Knowledge Management Team, South East Coast Strategic Health Authority knowledge.management@southeastcoast.nhs.uk nww.sec.nhs.uk/knowledge
INSIDE THIS ISSUE 1
Welcome
1
Vital Signs update
2
Coding Corner
2
Hellos and goodbyes
3
A : Ask an Analyst
4 5 6 6 7 8 8
3
Skills builder – confidence intervals Workforce profiling tool Index of Multiple Deprivation Christmas Quiz winner Making links – National Audit Office News and updates Useful links
Fun Fact During 2006/7, South East Coast Trusts admitted three victims of volcanic eruption, two victims of earthquake and two victims of lightning.
Vital Signs Update
February 2008 Volume 1 Issue 5
Welcome to Knowledge Matters By Samantha Riley
Hello everyone and welcome to another fun-filled, fact-packed edition. I am extremely pleased to announce that the Knowledge Management website went live at the end of January. Already we have over 140 registered users across South East Coast and a handful of members from elsewhere in the country. Registering on the website enables users to participate in a range of on-line forums and download analyses and products developed by the Knowledge Management team. This is a great step forward for the team as we are now not reliant on e-mail – so your in-boxes will breathe a sigh of relief! Please do monitor the website for additional and updated products – for the next few months we will e-mail you reminders, but then the onus will be on you to check out the site….. We really do want the website to enable the sharing of useful products, tools and knowledge from across South East Coast so I would encourage you all to actively participate and share. A few additional items of good news…. Within the last couple of weeks, we have welcomed a new member of the team – Peter Nyaga who has joined us from the army (read more on page 2). In this issue we also announce the winner of the Christmas Quiz (more details on page 6) – thanks to those of you who took part! It’s been a busy couple of months - Adam has developed a Better Care, Better Value indicators dashboard which we will update on a regular basis (and of course post on the website), the team have further developed training modules (dates available from the Academy website), discussions have commenced with NHS Careers and local Universities to encourage analytical careers within the NHS, I have developed a draft Knowledge Management strategy for South East Coast which will be available to you all in the middle of March and finally Rebecca and David have been very busy with Vital Signs (as have many of you too). See you next time! If you need an update in between, please do contact me – I would love to hear from you! Samantha Riley
By 26th February all Vital Signs submissions should have been received by the SHA, with the following exceptions: VSA04 and VSA05 (RTT trajectories and supporting activity data): as per letter from Marianne Griffiths the deadline for these lines is now 10am on 3rd March to enable the extra planning work required to plan for achieving 18 weeks by the end of September. VSB15 (Patient Satisfaction Survey) and VSB17 (Staff Satisfaction Survey): following revision of guidance from the Department of Health, the deadline for these lines has been extended to 29th February. The SHA will provide feedback on the trajectories submitted on 26th February by 3rd March and final submissions will be made to the Department of Health by close of play on 10th March. Discussions on Operational Plans will continue with PCTs throughout March. Please continue to email any queries to planning@southeastcoast.nhs.uk Additional guidance around C.Diff has now been sent out; the deadline for this line has been extended till 4th March.
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Andrew’s Coding Corner Numbers of admissions where one of the Z56 codes were in the diagnoses for SEC providers last year: Z56.1 - 1 Z56.2 - 1 Z56.3 - 11 Z56.6 - 14
Hi everyone – look at my new T-shirt – ‘Problems related to employment’. Hopefully none of these issues affect any of you….. Anyway, this edition I’m focusing on the topical and important issue of the coding of infections. It is not widely known that clinical coding has always made information on bacterial infection in hospital available to management. All that is required is an understanding of the ICD10 diagnostic coding conventions and where to look for the data. • • • •
Patients may be already carriers of infection on admission. It may that an infection is not present or incubating prior to admission, but occurs a number of days after admission within the hospital Infection may arise post-operatively as a wound infection. If the infection occurs some time after discharge the patient may be readmitted and the infection may be the main reason for admission.
