Knowledge Matters Volume 2 Issue 6

Knowledge Management Team, South East Coast Strategic Health Authority knowledge.management@southeastcoast.nhs.uk nww.sec.nhs.uk/knowledge

INSIDE THIS ISSUE 2

Data Quality

Patient Experience Tool

4 5 6 7 8

Making Links – NHS Institute Unify 2 Developments Professionalising Health Informatics Portal Specialist Commissioning Library Skills Builder – Designing a Dashboard

HCAI Dashboard

A : Ask an Analyst

12 14 16

Who’s who in the Quality Observatory News and updates Institute Tools and Christmas Quiz results

Fascinating Fact Between April and December 2008 in South East Coast acute Trusts: One man was treated for "Third degree perineal laceration during delivery" and another was treated for "Other specified pregnancyrelated conditions"!

February 2009 Volume 2 Issue 6

Welcome to Knowledge Matters By Samantha Riley

Hello and Happy New Year! It has been a really exciting start to the New Year for me.... I am writing to you for the first time as the Head of the Quality Observatory for NHS South East Coast. ‘What does that mean?’, you may be asking. “High Quality Care for All” outlined the expectation of the Department of Health that each SHA would establish a Quality Observatory which built on existing analytical arrangements, to enable local benchmarking, the development of metrics and identification of opportunities to help frontline staff innovate and improve the services they offer. There has been no nationally prescribed model for a Quality Observatory; instead the Department of Health has described the functions that they expect the Observatory to provide. As a consequence the models which are emerging across the country are quite varied. Here at South East Coast, we have for some time had the Knowledge Management team. You will (I hope) be aware that we have developed a wide range of benchmarking tools and dashboards (nearly 40 in fact) which we have provided to local organisations to enable them to understand how they are performing over time against a wide range of indicators. We have also worked with local clinicians and managers to undertake more exploratory work in the field of clinical metrics – examples of this include the stroke and dementia metrics and Safer, Smarter Nursing Metrics. So, in many ways we already have a Quality Observatory established (so in some way minimal change for us). The context in which we are working has, however, changed and the formal establishment of a Quality Observatory provides us with a fantastic opportunity to re-focus our priorities to ensure that the information that we are providing to local organisations really drives improvement in the quality of care that patients receive. We will continue to provide support to the local NHS in the form of the provision of benchmarking information and measurement advice. In addition, we aim to work with local organisations to increase the ability of clinicians and managers in the area of measurement and interpretation of data. Strong links already exist with the Public Health Observatory and Government Office of the South East – these links will be formalised and additional links made to other regional bodies and teams to ensure that maximum synergy between related functions is realised. The work programme of the Quality Observatory will be overseen by the regional Quality Board (chaired by Candy Morris). I would be really pleased to present to any local groups that would be interested to learn more about the Quality Observatory and what we can provide. This will enable me to gain a better understanding of how we can help all of you to improve the quality of care that patients receive throughout Kent, Surrey and Sussex. I look forward to hearing from you!

Samantha Riley

Knowledge Matters

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Data Quality Dashboards & KPIs

Lorraine Gray, Programme Manager, SUS/HES Data Quality The promotion of data quality is a core work stream of the NHS Information Centre for Health and Social Care (IC). In order to support the quality of Commissioning Data Sets for providers and commissioners of NHS patient care, the IC has developed and continues to develop tools to report progress and status of data quality and completeness. The Data Quality Dashboards are published as national resource to support the improvement and completeness of Commissioning Dataset (CDS) data flows to SUS in accordance with published data standards. The dashboards also assist organisations in preparation for PbR and 18 week monitoring through SUS, with regular reports on the quality of data items used in the PbR and 18 Week algorithms that enable the allocation of a national tariff or link records into Referral to Treatment pathways. Two versions of the Dashboard are available – one that allows the user to drill down to Provider level data and one to Commissioner level data. The dashboards use CDS data submitted by providers of NHS funded care for: - Admitted Patient Care (APC) - Outpatient (OP) - Accident and Emergency (A&E) The current dashboards are based on data submitted to SUS for 2008/09 by the Month 8 PbR inclusion date (19/12/2008). Recent updates include the addition of new data items 'Site of Treatment' and 'Neonatal Level of Care'. For specific validation rules applied to these items, please use the 'more info for data item' button within the Dashboard. 'Neonatal Level of Care' has been included in order to assist organisations in preparation for the use of HRG4 in 2009/10, as records where this is null are considered invalid for grouping. " More information on the Data Quality Dashboards is available at http://nww.connectingforhealth.nhs.uk/reporting-services/data-quality

The monthly SUS CDS submission Key Performance Indicator (KPI) report reports on Commissioning Data Set (CDS) submissions to the Secondary Uses Service (SUS) in light of the future direction outlined in the 2008/09 NHS Operating Framework (see left) "From April 2008, we expect providers to deliver initially coded datasets weekly to support achievement of the 18-week target, and comprehensively coded datasets monthly. These are expected to be through the Secondary Uses Service (SUS), as soon as each provider can make the necessary technical changes. This is in preparation for April 2009, when the NHS should use SUS as the standard repository for activity for performance monitoring, reconciliation and payments." [NHS Operating Framework 2008/09 - section 3.35] • • • •

KPIs 1.1-1.3 looks at the percentage of providers showing evidence of weekly CDS submission for APC, OP and AE datasets. KPI 2 looks at the percentage of providers showing evidence of comprehensively coded monthly APC CDS submission. KPI 3 looks at the percentage of providers with 100% of APC CDSs sent using net protocol. KPI 4 looks at the percentage of providers using version 6 APC CDS with key 18 week wait fields populated.

The KPI report can be downloaded monthly from the http://www.connectingforhealth.nhs.uk/systemsandservices/sus/whatsnew Interpretation notes are included on the "Notes" worksheet within the report. Do you have something you would like to contribute to Knowledge Matters? Please contact us!

