated, including the more extensive use of antiseptics in cleaning wounds and improved techniques for the debridement of wounds to improve healing. There were various technological advances which had an impact too; for example the development of the Thomas splint was widely credited with reducing mortality rates from fractured neck of femur from a staggering 80% to just 20%.

And then there were the basics; hand hygiene, short hair cuts and regular delousing, and keeping toilets well away from water sources drastically reduced some of the big killers such as typhus and dysentery.

The ‘sanitary committee’ and the Sanitary Section (a kind of hygiene hit squad) were instrumental in ensuring that some of the basics of disease prevention were adhered to. A Sanitary Section (consisting of a Lieutenant or Second-Lieutenant, 2 Sergeants, 2 Corporals, 20 Privates and 1 batman) was tasked to maintain as far as possible clean water supplies, cooking facilities and billets, de-lousing stations and similar facilities. It couldn’t have been pretty, but was no doubt critical in the reduction of disease casualties.

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Association of Professional Healthcare Analysts To paraphrase the famous line, “It is a truth (almost) universally acknowledged that there is a lack of development and networking opportunities for people involved in healthcare analysis”. We have a bit of a bee in our bonnet here at QO Towers about the training and development (or lack thereof) available to healthcare analysts who, when all is said and done, provide the bedrock on which proper decision making stands in the NHS. So we’re very chuffed to see the Association of Professional Healthcare Analysts (AphA) help to fill the void. Created just last year AphA has a number of ambitious aims: 

Support information specialists/analysts working across the healthcare sector

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Promote best practice and innovation amongst all NHS staff involved in analysis and interpretation of data

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Support professional and personal development

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Promote the highest standards in healthcare analysis

AphA are set to act alongside other Health Informatics professional bodies such as UKCHIP and BCS Assist (see the news section for an update on their latest activities) to provide opportunities for all healthcare analysts to network with each other, share learning and best practice and, of course, training opportunities.

AphA are a membership organisation (£30 per year) with members offered access to an online community and resources to promote personal and professional development and of course the chance to network with fellow analysts from across the country.

AphA also have an annual conference, the next one just around the corner on the 16th September. The event is designed for members to come and exchange ideas, hear all about the latest developments in the field and the opportunity to showcase all the exciting and (naturally) innovative work you’ve been up to!

For more information take a look at the AphA website at www.aphamembers.org or drop them a tweet @apha_members

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The Bayesian Approach

By Trishna Julha, Programme Support Analyst As a Statistics student, I would learn theorems, their proofs, other theorems to contradict or support previously learnt theorems and of course, their proofs too. The first year went by in utter incomprehension of the subject matter and a constant questioning of – Why am I studying Statistics? Will I ever appreciate these symbols from another planet? My ‘Wow’ moment showed up in my second academic year when I met Thomas Bayes – and no, he is not alive! He was a British mathematician and minister who described a process for adjusting and updating the likelihood of an event based on data, as the data is generated. In simpler terms, it could be synonymous to - reality changes with new information. Does it not?

Let’s have a go at it – I am turning 30, I have a great job, I have lots of friends, a pleasant partner and my parents are rich. Oops, the pleasant partner and great job suddenly are no longer part of this equation. Boom!

Reality changes.

Using the terms I learnt back in the days, Bayes’ Theorem is a formula for revising prior probabilities after receiving new information. The revised probabilities are called posterior probabilities.

Consider the probability that you will develop a specific cancer in the next year. An estimate of this probability based on general population data would be a prior estimate; a revised/posterior estimate would be based on both on the population data and the results of a specific test for cancer.

The formula for Bayes Theorem is as follows: Yes, the formula did not say much to me either!

Let's put Bayes' Theorem to practical use.

Let's say that cancer is known to have a prevalence of 1 out of every 1000 people in a given population. This gives us our prior estimate. Let's also say that we have a test for cancer that is very sensitive, but has an inherent false positive rate of 10%.

Now, we need to use the test on 1000 individuals to determine if they have the disease.

The pre-test probability that any one of the individuals has the disease is 1/1000, or 0.001. When we test 1000 people, we may find (on average) the 1 person in 1000 that has the disease. But we also find 100 people who test positive but do not have cancer (10% false positive x 1000 people = 100 false positives). So, we may expect on average to find 101 people that test positive out of the 1000 people tested (1 true positive and 100 false positives).

Therefore, of these 101 suspects, each of them only has a 1/101 chance of having the disease. The denominator, 101, represents the sum of our 2 possible hypotheses (101 positive tests = true positives and false positives).

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7 Without understanding that we need to combine the new data with the prior probability, a clinician may tend to raise an unwarranted amount of fear in these 101 patients even though it is likely that only 1 of them has cancer. Without the Bayesian perspective, these 101 people will likely all become convinced that they have cancer.

We can turn the process above into an equation, which is Bayes’ Theorem. It lets you take the test results and correct for the skew introduced by false positives to get the real chance of having the event.

Going back to the Bayes theorem formula, Pr(A|X) = Chance of having cancer given a positive test (X). This is what we want to know: How likely is it to have cancer with a positive result?