Clostridium Difficile (Cdiff) is a bacillus that can cause considerable disease, including diarrhea, colitis and septicemia. C-diff has its own clinical code. The clinical notes should of course carry a record of infection and the clinical coder must be advised by clinicians on the correct interpretation for coding purposes. Putting information to use So all that information is now recorded. How can we best make use of it to improve patient care? Apart from the patient’s notes, the Commissioning Dataset (CDS) is a great set of information. The CDS is generated by the Patient Administration System (PAS) provides information on all admissions and outpatients and can carry up to fourteen diagnostic codes for each episode of care. The CDS is dispatched to Commissioners through Secondary Use Services (SUS) - it is here that the richness of clinical coding can be accessed. Information on infection will be found among the diagnoses - often between the third and sixth mentioned secondary diagnosis, or even lower down in particularly complex patients. A search on the ICD10 code for C Diff for example, mentioned in any position among the diagnosis codes, should yield the required history of C Diff experience in each hospital. This can be translated into an understanding of infection rates, associated with risk factors such as age, specialty and location, and provide evidence of improvement over time. Further information on the coding conventions associated with infections is available from the downloads section of the Knowledge Management website.
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Hello …. We are pleased to welcome Peter Nyaga who joined the SHA Knowledge Management February as Team on 11th Management Information Support Analyst. Peter is completely new to the NHS and joins us from the Army where he served for five years both in the UK and abroad. Peter is aware of the challenges associated with the transition from being a field soldier to an NHS analyst. He is in the process of exchanging familiar Army jargon with NHS abbreviations and coding conventions. “Though I have been with the team for only a short period, I have learned a huge amount and am really excited about working in the NHS. I feel really lucky to be part of a forward thinking and dynamic team and I look forward to getting to know all of you!” Peter
Good bye to…. Last month we said a temporary good bye to Kate Cheema who went on maternity leave for 6 months. In Kate’s absence, any queries related to performance or 18 weeks should be directed to Rebecca Owen. Kate will be rejoining the team in August. It is with sadness that we announce the imminent departure of another member of the team……… Andrew Wilk will be retiring from the NHS at the end of April. Andrew has previously worked for the DH, private healthcare sector and spent 15 years in the NHS. Andrew is sad to be leaving, but is looking forward to spending more time on his many interests, including his granddaughter Ruby, photography, travel writing and spending time in France.
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A3: ASK AN ANALYST If you have a question for the team please e-mail: Knowledge.management@southeastcoast.nhs.uk Q – With so many people moving over to using NHS.net accounts now, I’m worried about making sure that I am using the correct e-mail address for people. Can you help? A – It is difficult to try and guess NHS.net email accounts as they don’t follow a particular format, but it is possible to browse email addresses by organisation on www.nhs.net. Go onto the website then select the ‘contacts’ tab. This gives 2 options for searching for people. Either search for a particular name (top half of the page) or see a list of people per organisation (bottom half of the page). If you are looking for people in an Acute Trust or PCT select ‘Browse by Organisation Type’ click on ‘Browse’ then select ‘NHS Trust’ or ‘Primary Care Trust’ by clicking on the magnifying glass icon next to the organisation type. This will bring up a list of organisations - selecting one will bring up an information page for that organisation including an option to see a list of it’s members. The drawback to looking up people this way is that you can only scroll through an organisation’s members one page at a time, so it could take a while for surnames beginning with ‘M’! But all people with NHS.net email addresses should be listed. - Rebecca Owen, Performance and Planning Analyst Q – I’ve been asked to calculate the specialty outpatient new to follow-up rates. Can you explain how I should go about doing this please? A – To determine the number of attendances select codes 5 and 6 for from the “Attended or Did Not Attend” field in the outpatient record. National Codes 5 Attended on time or, if late, before the relevant care professional was ready to see the patient 6 Arrived late, after the relevant care professional was ready to see the patient, but was seen Andrew Wilk