SUS

What's

New

website

Knowledge Matters

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Patient Experience First Steps Diagnostic Tool Jeremy Burrows, Assistant Statistician, Department of Health

When we go into hospital, or visit our GP, it is a pretty stressful time and of course our number one priority is to have good treatment and to get well. However, people also want to be treated with dignity and respect, to be listened to and to have a say in their care and treatment, and how local services can be shaped to meet their needs. The Department of Health is committed to achieving sustained improvements in patient experiences as measured by independently validated surveys. This is set out in the Department of Health’s PSA target 19.1 ‘The self reported experience of patients/users’. The Healthcare Commission is responsible for managing the national patient survey programme. The surveys are conducted among a sample of recent service users, and are completely standardised – all Trusts/PCTs use the same questionnaire, select patients in the same way, conduct the survey at the same time, and analyse results in the same way. This means that the experience of patients using services provided by different trusts/PCTs can be compared. So, how can a toolkit help? Analysts and policy leads in this area believe that organisations can make big improvements in patient experience by focussing on a relatively small number of key areas. The sheer volume of data can make it extremely difficult to identify where those key areas are. With this in mind, the Department of Health has developed a ‘Patient Experience First Steps Diagnostic Tool,’ to aid understanding of the available data sets. The tool concentrates on data from surveys across five healthcare settings and uses the latest available data : - Adult inpatients 2007/08; community mental health services 2007/08; primary care services 2007/08; outpatients 2004/05; A&E 2004/05. Select your organisation type: The tool is really easy to use. From the ‘Start Here’ page users can select their organisation type, their specific organisation and the survey of interest. The page then displays all the questions used to calculate the domain and overall PSA scores. Users can 'drill down' to the individual questions for each domain to see how the scores are built up and can easily see which questions they need to improve upon to increase their score. The two most recent years of data available are shown where possible. Charts show the selected Trusts score against the 80th percentile score.

Acute trust

Aintree Hospitals NHS Trust

Then choose a survey: Inpatient 2007/08

Overall scores - click on a 'domain' to see how the score is built up: 2007/08 Data

Q9: How do you feel about the length of time you were on the waiting list before your admission to hospital? 1

80 70 Score

60 50 40 30 20 10 0 Aintree Hospitals NHS Trust

Aintree Hospitals NHS Trust

Ashford and St Peter's Hospitals NHS Trust

Barking, Havering and Redbridge Hospitals NHS Trust

Inpatient 2007/08 survey 80th percentile (07/08)

Barnet and Chase Farm Hospitals NHS Trust

Barnsley District General Hospital NHS Trust

Inpatient 2006/07 survey England average (07/08)

Barts and The London NHS Trust

80th percentile 87

Safe, high quality, coordinated care

Drill down

Better information, more choice

Drill down

Building relationships

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Clean, comfortable, friendly place to be

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Domain scores against 80th percentile

Score

2006/07 Data

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Overall

Select the question you would like to chart from the Inpatient 2007/08 survey

Trust Score

Access and waiting

OVERALL DOMAIN SCORES

Q9: How do you feel about the length of time you were on the waiting list before your admission to hospital?

100

DATA MINING On this sheet you can drill down from the national patient experience scores. For example, you can look at the headline scores included in plans for Vital Signs and drill down to see which survey questions feed in to those scores. Use this sheet to find out which survey questions feed in to the national scores and to identify the question areas where you might focus attention to improve the overall score.

Choose your organisation:

100 90 80 70 60 50 40 30 20 10 0

aw shqcc bimc br aw

shqcc

bimc 80th percentile

ccfp

Overall

ccfp

Trust Score

Overall

The ‘Possible quick wins’ page automatically displays three questions for which the selected Trust performs poorly in relation to other Trusts. It also shows four questions where scores are low across most Trusts. Users are able to select up to six other Trusts for comparison of scores. The ‘Comparison across the SHA’ page enables Trusts to compare their scores, for all questions that make up the domain and overall PSA scores, with other Trusts within their SHA or elsewhere. Along with the selected Trust’s score, the England average and SHA average scores are given for comparison.

The ‘Chart data’ page allows users to select individual questions to be charted from their chosen survey. A bar chart displays data from the survey and, where possible, the previous year’s survey for trusts selected from the ‘Possible quick wins’ page. Lines indicating the England average and the 80th percentile scores are also shown. If you would like to download the tool, please go to the following link. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091660 The tool will be updated as and when new survey data is available (new data for the A&E 2008 and Adult Inpatients 2008 surveys will be available soon). Keep an eye on Knowledge Matters for further news. I hope that you find the tool of use - comments or suggestions for improvement are most welcome as we really do want this to be a useful resource for the NHS. Here is my e-mail address jeremy.burrows@dh.gsi.gov.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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Knowledge Matters

Making Links – NHS Institute Martin Samuels, Head of Commissioning for Health Improvement ‘All too often healthcare managers and leaders see data as the beginning and ending of the journey. They live and die by numbers. The data allow us to set our improvement journey, not define an end to the journey.’ Dr Robert Lloyd, Executive Director of Performance Improvement for the US-based Institute for Healthcare Improvement Measurement for improvement The latest Operating Framework describes measure for improvement as ‘an important priority for all NHS organisations and staff in 2009/10’ (p 25) and here at the NHS Institute we offer a programme built around improving technical capability in this area. It is one part of a broader commissioning work programme that is currently being negotiated with the ten Strategic Health Authorities for the 09/10 financial year. In addition to improving technical capability in a range of areas, we can also offer support in the areas of enabling change and working with partners. We also signpost to other support and guidance available to commissioners, see www.institute.nhs.uk/pctportal Improving technical capability in measurement for improvement The NHS Institute currently offers a powerful combination of data tools and a development programme – Turning data into information for improvement. We provide a wide range of data tools – please have a look at the back page of the newsletter for a summary of what is currently available. In September of last year, we launched Turning Data into Information for Improvement, a six-month development for Strategic Health Authorities, Primary Care Trusts and their partners. We are privileged to be working with Dr Robert Lloyd, Executive Director of Performance Improvement for the US-based Institute for Healthcare Improvement, who leads each of the three workshops. Bob is the only person that I know that can make statistical process control exciting; he is an excellent communicator and a great teacher. When we set out on this journey early last year, we knew that world class commissioning was placing greater emphasis on a sound evidence base and that a greater level of sophistication was required in the use to which data was put. The NHS typically uses data as a tool for performance management, rather than as a tool for service improvement. We wanted to create a movement that challenged that. But we didn’t want to provide only a lesson in theory; we wanted to deliver a practical programme that enabled real progress to be made on local challenges.