Pr(X|A) = Chance of a positive test (X) given that you had cancer (A). This is the chance of a true positive, 10% in our case.

Pr(A) = Chance of having cancer (0.001).

Pr(~A) = Chance of not having cancer.

Pr(X|~A) = Chance of a positive test (X) given that you didn’t have cancer (~A). This is a false positive.

This exercise demonstrates how we gain a much clearer perspective about test results by combining prior knowledge with new data and updating our position. It demonstrates how we arrive at the positive predictive value of a test. However, the Bayesian methodology was often shunned, with much debate between Bayesians and frequentists: The Bayesian methodology begins with uncertainty and corrects itself with each new observation towards the likely truth. Meanwhile, in frequentist statistics, probabilities are determined only after all data is collected. Conclusions tend to be binary, that is, we either reject the null hypothesis in favour of the pet hypothesis, or we do not.

With new technology, especially in the IT and phone industries, Bayesian methodology has been revisited and appreciated. Prior probabilities are now calculated from prior scientific knowledge, specialized expertise or by recently developed statistical techniques.

Debates over the supremacy of each school of thought have lasted centuries and to date, they seem unfinished. We cannot know what goes on in a scientist’s mind and which methodology will be favoured.

But the Bayes formula still remains for me, a ‘Wow’ theorem.

References and Links Bayesian methodology https://sites.google.com/site/skepticalmedicine//bayesian-methodology An intuitive and short explanation of Bayes Theorem http://betterexplained.com/articles/an-intuitive-and-short-explanation-of-bayes-theorem/ The Bayes theorem, explained to an above-average squirrel http://blogs.sas.com/content/sastraining/2011/01/31/the-bayes-theorem-explained-to-an-above-average-squirrel/

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Calculations and Textbox masking Input Forms Application: Excel 2007/2010 (xlsm) Dear Ask an Analyst I am trying to create a user form in Excel and have gotten a bit stuck. Half way down the form I have the following 4 fields: 1.

2.

3.

4.

Income Expected Costs Margin Margin %

I need to make sure that the input is numeric only and I need number 4 to be calculated as number 3 divided by number 1.

Is the textbox the right control to use or is there a better one that allows you to format mask, like in Access?

Eloise Armstrong Business Analyst NHS Central Southern

Solution: Complexity 3/5 — Form validations with event based VBA Hi Eloise Thanks for getting in touch.

With Excel you can format and validate cells on a spreadsheet easily, but there is no direct option to format mask or validate the data that is input into the textbox. The closest option to a validation you have readily available in Excel is the “MaxLength” property to set the maximum number of characters.

To ensure that people can only add numbers to the textbox we will need to use some event based VBA. There are 3 potential textbox events that we can use to trigger our input checking code; these are KeyDown, KeyPress and KeyUp. There are some differences between these events. KeyDown and KeyUp events return an MS KeyCode value, and KeyPress returns the Ascii code for the key that has been pressed.

In this example we are going to use the KeyPress event to run some VBA code that will check the input data.

In your Developer tab switch into Design Mode.

I have created 4 textboxes named TextBox26-29 (as below).

TextBox26 TextBox27 TextBox28 TextBox29

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9 Select the first textbox on the form and right click and select View Code to pop up the VBA Editor.

The editor will load with the default “Change” event.

We want to utilise the “KeyPress” event so from the drop down at the top right of the editor window select “KeyPress” The KeyPress event makes the “KeyAscii” variable available to us to use in our code.

This variable holds the Ascii value of the key that is pressed e.g. the numbers 0-9 have Ascii values of 48-57.

This gives us the basis for the logic we can use to evaluate if the data being input is a number or not. In this example I transform the KeyAscii value back to the character that it represents with chr() and use the IsNumeric() function to evaluate it. Setting the KeyAscii value to 0 in the False evaluation step will stop the character being displayed in the textbox.

In the finished example I have used an If statement but you could use Select Case for multiple validation rules Private Sub TextBox26_KeyPress(ByVal KeyAscii As MSForms.ReturnInteger) If IsNumeric(Chr(KeyAscii)) Then ‘action to do if is a number i.e. let it through Else ‘action to do if is anything else i.e. don’t do anything KeyAscii = 0 End If End Sub For the calculated value in Textbox29 we want to divide the value of Textbox28 with the value of TextBox26. We probably only want to perform this calculation when the value of the textbox changes so we can utilise the Change event, and for Textbox26 we probably want to check that Textbox28 is not blank. So we can add something like : Private Sub TextBox26_Change() On Error Resume Next ‘ this is just in case the system tries to divide by zero (and other errors!)

If TextBox28.Value = "" Then ‘do nothing Else TextBox29.Value = TextBox28.Value / TextBox26.Value End If End Sub You will need to repeat this for Textbox28 as well, don’t forget that on the Textbox28_Change() event you will want to check if TextBox26 is blank. You may also want to set Textbox 29’s “Enabled” property to False to stop people overwriting the calculation.

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NEWS New Starters

Trishna Julha

We have had 3 new starters since the last newsletter. I’ll let them introduce themselves!