For patients who attended (as above), from the “First Attendance” field, select codes 1 and 3 for the number of First Attendances and codes 2 and 4 for the number of Follow-up Attendances National codes 1 First attendance face to face 2 Follow-up attendance face to face 3 First telephone or telemedicine consultation 4 Follow-up telephone or telemedicine consultation The new to follow up ratio is the number of follow-ups who attended divided by the number of first attendances who attended, so that the indicator is the ratio of follow-up attendances per first attendance. e.g. if there are 12,000 followups and 750 firsts this will give the result 16. There are 16 follow-up attendances for every first – which can be written as a ratio 1:16. To calculate useful comparative specialty benchmarks from national data is it advisable to undertake the following: • select only similar, appropriate types of organisation, for example: for district general hospitals, exclude PCTs, Teaching and Specialist hospitals and Mental Health • group activity at specialty level into broad main specialties, to avoid the presence or absence of sub-specialties distorting comparison • exclude very low levels of activity which distort the ranking and may be the result of, say, a single outreach clinic with an untypical workflow After selecting the appropriate comparative organisations, typically the best quartile ratio provides a good performance benchmark. However caution is always required in drawing conclusions about performance, which may occur as the result of a different local model of service. However questions are always a good starting point for realising improvement in services. - Andrew Wilk, Business Intelligence and Information Advisor
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Skills Builder: Confidence Intervals In previous issues of Knowledge Matters there have been articles looking at the normal distribution and measures of central tendency such as mean and median, accompanied by a brief look at standard deviation. The next stage is to start to use some of these statistics to make inferences about what our data is telling us. One of the simplest ways to do this, and very useful in terms of looking at abnormal variation from a central tendency, is the calculation of confidence intervals. As the name suggests, confidence intervals can be used to assess how confident we can be that any given value actually came from the data set upon which the confidence intervals are based. For example, in a sample of data where the mean length of stay is 2.4 days for a specific procedure, is an individual’s length of stay for the same procedure of 3 days something to worry about? Is it likely to have come from the same data set? Of course we could use the mean of the data set to compare a value against but this is just one value and we would have to judge how far is too far away from the mean; in the previous example, 0.6 days above the mean may or may not be too far! By calculating confidence intervals we are given a range of values, rather than a single value for comparison. The range calculated gives us an indication of the likelihood that the single value we have is from the same data set as our other readings or that 95% (or 99% or whatever we decide to calculate) of the samples drawn will result in confidence intervals that contain our value. Usually, we calculate at 95%. How this relates back to the normal distribution and the mean and standard deviation is best shown graphically (figure 1).
Figure 1 Sample Mean
In figure 1, the bold central line is the sample mean. To calculate a 95% confidence interval, we multiply the standard deviation by 1.96 and add it to the mean to give us the upper interval, and subtract it from the mean for the lower interval (see table 1 for the values to multiply by for different levels of confidence). In figure 1, the area under the curve given by this calculation is shown in red.
-1.96 sd
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+1.96 sd
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So, let’s say we have our mean length of stay of 2.4 days. Is our value of 3 days outside of what we might expect 95% of the time, in other words should we look upon it as unusual in relation to our existing data set?
Page 5 Table 1: Confidence interval 99.9% 99% 95% 90%
Multiplication value standard deviation +/- 3.3 +/- 2.577 +/- 1.96 +/- 1.645
for
Say the standard deviation is 0.3 days. This would make the 95% confidence interval between 1.81 days and 2.99 days. Strictly speaking, 3 days is outside of the confidence limit so we might wish to investigate this individual further- why have they stayed for longer than we would usually expect? However, there are two points to bear in mind in this case; firstly 3 is very close to 2.99 and secondly, we have the values that fall into the non-shaded areas under our curve- there are always exceptions. What needs to be ascertained is why the exception exists- is it natural or special cause variation? This leads very neatly onto applying the concept of confidence intervals in statistical process control, but that is for another time! Additional sources: An excellent and handy reference book that relates well to medical statistics is PDQ Statistics, by Geoffrey Norman and David Streiner. It includes extensive use of Convoluted Reasoning and Intellectual Pomposity (C.R.A.P) detectors. http://en.wikipedia.org/wiki/Confidence_interval has a good overview of the mathematical aspects of confidence intervals and touches on using them with distributions other than the normal distribution.