Dr Robert Lloyd

Over the last five months we have been joined by over 600 individuals who have engaged in thought provoking conversations about aim statements, driver diagrams and variation. They have also provided our logistics team with a fair number of challenges! Not only are we taking our participants on a learning journey, but after each session in London we travel en masse to Manchester to get ready to meet our colleagues from the north of the country. We spend the journey reviewing the feedback forms to identify any improvements that we can make to day two – that’s assuming we all manage to get on the same train! Colleagues from NHS South East Coast are playing an active part in applying the principles at a local level and we are grateful for their contribution to the development of support material. We are currently exploring the potential to work more intensively with selected PCTs across the country to learn how best to embed the science of improvement in commissioning organisations. I’m really excited about where we have got to and look forward to working with you all more closely as we turn data into information for improvement For more information about the NHS Institute’s work in commissioning go to www.institute.nhs.uk/commissioning or email me martin.samuels@institute.nhs.uk - I am happy to put you in touch with a member of my team to discuss any aspect of our work in more detail. Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

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Unify 2 Developments ……. Dianne Tew, Department of Health Hello and Happy New Year! In this issue I am aim to provide you with an overview of forthcoming developments to improve Unify and make your lives easier! Plus update you on progress made over the last 2 months. UNIFY2 Enhancements I am pleased to report that the Information Systems Programme Board (ISPB) board met at the end of January and approved Phase 1 of the proposed enhancement project. Improvements in the following areas are included in this phase of the project – we believe that these improvements will make a significant difference to all of you who use Unify on a regular basis : • • • • • • • • •

Improvements to the status reporting of data entered into Unify2; Performance tuning and improved functionality in the View/Manage module; Greater control over when the NHS can upload data into the system; Efficiencies in the management of user accounts to reduce errors and improve security; More flexibility in the administration of user forums; Automation of the “un-collect” process that allows collections to be rolled back to Provider level, allowing resubmissions; Access enabled for a wider NHS audience; Improvements to the processes for data revision and the migration of data into the system; A comprehensive and definitive set of testing scripts for the system, together with training and guidance material

We are proposing a second phase of the enhancement project which will incorporate more strategic changes to Unify2 that will improve the performance and scalability of the system to cater for the current and future growth in demand. I will tell you more about this in a future issue.

Coming soon to Unify 2 …..

Report library problems A number of problems raised in respect of the report library have now been addressed. Seven of the 10 previous period’s logs have been completed and are now live. The final two library logs are planned to be part of the March release. The January release contained fixes for another two logs relating to the report library. As a result of this work, feedback from users suggests that the report library has become more stable and easier to use. If you are still experiencing problems, please do contact the Unify 2 Inbox : unify2@dh.gsi.gov.uk Quick place Quick place is a collaborative working tool which we think could be really helpful to Unify users as it can store a range of documents relating to the day to day management of Unify2 and other useful information in one place. We have begun to populate the Unify2 Quickplace with Unify2 News and other supporting documents. We will be testing this out with selected users and then hope to provide access to all Unify 2 users later in the spring.

PEXIS (Patient Experience) The Patient & Public Empowerment team are keen to store Pexis data within Unify2. This will enable patient experience data to be compared and combined with other data collected by Unify2. Central Contracts Management Unit (CCMU) The CCMU collects data from Independent Sector Healthcare providers. In the future, we hope that this data will also be collected by Unify2.

Good news The number of outstanding logs are at the lowest level since Unify2 was launched in May 2007. There are currently 59 logs on the Unify2 Logs database. Progress is now being made in reducing the overall number of logs.

Again, can I please take this opportunity to remind you all to please continue to log your queries with the Unify 2 Inbox unify2@dh.gsi.gov.uk If you have forgotten your password or need a Unify 2 account created, you can contact Rebecca Owen or one of her team (contact details appear on page 13). Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

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Professionalising Health Informatics Portal By Jackie Smith, Health Informatics Development Manager Introduction The aim of the Professionalising Health Informatics (PHI) portal is to provide an online facility, a 'one-stop shop', containing information and links to Health Informatics professional and personal educational, leadership and managerial development opportunities. It has been developed in response to an identified need for the availability of a single URL for individuals and organisations, providing access to information on personal and professional development activity in Health Informatics. • • • •

A comprehensive single point of access, an online ‘one-stop shop’ for all HI-related development opportunities; Primarily an information filter, rather than duplicate information available elsewhere, PHI signposts users to original sources ensuring latest versions of resources and information remain with and are owned by the originator; Main sections: About Us, Personal Progression, Hot Topics and Useful Links; Key Resource – the Learning Web.

Background As the development of Health Informatics has progressed and development opportunities and materials have multiplied growing need was identified for an online ‘one-stop shop’ facility containing information and links to all Health Informa professional, personal, educational, training, leadership and managerial development opportunities. In order to ensure the success of PHI and deliver a consistent and quality assured online resource, we need the support of everyone working in health informatics to help identify relevant, up to date content. The interests of the PHI audience are key to determining its content which is why you are encouraged to use the feedback facility to forward suggested changes and additions. If you would like to bring a subject to our attention please send details using the feedback form under the Contact Us section: http://www.connectingforhealth.nhs.uk/phi/about/contact-us PHI is hosted on the NHS CFH website and the project team has worked closely with the NHS Connecting for Health team plan and develop this online facility, which was launched on Friday, 9 May 2008. Hot Topics Content 'of the moment' is available through this section of PHI. References will change to reflect key topics at the time, or new development opportunities in Health Informatics Further development The content of PHI will continue to be regularly reviewed and increased, with additional pages being added over time. The Learning Web has also been designed to enable further sections to be added. The content of PHI will continue to be regularly reviewed and increased, with additional pages being added over time. The Learning Web has also been designed to enable further sections to be added. Find out more The best way for users to familiarise themselves with PHI is to explore the resource, as there are likely to be topics of interest to all. These include subjects like mentoring, networking, leadership, career pathways and the development of essential IT skills. To find out more visit PHI by following this link: http://www.connectingforhealth.nhs.uk/phi. Do you have something you would like to contribute to Knowledge Matters? Please contact us!