Hi. I am Trishna Julha, the latest fresher to tune into the Quality Observatory bandwidth. For the coming months, my editorials will focus on the Friends and Family Test’s cuttings!

Becki Ehren Hi I’m Becki, the second newest recruit to the Quality Observatory. My role is the Team Administrator, so I am the ‘go to’ person for organising the team for meetings etc.

I have previously worked in pensions administration and as cabin crew (two very different industries!), and I am enjoying working for an organisation as interesting as the NHS.

Dani Collier Hello, I’m Dani. I joined the team at the Quality Observatory in July 2014.

I am helping out on the Friends and Family Test Project.

I have worked in the NHS for nearly 4 years. I was previously working as a Healthcare Assistant on a mixed sex 19 bed inpatient ward in acute psychiatry. I’m really enjoying the work and it is great using the data to see why things are changing on the wards. It really is an eye opener!

After having spent years in front and behind a camera to present probed information, and with prior experience in market research and media audience insight, I will be making thorough use of my Statistics educational training and analytical mind to process, analyse and report programme related data at the Quality Observatory. Five, four, three, two, one … On Air!

New Office Update The saga continues…….. It seems that we were overly optimistic in our projection that we would have moved to our new home by this issue, especially with our new arrivals!

It’s not all bad news, contracts have been signed and we are now able to gaze over the road at our future new premises at The Gables, Massett’s Road, Horley while we wait for the seemingly correct stars and planets to align for the fit out works to be carried out and N3 connection installed.

In the interim it acts as a meeting space for us when York House is full!

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NEWS The consultation doesn’t end until October so there is still plenty of time to get involved in this work.

BCS Assist members can take a look at http:// www.bcs.org/content/conWebDoc/52449 to answer the initial consultation.

Birthdays A quiet couple of months since the last issue with only Amit and Becky celebrating getting a year older (apparently fuelled

Free Course: Explore Statistics with R

entirely by gin and bubbly respectively)

Update on the Federation of Health Informatics It’s a great time to be in health information. Never before has the profession had so many channels for professional development (take a look at the article from ApHA on page 5) but there is still work to be done to improve awareness and underline just how critical high quality information is to improving care.

You may remember last time we mentioned the consultation on the creation of a Federation of Health Informatics, to provide a new and strong voice for health informatics professionals.

The results of the initial consultation are now available to view here: http://www.bcs.org/upload/ pdf/assist-federation-consultation.pdf The main message is that respondents believe that we need leaders in the health sector who understand the importance of Health Informatics and appreciate the value of Health Informatics professionalism to patient safety and public trust.

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I’ve been made aware of a free EDX Massive Open Online Course (MOOC) called “Explore Statistics with R” being run over 5 weeks starting on the 9th of September with an estimated effort of 8 hours a week. It’s being run in English by the Karolinska Insituet in Sweden .

“In this course you will learn the basics of R, a powerful open source statistical programming language. Why has R become the tool of choice in bioinformatics, the health sciences and many other fields? One reason is surely that it’s powerful and that you can download it for free right now. But more importantly, it’s supported by an active user community. In this course you will learn how to use peer reviewed packages for solving problems at the frontline of health science research. Commercial actors just can’t keep up implementing the latest algorithms and methods. When algorithms are first published, they are already implemented in R. Join us in a gold digging expedition. Explore statistics with R. “

If you do go for it let us know what you think!

More details are available on https://www.edx.org/course/kix/kix-kiexplorx-explore -statistics-r-1524#.U_3fdsVdWO5

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The Postcode Lottery I've heard of the postcode lottery, It's been in the news quite a lot Says it's dependent where you live, whether you get treated or not.

This causes a bit of a worry, In some cases rightly so, But sometimes there are good reasons, Which we do not yet know.

Demographics is part of the answer You might live among weak and old, You may live in somewhere that gets sickly, Whenever the weather is cold.

Fascinating Facts Babies’ kneecaps don't form and properly harden till they are around 5 years old.

Having seen how often my little one falls over I can say that’s a very handy thing!

I know when we're sick and we're poorly, It doesn't seem just or quite fair, Traveling miles to get our treatment, But you can't have it all everywhere.

So don't worry if you live where mortality's high For cancer or defenestration, It doesn't mean you'll die that way, Remember correlation isn't causation.

Simon says…….

Having spent time recently navigating bureaucracy, red tape and all too often having to “wait for the next meeting”, it has sometimes felt like processes and procedures are used as a convenient shield to not to take personal responsibility for decisions and take action!

Being able to take responsibility and make decisions and quickly take action is one of the behaviours, I feel, we will need to encourage to allow us all to provide a responsive service to our customers, and ultimately will be reflected in the services delivered to patients!

Knowledge matters is the newsletter of NHS South East Coast’s Quality Observatory, to discuss any items raised in this publication, for further information or to be added to our distribution list, please contact us.

Hosted by: Central Southern Commissioning Support Unit E-mail: info@qualityobservatory.nhs.uk To contact a team member: firstname.surname@qualityobservatory.nhs.uk