Workforce Profiling Tool developed Announcing the release of the SEC Workforce profiling tool! This tool allows you to view age, ethnicity, disability and pay scale information grouped into different areas. The tool allows you to drill down or summarise by SEC organizations, Job Roles and Staff Groups. The Graphical outputs can be manipulated using the Tick Boxes at the sides to add or remove items from the display. This tool is populated with Sept 07 data from the ESR Data Warehouse Updates for this product are planned for a Quarterly basis, For more information or to download a copy please visit our Website: http://nww.sec.nhs.uk/knowledge
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Index of Multiple Deprivation By David Harries, Health Analyst David Harries
The Index of Multiple Deprivation 2007 combines a number of indicators, chosen to cover a range of economic, social and housing issues, into a single deprivation score for each small area in England. This allows each area to be ranked relative to one another according to their level of deprivation. As with the 2004 Indices, the Indices of Deprivation 2007 have been produced at Lower Super Output Area (LSOA) level, of which there are 32,482 in the country. There are also six district summary scores for each Local Authority district (there are 354 districts in England) and for each County Council and higher tier (there are 149 of these). A relative ranking of areas, according to their level of deprivation is then provided. There are also supplementary Indices measuring income deprivation amongst children and older people: the Income Deprivation Affecting Children Index (IDACI) and the Income Deprivation Affecting Older People Index (IDAOPI). The Indices are used widely to analyse patterns of deprivation, identify areas that would benefit from special initiatives or programmes and as a tool to determine eligibility for specific funding streams. All components of the ID 2007 (i.e. SOA, district, county) can be used to describe deprivation in a particular geographical area. The level chosen will depend on the analysis being undertaken and the purpose for which it is to be used. The Index can be used to compare the extent of and concentrations of deprivation within and across local authorities. Domains at LSOA enable a focus on deprivation at a small geographical level. It is therefore possible to identify either the proportion of LSOAs within a local authority which fall within the 10% most deprived nationally (concentration) or the proportion of England’s most deprived LSOAs that fall within each district (extent). Some caution is required when using deprivation scores; patterns of deprivation are complex. In some areas the entire LA may be generally deprived, but with no very severe areas of deprivation. Elsewhere, deprivation may be concentrated in very severe pockets that co-exist alongside generally affluent areas. In interpreting deprivation scores it is also important to remember that the IMD 2007 is a relative measure of deprivation and therefore it cannot be used to determine ‘how much’ more deprived one LSOA is than another. For example, it is not possible to say that LSOA X, ranked 20 is twice as deprived as LSOA Y, which is ranked 40. However, it is possible to say that X is more deprived than Y. SEPHO are currently undertaking a comparision of IMD 2004 to IMD 2007 and this will be available within the next couple of months.
Christmas Quiz Winner!
For further information on IMD 2007, see the website below: http://www.communities.gov.uk/communities/neighbourhoo drenewal/deprivation/deprivation07/
Many congratulations to Damon Rollinson for winning the Knowledge Management Christmas Quiz. Damon is an Information Analyst working at South Downs Health. Amongst other things Damon receives a copy of ‘Excel Charts’ by John Walkenbach (also known as ‘Mr Spreadsheet’). The lucky prize winner was surprised and delighted at the news: “I am really pleased with the book as those who know me know that I'm a bit of an Excel-geek so this is right up my alley! I'd like to think I won on my answers to the technical questions - however, I suspect that it was my guess as to which of your team loved shoes and handbags that clinched it! Much as I would like to keep it all to myself, I will be leaving this at work so we can use it as a shared resource!” The answers to the Christmas Quiz will be released on our website http://nww.sec.nhs.uk/Knowledge Do you have something you would like to contribute to Knowledge Matters? Please contact us!
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Creating Links By Karen Taylor, Director, Health Value For Money Audit The National Audit Office (NAO) is an independent public sector body that scrutinises public spending on behalf of Parliament. We conduct financial audits of all government departments and agencies and many other public bodies, and report to Parliament on the value for money with which these bodies have spent public money. Our work saves the taxpayer millions of pounds every year, at least £9 for every £1 spent running the office. Within the NHS, the NAO can sometimes be confused with the Audit Commission, which is responsible for auditing the accounts of individual NHS trusts and PCTs. However, the NAO audits the consolidated accounts of these NHS bodies and has a statutory responsibility to report to Parliament on the economy, efficiency and effectiveness with which the “Our work saves the taxpayer Department of Health and NHS bodies are using their resources. We carry out six or seven millions of pounds each year, at major value for money studies per year on the Health Area, each of which results in a least £9 for every £1 spent report to Parliament and an examination of our findings by the Committee of Public running the office.” Accounts. As well as holding the NHS to account, we also seek to identify and highlight good practice. In order for us to collect sufficient robust reliable information and data on NHS activity we require the cooperation of the Department and the NHS Trusts, for example through surveys, and other requests for information. The chief executive of each NHS body is appointed as the organisations ‘accountable officer’ and as such is required, by statute, to respond to our requests for information. However before we seek the information we need, we first establish whether that information is available from any other source and, if so, make use of that information. With this in mind, we are a voluntary signatory to the Healthcare Inspection Concordat which is an agreement with other audit, inspection and regulatory bodies to help reduce duplication of data collection. In 2007 we published reports on a wide range of issues: Clinical Governance in Primary Care; Dementia services; GP Prescribing Costs; Crisis Resolution Home Services; Neonatal Services; the Consultants’ Contract; and the Dr Foster Intelligence joint venture. A summary of these reports and details of our current work programme can be found on our website at http://www.nao.org.uk/guidance/Health_Focus/Health_Focus_Autumn_2007.pdf. Our most recent reports include a review of Arms Length Bodies (published 25 January); and GP Contracts (due to be published on or around 28 February).