On-line communities…

eSpace is a community based tool dedicated to improving healthcare by encouraging members to share their experiences of technology enabled change. Communities are groups of people with a common interest, including R&D, technologies and many more. You can join a community by clicking on the Community Insights tab - just click on a community link to request access. There are loads of links to news and events that can affect all Health Informatics professionals; registration is free. Check it out at: http://www.espace.connectingf orhealth.nhs.uk/

Knowledge Matters

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National Library for Health - Specialist Commissioning Library Trudy Turner, Library and Knowledge Services Manage, Kent and Medway NHS & Social Care Partnership Trust & Eastern & Coastal Kent PCT

I would like to tell you about a unique on-line information service which will help PCTs commission effectively. Commissioning health services is an increasingly important and complex task. Commissioning teams have responsibilities ranging from assessing population needs and prioritising health outcomes, to procuring products and services, and managing service providers. The Commissioning Specialist Library (CSL) is a new, online information service delivering 24/7 desktop access to timely and high quality information and knowledge resources for anyone with an interest in, or responsibility for, commissioning for health and wellbeing. The CSL, managed by The King’s Fund, offers guides on the various types of commissioning and brings together resources on commissioning processes and competencies such as collaborative working or engaging the public, as well as advice on developing knowledge and skills. The CSL offers Key Topics brief summaries and links to useful sources of information on some tricky subject areas, including demand management and transformational change. It also provides a stash of Toolkits to help with many commissioning challenges. The anticipating future needs toolkit, for example, provides a proven, consistent methodology for consultation on the future care needs of older people in the local community. Dig deep, and there are some great nuggets on this site. Some time-saving model job descriptions and person specifications as well as a useful little set of legal references. There are signposts to comparative, demographic, episode, financial and performance statistical resources and, if you click over into commissioning competencies, supporting materials for everything from financial investment to stimulating the market. New additions to the site are highlighted, but if you aren’t going to have time to visit too often, why not sign up for an RSS feed to alert you of the very latest resources available? To be an excellent commissioning organisation, you have to be a learning organisation, right? Have a look at the CSL’s handy list of professional journals accessible via your desktop. Titles include Development and Learning in Organizations, Leadership and Organization Development Journal and Public Management Review. Electronic journals can be tricky to access, and for many you will need an NHS Athens account. Ask your local health librarian to demystify electronic journals for your commissioning team to promote active learning and engagement with the evidence base in its broadest sense. Find your local health library service at the following link http://www.library.nhs.uk/mylibrary/default.aspx As a frequent user of many web based knowledge resources, I sometimes longed for more ‘overview’ information for each subsection of the site – instead of being launched straight into the resource collection for each site area. Some people, especially busy commissioning teams, may not agree and may argue that the 3 clicks rule (If users can't find what they're looking for within three clicks, they're likely to get frustrated and leave the site) matters more. Also, in places, the content of this site seems to work against the rigid specialist library website structure, with case studies crow-barred into the guidance and pathways tab for example. The patient information tab often feels underused and therefore slightly pointless. However, the site is a wonderful collection of genuinely mission critical information resources. I would urge you to visit and browse the full content. Then, set up your RSS feed to receive regular updates from this valuable new resource. For help and support in making the best of the CSL, and converting the many useful online information resources into a usable business asset for your commissioning team, contact your local NHS Library Service! Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

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Skills Builder – Designing a Dashboard Charlene Atcherley-Steers and Nia Naibheman Performance Analysts, South East Coast SHA

I am sure you have all been wondering how we create such beautiful dashboards. Believe it or not, it is much simpler than you think. Especially if you follow our step by step instructions. If you are unsure of what a dashboard is here is a simple definition: “A visualisation tool that provides graphical depictions of current key performance indicators in order to enable faster response to changes in areas” In just three articles we will cover an in-depth guide on how to make your own dashboard. In this first part, we will discuss the design of your dashboard including graph types, colours and the types of questions that a dashboard can help you answer. The second part (in April) will cover the data sheet behind your dashboard and the final part (in June) will bring it all together. Before you can start to create your dashboard you need to be clear about its purpose. Are you trying to compare performance across a range of organisations? Or actual performance over time against a plan or target? Or, are you trying to gain an understanding of how a range of indicators might be inter-related? This really is the most important part of your dashboard design. If you don’t know what you are trying to answer, a lot of time will potentially be wasted on the development of a dashboard which doesn’t tell you what you want to know. For those of you who are not analysts, we would recommend that you sit down with your local analyst at the very start and have a discussion about what you are thinking of – by doing this you should end up with a better product. Let’s have a look at a few examples…..

EAST SUSSEX DOWNS & WEALD

EASTERN & COASTAL KENT

HASTINGS & ROTHER

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Some of you may simply view this data in a table or spreadsheet. One of the problems with this is that it

Actual Monthly Figures

BRIGHTON & HOVE

Mar-08

For a simple question such as ‘What percentage of GP’s are offering extended surgery hours’ we use a simple dashboard (right) which the target percentage (in blue) and the actual percentages reported each month. At SHA level, we are interested in all PCTs (we have 8) so we have a graph for each of these. A PCT may be interested in how other local PCTs are performing, but would also want to have a look at individual practice performance.

