Welcome to Knowledge Matters Hello everyone I thought that you may be interested to hear about a really useful Webex that I was involved with earlier this month. The Webex was organized by the NHS Institute for Innovation and Improvement and focused on the measurement challenges facing the NHS in relation improving quality whilst at the same time reducing cost. Nearly 100 participants were involved with the Webex which aimed to both identify the key measurement challenges and share examples of what works well currently in different parts of the system. There was a very lively ‘ chat room’ which created a wealth of ideas and practical examples of tools and techniques. A full recording of the Webex is available on-line and I would encourage you to take the time (just over an hour) to listen to the recording https://nhs.webex.com/nhs/lsr.php?AT=pb&SP=MC&rID=7932912&rKey=63FB4809033154BD The Institute will be writing up a report of the Webex and are hoping to establish an ‘Ideas Channel’ for measuring cost and quality. This will provide an excellent opportunity to gather (and subsequently share) the wealth of ideas, knowledge and wisdom from within the NHS about this crucially important topic. You will already be aware that from 1 April 2009, all providers of NHS-funded care have been required to collect Patient Reported Outcome Measures (PROMs) for four clinical areas: hip replacements; knee replacements; hernia and varicose veins. PROMs measure quality from the patient perspective. The first set of provisional preoperative PROMs data has recently been published covering the period April 2009 – November 2009. This is the first NHS Information Centre publication of experimental statistics outlining information collected for the programme and sets out key statistics on patients' self-reported health status before undergoing surgery. Information on PROMs can be accessed from the following link http://www.ic.nhs.uk/proms An article will be published in the next edition of Knowledge Matters which provides some commentary on what PROMs data is saying for organisations within South East Coast. See you in June!
Inside This Issue : Enhancing Quality : Clinical Leadership
2 Door to doctor in 30 minutes
6
Analysis in action
12
Mortality rates in Europe
4 A3: Ask an Analyst
8
NICE News
13
Analytical tools—ambulatory care
5 Health & Social Care Awards
9
Normalising birth
14
5 Skills builder—understanding activity data
10 News, Fascinating Fact, plus more!
http://nww.sec.nhs.uk/QualiityObservatory
15
Page 2
Enhancing Quality Programme—Clinical Leadership By Kay Mackay, Programme Director, Enhancing Quality The Enhancing Quality Clinical Leadership team welcome the opportunity to introduce themselves! I am sure that you will remember reading in Knowledge Matters last year about the Enhancing Quality (EQ) programme across South East Coast. Essentially it is a clinical change programme which uses triangulated information to drive quality improvements in clinical interventions; patient reported outcomes and patient experience. An incentive system through CQUIN will recognise and reward providers to deliver reliable care for their patients every time. EQ aims to streamline care, improve documentation, and generally make the care provision more consistent and reliable – every time for every patient. We know that reliable care will yield higher quality clinical care, better outcomes and lower costs.
To contact any of the Clinical Leaders please email: c/o kay.mackay@westsussexpct.nhs.uk
Acute Heart Failure
Hugh F McIntyre Acute Heart Failure
Community Acquired Pneumonia
Lisa Vincent-Smith Community Acquired Pneumonia
Heart failure, already the commonest cause of hospital admission in people over the age of 65, is becoming increasingly prevalent in aging populations. Although we already know that both coordinated care planning and appropriate therapeutic interventions can improve symptoms, prolong life and reduce hospitalisation, service delivery remains fragmented. The challenge for us all must surely be to improve patient outcome through embedding effective local delivery of these proven care strategies. But will this work and if so how? We need accurate measurement of the care we deliver for heart failure to allow identification of our strengths and weaknesses and the implementation of changes that can enhance the quality of subsequent care. The Enhancing Quality Programme offers the opportunity and resource not only to deliver these objectives but also to show that with better quality care, comes better outcomes for patients. With the help of community and hospital specialist nurses I have led the Hastings Heart Failure Clinic for the last 10 years. To me the challenge is to use the Programme to show if the service we have developed has improved, and can continue to improve, patient care.