“The NAO has a statutory responsibility to report to Parliament on the economy, efficiency and effectiveness of the NHS”
Over the next 6 months we intend to publish reports on NHS and Social Care Complaints Handling, Access to Alcohol Services, End of Life Care and a follow up on progress with the National Programme for NHS IT (Connecting for Health). We are also in the process of scoping studies on Agenda for Change and an update on progress on Hospital Acquired Infection, which we hope to publish towards the end of 2008/early 2009. In choosing the subjects for a national examination, we aim to cover a balanced portfolio of issues, for example looking at key areas of risk or materiality to the NHS or identifying areas that may be considered ‘cinderella’ services. In order to be effective we need to understand the issues from the patient and NHS staff viewpoint. If you feel that there is an area that you think we should consider examining or are interested in sharing your views about any of the above subjects, then we would love to hear from you, please contact Andy Fisher, Audit Manager at karen.taylor@nao.gsi.gov.uk
“In order to be effective we need to understand the issues from the patient and NHS staff viewpoint”
For further information visit our website www.nao.org.uk Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team
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News and Updates…
This Issues Useful Links …
Joint Strategic Needs Assessment guidance published
NHS Data Model and Dictionary Service
The JSNA guidance is now available on the DH website: http://www.dh.gov.uk/en/Publicationsandstatistics/Pu blications/PublicationsPolicyAndGuidance/DH_081097
This site provides information on the NHS Data Model and Dictionary Service (NHS DMDS) and related products. This site is aimed at supporting the process of Data Standards implementation across the NHS. http://www.connectingforhealth.nhs.uk/systemsandservice s/data/datamodeldictionary
The South East England health strategy launched The first Health Strategy for the South East was launched on 7th February. The strategy aims to ensure that the region becomes the healthiest place to live in the UK and one of the healthiest regions in Europe. This strategy will be of interest to all organisations and groups that have a role to play in helping improve the health and well-being of the population and reducing inequalities. http://www.sepho.org.uk/pages/viewResource.aspx?id =11138 NHS South East Coast Operating Framework published The NHS South East Coast Operating Framework was published on 19th February. This is a document which sets the strategic direction for services and the standards required of NHS organisations within South East Coast over the next three years. http://www.southeastcoast.nhs.uk/documents/NHSSEC OperatingFramework2008-11.pdf Better Care, Better Values Indicators The next release of data is due to be published midMarch.
Microsoft NHS Resource Centre An interactive web portal dedicated to NHS staff and healthcare partners in order to share best practice and experience across healthcare and IT through articles, events, tips, user groups and discussion forums. There are a range of on-line training resources on Powerpoint, Excel, Word and Outlook which can be freely accessed once registered on the website. http://www.microsoft.com/uk/nhs/default.aspx Association of Public Health Observatories (APHO) The Association of Public Health Observatories (APHO) represents a network of 12 public health observatories working across the five nations of England, Scotland, Wales, Northern Ireland and the Republic of Ireland. APHO produce information, data and intelligence on people's health and health care for practitioners, policy makers and the wider community and have a lot of expertise of turning information and data into meaningful health intelligence. The website contains a significant number of tools and resources, technical briefings and details of national events. http://www.apho.org.uk
Prize available The Knowledge Management website has now been live for nearly a month and has over 140 registered users.
Knowledge matters is the newsletter of NHS South East Coast’s Knowledge Management Team, to discuss any items raised in this publication, for further information or to be added to our distribution list, please contact: Knowledge Matters C/O Knowledge Management Team NHS South East Coast York House 18-20 Massetts Road Horley,Surrey, RH6 7DE Phone: 01293 778899 E-mail: Knowledge.management@southeastcoast.nhs.uk To contact a team member: firstname.surname@southeastcoast.nhs.uk
The benefits of registration include the ability to download tools and products and participate in a range of on-line forums. The first 200 registered users of the website will be entered into a prize draw, so get registering – it could be you!
Quick Quiz Which of the following would be appropriate for a t-test to determine? 1. If a small set of pieces of oak firewood burn longer than pine firewood 2. Whether the weight of all male golden eagles in a population is statistically different 3. Which of several medicines has the greatest effect on cell growth 4. Whether an anti-cancer drug increases the number of patients who survive more than one year
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