0809 Vital Signs Target

PERCENTAGE OF PRACTICES OFFERING EXTENDED OPENING

can be difficult to identify trends. The benefit of a data table is that it provides you with the exact values which may be difficult to identify on a graph. If precise data values are important to you, we would recommend using a data table in addition to a graph showing progress over time. Some areas are more complex and therefore require a more sophisticated dashboard. A good example of this is 18 weeks. Here’s our weekly PTL commissioner based dashboard (left). We are using a broad range of indicators – all of which directly impact on achievement of 18 weeks. By viewing the indicators together, we gain a richer picture of how an organisation is performing in this area. Here we are using a range of drop down boxes which enable the user to select the view that they are interested in – e.g. admitted or nonadmitted patients, different providers. Again, we can see actual performance over time against the target. Colour is used to differentiate between time bands on the bottom right hand graph. Have a look at the dashboards section of our website (nww.sec.nhs.uk/knowledge) for more examples of dashboards that we have created. Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

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Another example of a more complex dashboard is the provider based stroke metrics dashboard which Simon has recently completed. Drop down boxes enable different types of patients to be included/excluded in each graph. Ashford & St Peters Hospital Trust Stroke Dashboard - All Patients - ICD10 I61-I64 ASU RSU CSU

5 5 4

T Sentinel Overall 08 vs 06

Exclude I60 - Subarachnoid Haemorrhage

Admissions 140

% Patients With CT Scan / MRI Scan

Mortality 30%

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% Discharge Destination

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Total Value of Activity 000's

Average Value per Spell 70%

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30% CT Scan

% Stroke Patients Admitted from UPR & Discharged to UPR

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

20%

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

Most Recent 100 Patients Run Chart 90 Alive

Died

Unknown

Mean 10.7

UCL 46.5

80 60%

£4,800

£500

70 50% £400

£4,600

£300

£4,400

Days

40%

30% £200

50 40 30

£4,200 20%

20 £100

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10%

Site

National

18/03/08 19/03/08 24/03/08

11/03/08

02/03/08 07/03/08 08/03/08

20/02/08 22/02/08 23/02/08 25/02/08

15/02/08

01/02/08 04/02/08 07/02/08

27/01/08

17/01/08

11/01/08

06/01/08

31/12/07

28/12/07

24/12/07

21/12/07

17/12/07 18/12/07

0 12/12/07 13/12/07

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

£3,800

04/05 Q1 04/05 Q2 04/05 Q3 04/05 Q4 05/06 Q1 05/06 Q2 05/06 Q3 05/06 Q4 06/07 Q1 06/07 Q2 06/07 Q3 06/07 Q4 07/08 Q1 07/08 Q2 07/08 Q3 07/08 Q4

£0

Additional information is provided on the top left hand corner of the graph – here we can see what types of stroke unit are available at each hospital site and also how each organisation performed on the sentinel audit. The large graph is an SPC chart – this shows the length of stay for individual patients, colour coding adds an additional dimension by indicating whether a patient were discharged alive or died. Some colours have preconceived meanings, for example using Red, Amber and Green are commonly used to indicate bad, ok and good respectively. So if you are showing something good try not to use red! Consistency is imperative, keep the colour scheme the same if possible on each chart,

further more make sure that the background colour scheme doesn’t drown out the foreground. Some national benchmarks are provided on the stroke dashboard. We’d recommend that you include national comparators where at all possible. The national average can be useful, but indicating performance within different quartiles adds even more value. It isn’t possible to obtain national comparators for every single indicator and you may have difficulty in tracking national comparators down. This is an area that we can potentially help you with – please make contact with one of the team who will help you out. If you have labels on your chart make sure they are readable, although it is easy to get carried away with fancy fonts it may not always be easy to read and defeats the purpose. A good rule to keep in mind is that any information on a dashboard should be adding value and providing the user with additional, relevant information – meaningless distractions are not helpful and should be avoided at all costs. If you need to show a key on your chart then the positioning is also important, again try to keep it consistent across all charts so the user can see easily which chart it relates to. The aim of the dashboard is to make it easy for the user to ‘read’ and navigate.

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Positioning of the drop down boxes is essential in giving a guide to the user on how they work. Placing the drop down boxes at the top will lead the user to believe that the whole dashboard will be affected by their

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selection. Placing the drop down box above a chart should tell them that it changes only that chart. It is also important that you size the boxes appropriately so that the whole line of a selection can be seen. These features provide a good foundation for a dashboard. But as we explained at the start, one of the most important steps in dashboard design is being clear about it’s purpose – please please do take time to think this through and plan your dashboard design with your local analysts In the next edition we will be explaining how to create the data sheet that drives your dashboard. In the meantime, if you have any questions on dashboard design (or can’t wait until April for the next instalment), please do get in touch with one of the team – we would be more than happy to help and advise you. Finally, we do have a large number of dashboards already created – log on to the website (remember that you need to be registered as a user) and have a look – you may get some good ideas about the type of dashboard design which will best support your needs. See you in April! Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Page 10

HCAI Information Katherine Cheema, Specialist Information Analyst The issue of healthcare associated infections (HCAI) is a big priority for the NHS and there are pledges in place from the Department of Health, the SHA and HM Government to decrease incidence in a big way. As it is not currently possible to monitor all infections, the focus has been on two: MRSA and Clostridium Difficile, both very nasty little bugs (see the boxes!). As with all targets in the NHS there is an expectation that Trusts, PCTs and SHAs monitor progress against agreed trajectories very carefully and provide assurance to all that issues are being dealt with. The main data source for HCAI is the HPA Surveillance database (also referred to as MESS, which stands for MRSA Enhanced Surveillance System) which is updated by acute Trusts. And here is where things get tricky……not all incidences of HCAIs (in this case defined as MRSA and C.Difficile) are acquired in a hospital but it is almost always a hospital based lab that carries out tests and report cases. So, how do we decide what has been acquired inside hospitals (trust acquired) or outside hospitals (community acquired)? Well, the definitions have been fought out by the microbiology people; there are two different definitions for MRSA and C.Difficile:

• Only MSRA bacteraemia (blood stream infections) are monitored • Antibiotic resistance makes it difficult to treat • Killed by alcohol hand gel

For MRSA if a person has tested positive for a bacteraemia (blood stream infection) less than 48 hours after they have been admitted then the case is considered community acquired

For C.Difficile, if a person has tested positive less than 72 hours after they have been admitted then the case is considered community acquired. In both cases, the HPA considers cases where patients have not been admitted to the acute Trust (e.g. are diagnosed in A&E or a PCT run hospital) as community acquired UNLESS (yes, unless) they had been admitted in the previous 28 days (in which case it can still be acquired in the acute hospital).

• Over 85% cases occur in the 65+ age range • Produces spores that can stay dormant on surfaces until ingested • Only effective hand washing will get rid of it!