Acute Heart Failure Trust Leads Ashford & St Peters Hospital NHS Trust Ian Beeton Brighton & Sussex University Hospitals NHS Trust Adam DeBelder Dartford & Gravesham NHS Trust Jagdip Sidhu/Ed Petzer East Kent Hospitals University NHS Trust Dr Kevin Ward East Sussex Hospitals NHS Trust Dr G Lloyd/Nik Patel Frimley Park Hospital NHS Foundation Trust Dr Matt Faircloth Maidstone & Tunbridge Wells NHS Trust Clive Lawson/Derek Harrington Medway NHS Foundation Trust Dr Sandeep Gandhi Royal Surrey County Hospital NHS Trust Dr Mick Hickman Surrey & Sussex Healthcare NHS Trust Nandu Gandhi Western Sussex Hospitals NHS Trust Dr Barry Kneale SEC Ambulance Service NHS Trust Andy Newton
Dr Lisa Vincent-Smith is a Consultant Physician in Respiratory and Sleep Medicine working at Medway Hospital. I have long had an interest in pneumonia management and improving management of community acquired pneumonia. I see the Enhancing Quality Programme as a way of improving quality through repeated feedCommunity Acquired Pneumonia Trust Leads back on particular qual- Ashford & St Peters Hospital NHS Trust Paul Murray Dr Sarah Doffman ity measures. Through Brighton & Sussex University Hospitals NHS Trust Dr Sudhir Lohani improving the quality of Dartford & Gravesham NHS Trust Kent Hospitals University NHS Trust Dr Peter Farrow care improving patient East East Sussex Hospitals NHS Trust Dr David Maxwell outcomes, I hope that Frimley Park Hospital NHS Foundation Trust Dr Tim Ho Dr Ravish Mankragod as regional lead I will be Maidstone & Tunbridge Wells NHS Trust Dr Lisa Vincent Smith able take this Pro- Medway NHS Foundation Trust Surrey County Hospital NHS Trust Bill McAllister gramme forward and Royal Surrey & Sussex Healthcare NHS Trust Dr Devi Acharya make it a success. Western Sussex Hospitals NHS Trust Dr Dominic Whitehouse SEC Ambulance Service NHS Trust
Kath Start
Page 3 Community Heart Failure
Richard Blakey Community Heart Failure
I am delighted to have been appointed Community Heart Failure EQ lead for the South East Coast. I have been a GP in East Sussex since 1990, a clinical assistant in cardiology since 2000 and a GPwSI in Cardiology since 2004. Ever since the GP Quality Outcomes Framework came into being and the first NICE guideline for Chronic Heart Failure in 2003, primary and community care for heart failure has improved significantly with improved medical management, specialist nurses and rehabilitation. However there is still great room for further improvement, which I believe can be helped using the Enhancing Quality Programme. I believe it will be a great catalyst for change that will improve patient outcomes, including quality of life. Better achievement of gold standard care should also reduce major adverse events, hospitalisation, needs for interventions and mortality. Hopefully, a further consequence of such high quality care will be a relative reduction in costs, which is of great importance in the current financial climate. The outcomes of this programme will depend on how well we develop the new primary and community elements. I plan to put all available effort into making this as successful as I can. Community Heart Failure Trust Leads
Primary Care Heart Failure Leads NHS Brighton & Hove PCT NHS Eastern & Coastal Kent PCT NHS East Sussex Downs & Weald PCT NHS Hampshire PCT NHS Hastings & Rother PCT NHS Medway PCT NHS Surrey PCT NHS West Kent PCT NHS West Sussex PCT
Dementia
Kate Jefferies
AMI
Dr Peter Alderman Ally Hiscox Dr Richard Blakey To Be Appointed Dr Richard Blakey Sanjay Chatterjee Sally Edwards Kulvinder Singh Andrew Foulkes
Central Surrey Health NHS Eastern & Coastal Kent Community Services East Sussex Community Health Services Caroline Brennan Medway Community Health Care South Downs Health NHS Trust Bayly Surrey Community Health West Kent Community Health Services West Sussex Health
Mary Kirke Janet Heath/Jeni Kirsty Thurlby Angela Dunn Louise Hughes
I have been appointed Enhancing Quality Lead for the Dementia Pathway. I am a consultant in Old Age Psychiatry in Surrey and Borders Partnership NHS Trust. I am very keen to improve the Quality of Care that patients with Dementia receive. There are many examples of excellent care within our local area and it will be a great opportunity to use the EQ Programme to expand these throughout the area. I am looking forward to the opportunity of working with all the stakeholders in dementia care to improve care for patients and their carers.