In reality, it is difficult to measure time elapsed based on hours and the calculation is actually based on calendar days; this can cause some confusion when reviewing cases so it is important to be aware of the distinction. There are no fewer than three different trajectories for these organisms: an SHA ‘ambition’ trajectory for MRSA, seeking to reduce hospital acquired MRSA to zero by 2010/11; a national C.Difficile trajectory, looking to reduce the national incidence of the disease by 30% by 2010/11; and finally an SHA ‘ambition’ trajectory, hoping to bring SEC wide incidence of C.Difficile to less than 2,000 cases by 2010/11. Monthly Summary of Healthcare Associated Infections - South East Coast SHA Data Source: HCAI Data capture system - Health Protection Agency (last downloaded 14th January 2009) Number of C-Diff cases (aged over 2 and attributable to the Trust)

Number of MRSA Bacteraemia Monthly Actual

Local Limit

National Limit

Commentary:

Monthly Actual

National Limit (Vital Signs)

MRSA Performance:

Local Stretch Limit

Previous year actual

YTD, National limit 228, local limit 181, actual 188. The National cumulative rate of 5.19/10,000 ordinary admissions.

300

35 30

250

25 200

C.Diff Performance:

YTD, National limit 1475, local limit 1664, actual 994. The National cumulative rate of 2.96/1,000 ordinary admissions. Total C.diff for SEC in December is 157.

150 15 100

NB: national limits have been updated to reflect provisionally revised trajectories. Stretch limits remain at pre-refresh levels. Please interpret with caution!

Estimated rate of MRSA bacteraemia reported per 10,000 admissions Monthly Rate (actual)

Mar-09

Jan-09

Feb-09

Oct-08

Dec-08

Nov-08

Jul-08

Sep-08

Estimated rate of C-Diff cases (aged over 2) reported per 1,000 ordinary admissions (attributable to Trust)

Monthly Rate (limit)

Monthly SEC Rate (actual)

Aug-08

Apr-08

0 Jun-08

Jan-09

Mar-09

Feb-09

Oct-08

Dec-08

Nov-08

Jul-08

Sep-08

Aug-08

Apr-08

Jun-08

May-08

These are ambitious and high profile targets relating to an improvement programme that benefits from analyst input, enabling effective surveillance and ultimately governance. A recent HPA/DH publication has recommended that trusts implement antimicrobial management teams, stating clearly that an analyst be part of that team to effectively monitor and feedback on antimicrobial prescribing. The code of practice for the prevention and control of HCAI (part of the Health and Social care Act, 2008) also specifies the requirement for analytical capacity in Infection Control Teams.

Monthly Rate (actual)

National Rate (limit)

Local Stretch Rate (limit)

Monthly SEC Rate (actual)

Actions: PCTs and Trusts continue to report root cause analysis (RCA) information to the SHA, enabling continued local analysis of pre and post 48 hrs cases. Findngs will be shared with PCTs and Trusts. Collaborative working between Trusts, PCTs, community and pri

7 6

Local Stretch Limit for CDI currently under negotiation

4 3

Notes: Rate of MRSA bacteraemia reported per 10,000 admission - Based on HES 06/07 admissions

There is an SHA wide HCAI dashboard containing data on rates and cases, and a forecasting module. This is updated monthly and is available on the KM website under the banner of clinical information and patient safety. I’m the HCAI information lead and I’m keen to develop a network of analysts who are interested in this area so please get in touch if you think you might fit the bill! E-mail me at Katherine.cheema@southeastcoast.nhs.uk 2

Jan-09

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Do you have something you would like to contribute to Knowledge Matters? Please contact us!

May-08

Rate of C. Diff cases (aged 2+) reported per 1,000 admissions Denominator calculated using 06/07 HES data. For each episode within a Trust where the patients age at the start of the episode was 2 or more years ,and was classifed as an elective or emergency ordinary admission (this excludes daycases, but does include patients intended to be daycases but that stayed overnight, and patients intended to stay over night but discharged on the day of admission).

Knowledge Matters

Page 11

A3: ASK AN ANALYST – If you have a question for the team please e-mail: Knowledge.management@southeastcoast.nhs.uk Q – How can I add a vertical line to a chart? For example, on my 18 weeks charts I would like to add a line to mark18 weeks. Can this be done? Firstly, in your chart data you need to add a new series with data at the point where you want your line to be. For example, if you had a chart with patients waiting in various time-bands and you wanted a line at 18 weeks, you would need to have data in the 18 weeks column. You need to ensure that this figure is greater than the highest value of all the other series displayed in the chart – the best way to do this is to use a MAX or a LARGE formula to pick out the highest value. You could just look through the other values on the chart and pick out the biggest one, but this gives a lot of opportunity for error and also won’t work if you have a chart with a drop-down menu, so chart data that changes according to what is selected. Depending on your chart, you may want the line to be above all of the values – in this case you can just build an increase into your formula. If your chart data was in columns C-P in rows 12 and 13 you could ensure the value for your vertical line was 10% higher than any other value in the data by using the formula =(MAX(C12:P13))*1.1. This gives you the value for the vertical line which can then be added onto the chart as a new series. At the moment all you have is a dot in the right place on the chart – this now needs to be turned into a line. To do this, find the dot (you may need to hover over the chart to find where it is). Right click on this and ‘format data series’ then click on the Y error bars tab. You will need to select ‘minus’ for the display and the error amount should be equal to the amount you worked out with your MAX formula. Under ‘Error amount’ select ‘Custom’ and in the negative box the cell reference needs to be the cell with your MAX formula. This will give you a line starting at a point 10% higher than the highest value on the chart dropping to the x-axis. You can format this line if required by right clicking on it and selecting ‘Format Error Bars’. You can also add a data label in the same way as any other series on a chart. I have used this technique in the ‘Shape of RTT Pathways’ charts that I update on a regular basis (see right). You can download this dashboard from the 18 weeks downloads section of the Knowledge Management website. I hope that this helps you out – if you have any problems please do get in touch with me directly. Q – Do you know which function to use in Disco to convert a text format to number? The default for ‘overriden std grade hours’ is in Text for some reason and I need to do a condition that says ‘contract hours is less than override std grade hours’ but it won't let me as the override hours is a text format. The function you are looking for is the TO_NUMBER function The Syntax is broken down as follows: TO_NUMBER(char[, fmt[, nlsparams]]) Char would be the text string to convert. fmt is the format Mask and you can use any of the Following in combination to create a format mask : 9 999 0 0999 9990 . 999.99 , 9,999 $ $999 B B9.99 C C999 D 9D99

EEEE 9.99EEEE FM FM90.9 G 9G999 L L999 MI 999MI PR 999PR RN rn RN rn S S999 999S

TM TM U U999 V 99V99 X XXXX

Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Page 12

Who’s who in the Quality Observatory Samantha Riley, Head of the Quality Observatory Hello. As head of the team, I’m responsible for ensuring that we consistently provide our customers with high quality products that are delivered on time and which meet your needs. Over the coming months I am keen to meet as many current and potential customers of the Quality Observatory to gain a better understanding of how we can help you make improvements to services. I have good links with a wide range of national bodies – if you have any unanswered data/information queries please do contact me and I’ll do my best to obtain an answer! Simon Berry, Specialist Information Analyst My primary area of responsibility is around urgent care (A&E, Ambulance Trust) where I have developed a number of tools and dashboards. I also have responsibility around the acute sector and community services / PCT provider services. I have recently developed a provider based stroke clinical metrics dashboard and will shortly be developing something similar for commissioners and the cardiac area. I am the main point of contact for obtaining HES data within the South East Coast patch.

Kate Cheema, Specialist Information Analyst My key lead areas are healthcare associated infections and world class commissioning, which also encompasses using information for improvement in commissioning and the development of information skills for commissioners. I’m currently looking at the development of clinical quality metrics in primary care and also analyse the PBC survey and have been known to be involved with dentistry data too! I am also the lead analyst for patient experience data and have an interest in PbR and maternity, as well as the practical application of statistics in quality improvement projects! Adam Cook, Specialist Information Analyst Like Simon and Kate, my role focuses on developing and designing metrics, and tools to apply those metrics - very much with the quality agenda in mind. I’ve got the lead for Mental Health Data (including dementia metrics), and am also leading on the Nursing Metrics programme. I’ve added Data Quality to my portfolio and should be able to help you out with any queries related to SUS, HES or the data model and dictionary.

Peter Nyaga, Information Support Analyst Mostly I am involved in setting up various dashboards and tools as well as preparing the regular Board Information Pack. My other area of work involves managing as well as updating the Knowledge Matters website. Having recently developed a risk management tool for Foundation Trusts, I am now creating web-based finance and workforce dashboards as well as transforming our current dashboards to become web-based.

David Harries, Health Analyst I provide analysis to support work of the Public Health Directorate, particularly monitoring progress against South East Coast Inequalities Strategy. Other areas I cover include all Public Health related Vital Signs, Stop Smoking Services, Sexual Health, Clinical Quality and Outcomes, SUIs and Patient Safety, Thrombolysis, Immunisation and anything else deemed public health. I will be officially joining the newly created SEC Quality Observatory from the end of March. Other area of interest is in geographical visualisation (i.e. maps!)

Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

Page 13

Who’s who in the Quality Observatory Rebecca Owen, Performance and Planning Analyst I cover all areas of performance and planning including Vital Signs, 18 Weeks and Healthcare Commission targets. I have also been involved with setting up a primary care prescribing dashboard and monitoring the GP extended hours and PCT procurement returns. I’m currently looking at setting up a new dashboard to monitor the new cancer targets and, along with the other performance analysts, can help with anything to do with Unify2. Nia Naibheman, Performance Analyst Currently my main area of work is around 18 weeks. I am heavily involved in updating both the weekly and monthly dashboards. I also update numerous other dashboards such as the Performance dashboard for acute trusts and the PCT key performance indicator dashboard. If you need any help with Unify 2 please contact me - I can create accounts, reset your password and create Discoverer plus reports for you. Charlene Atcherley-Steers, Performance Analyst Most of my time is currently taken up on a Data Warehouse project which will be used along side our dashboards. I also report on the following Vital Signs VSA04 toVAS08, VSA11 to VSA14, VSB06 and VSB18. Other things I deal with are reporting timeliness and ad-hoc queries. I can also help with out with Unify 2 and resolve any problems you experience with our website. Kiran Cheema, Workforce Analyst I cover all areas relating to workforce information, including: monitoring through the ESR data warehouse, WIMS and redundancy returns; supporting forecast modelling tools and techniques for organisations in South East Coast; developing web based tools and collection systems for our products, and acting as a contact point of any ad-hoc queries and coding/classification advice.

Aleksandra Bujnicka, Workforce Support Analyst My main area of work is around workforce information. I am involved in updating the Workforce Dashboard with the records retrieved from ESR Data Warehouse. Additionally, I do some work around the CAST PLUS tool including customising and updating it, most recently specifically for the needs of the Midwifery Sector.

Festive Photos…. Images from the 2008 Christmas Party…All are real…… no photo manipulation involved – honest!

Nia

Kiran

Simon

Rebecca

Peter

Adam

Kate

Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Charlene

Knowledge Matters

Page 14

News

New Maternity Data Quality Dashboard

PROMS guidance published New guidance to support collection of patient reported outcome measures (PROMS) has recently been published by the Department of Health. New guidance that will support the NHS to collect patient feedback on the success of their operations was published today by the Department of Health. The new PROMs guidance sets out in detail: • The procedures for which PROMs data should be collected • Details of the national PROMs questionnaires • Roles and responsibilities of the different organisations involved in the delivery of the PROMs programme • A step-by-step guide to the administration of PROMs questionnaires. FREE HRG4/PbR Roadshows The PbR Assurance team of the Audit Commission will be taking part in the upcoming HRG4/PbR roadshows, along side the Department of Health, the NHS Information Centre and NHS Connecting for Health. The introduction of HRG4 in April will transform the way PbR is delivered by the NHS, and these events will give you the opportunity to hear key messages on from all four organisations. The dates and venues are: Monday 9th March 2009 – St. James' Park, Newcastle Wednesday 11th March 2009 – The Reebok Stadium, Bolton Friday 13th March 2009 – Villa Park, Birmingham Tuesday 17th March 2009 – The Emirates Stadium, London Wednesday 18th March 2009 – The Emirates Stadium, London Booking for these events is now open. See the Information Centre’s website for details http://www.ic.nhs.uk/newsand-events/events/calendar/all-events National Institute for Compendium published

Mental

Health

Outcomes

The Department of Health has recently published an Outcomes Compendium for Mental Health. The compendium provides information on available outcomes measures tools for use in mental health services. It provides an evidence based evaluation of existing measure to support informed choice. It is designed to support clinicians engaged in service delivery and development who wish to gauge clinical effectiveness and recovery in a balanced, culturally appropriate and ethical manner. For more news items visit our website: -

The Information Centre has recently added a maternity dashboard to their suite of data quality dashboards. This dashboard reports on the completeness and validity of codes used in key maternity fields, in each of the maternity related CDS types. Here’s the link to the dashboard http://nww.connectingforhealth.nhs.uk/reportingservices/data-quality/maternity.swf/ PbR National Benchmarker - Q2 data now available Q2 2008/09 data is now available in the PbR National Benchmarker. Further updates planned for the National Benchmarker are: 27 Feb 2009 - additional functionality - including the option to view all activity for a HRG or chapter within the data explorer 1 May 2009 - Q3 data available 29 May 2009 - HRG4 benchmarking - all measures updated for new PbR rules and currency, plus the addition of new HRG4 specific indicators The PbR benchmarker can be accessed via the Audit Commission website http://www.audit-commission.gov.uk/

New face for Health Informatics Careers …… NHS Careers have recently re-published their brochure for careers in health informatics in the NHS. The new face of NHS Informatics Careers is our very own Kate Cheema! The brochure provides useful information regarding the benefits of working for the NHS, describes the variety of roles within health informatics, provides an overview of the Career Framework and contains a number of real-life case studies (including Kate’s). Brochures can be ordered from :NHS Careers PO Box 2311 Bristol BS2 2ZX Tel: 0845 60 60 655 Alternatively, the brochure can be downloaded as a pdf from the NHS Careers website www.nhscareers.nhs.uk

nww.sec.nhs.uk/knowledge Do you have something you would like to contribute to Knowledge Matters? Please contact us!

Knowledge Matters

Page 15

QOF Benchmarking Tool Sneak Peak

Announcing the development of an on-line QOF Benchmarking Tool. This tool is being designed to use the QOF data tables to provide benchmarking on QOF disease areas at Practice and PCT Level. To the Left is a Screen Shot of the Practice level Tool in its current form. The tool is being developed to allow the display of indicators and ranking of recorded achievement against PCT/SHA/Country and ONS categories. For further information on this development or to get involved in the design of the tool please contact us: Knowledge.Management@southeastcoast.nhs.uk

Privacy and Dignity Peer Review Tool Update

The online privacy and dignity tool has been up and running for about six months now and we thought that we would give you an update on its progress! The tool was created to facilitate the collection of Peer to Peer assessment questionnaires developed from NHS institute collection template. Every NHS organisation within South East Coast has the ability to create self assessments, create and view peer reviews and to review reviews undertaken for them by others. To date 33 site assessments have been loaded on to the system by participating organisations. You can view Summaries of the South East Coast Position by one of the 4 Principle areas or by individual question on the KM website so log on and take a look! Principle 1: The board of directors actively support patientâ&#x20AC;&#x2122;s privacy and dignity

Principle 3: Individual staff actions actively support privacy and dignity.

Principle 2: The physical environment actively supports patients privacy and dignity

Principle 4: Record keeping and management of patient information actively supports privacy and dignity

Is there something that you wish you knew more about? To suggest future topics for knowledge matters contact the team

Knowledge Matters

Page 16 LOVE …… (in SQL!)

New!

SELECT You.[UniqueID], Me.[UniqueID], You.[UniqueID]&" and "&Me.[UniqueID] AS Us FROM You LEFT JOIN Me ON You.[Date]=Me.[Date] GROUP BY You.[UniqueID], Me.[UniqueID], You.[UniqueID]&" and "&Me.[UniqueID] HAVING ((Me.[Date])=#1stDate#) AND (You.[End Date]) Between #Never# And #Forever#) AND (Me.[Heart])=(You.[Heart]) And Max(Me.[Soul])=Max(You.[Soul];

The provider based stroke dashboard is now available to download from the KM website. See where to find it in our website news section….

Data Tools available from the Institute www.institute.nhs.uk/wccdatapack complements the world class commissioning data pack issued by the Department of Health. It presents your data in a range of different formats, moving you from performance management towards identification of improvement opportunities and service redesign. www.institute.nhs.uk/opportunitylocator explores the potential for shifting services from an acute hospital setting into the community at PCT and PBC cluster level. www.institute.nhs.uk/priorityselector facilitates objective scoring of proposals for service improvement, in order to develop a portfolio of projects that combine impact with practicality (contact me for your organisation’s password). www.institute.nhs.uk/scenariogenerator is a software tool specifically designed to allow simulation of whole health and social care systems. www.productivity.nhs.uk will take you to the Better Care, Better Value Indicators. The website is based around 15 high level indicators that identify potential areas for improvement in efficiency. www.library.nhs.uk/commissioning provides access to high quality information resources for all those involved in commissioning for health and wellbeing.

Christmas Quiz results 173 people took part in the 2008 Christmas Quiz Congratulations to Jo Woolgar from West Sussex PCT who is the overall winner of the Quiz. 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

Rosie Harding from Surrey PCT was this year’s runner up. The team have voted the winner of the tie-breaker question (which asked which your favourite bit of Knowledge Matters was ) as Del Herridge with: ‘I still have it to look forward to reading on Xmas Day :)’ Other’s that we liked include: ‘The organisational coding questions of course – who would not love those’ ‘Testing the knowledge that I thought I had but realise I haven’t!’ ‘….. discovering that Max Bygraves fans still exist!’ Many congratulations to all of you. Prizes will be winging their way to you!

Do you have something you would like to contribute to Knowledge Matters? Please contact us!