Dementia Trust Leads Kent & Medway NHS & Social Care Partnership Trust Surrey & Borders Partnership NHS Trust Sussex Partnership NHS Trust
Barbara Beats Cathie Sammons Dr Mokhtar Isaac
AMI Trust Leads Ashford & St Peters Hospital NHS Trust Brighton & Sussex University Hospitals NHS Trust Dartford & Gravesham NHS Trust East Kent Hospitals University NHS Trust East Sussex Hospitals NHS Trust Frimley Park Hospital NHS Foundation Trust Maidstone & Tunbridge Wells NHS Trust Medway NHS Foundation Trust Royal Surrey County Hospital NHS Trust Surrey & Sussex Healthcare NHS Trust Western Sussex Hospitals NHS Trust SEC Ambulance Service NHS Trust
Hips and Knees
Janet Brogan Sue Baldwin Sarah Terry/
Peter Wilkinson Adam DeBelder Jagdip Sidhu/Ed Petzer Dr Kevin Ward Dr D Walker/Nik Patel Dr Matt Faircloth Scott Takeda/Derek Harrington To Be Appointed Dr Mick Hickman Dr Richard Allen Dr Barry Kneale Jane Pateman
Hips & Knees Trust Leads Ashford & St Peters Hospital NHS Trust Brighton & Sussex University Hospitals NHS Trust Dartford & Gravesham NHS Trust East Kent Hospitals University NHS Trust East Sussex Hospitals NHS Trust Frimley Park Hospital NHS Foundation Trust Maidstone & Tunbridge Wells NHS Trust Medway NHS Foundation Trust Royal Surrey County Hospital NHS Trust Surrey & Sussex Healthcare NHS Trust Western Sussex Hospitals NHS Trust
Constant Busch Phil Stott Farid Moftah Dr Philip Housden Mr A Butler-Manual Lt Col Peter Hill Paul Skinner Dr Srinivasa Samsani Kerry Acton/Neil Bradley George Tselentakis Lee Taylor
Page 4
Mortality rates in Europe—how does the South East Compare? Rachel Crowther and Isobel Perry, South East Public Health Observatory This project was commissioned because of the need to find suitable comparators for the relatively affluent and healthy South East. SEPHO compared direct standardized rates for All Age All Cause Mortality in the South East with other European regions for the period 2004-2006. We also explored the possibility of using Purchasing Power Parity (PPP) per capita to identify a close comparator group of twenty more affluent regions similar to the South East. The full report can be downloaded from the SEPHO website — http://www.sepho.org.uk
Page 5
Directory of Ambulatory Emergency Care for Adults By Simon Berry, Specialist Information Analyst The Directory of Ambulatory Emergency Care for Adults was developed by the NHS Institute for Innovation and Improvement in 2007 and has recently been updated. The Directory provides an outline of potential conditions that can be managed using ambulatory care resulting in zero or short hospital stays. Patients are identified using a combination of the diagnosis code and specific HRG codes and each condition has a range of potential delivery of ambulatory care based on current rates of non-zero length of stay bed-based admission in areas where ambulatory emergency care is relatively underdeveloped. Across the South East Coast patch in 2008/09 admissions for conditions identified within the directory totalled 134,000 and consumed 593,000 bed days. Using the Directory’s prescribed ‘range’ of potential delivery of these conditions with ambulatory care, and the observed rate of zero to non-zero length stays, it is possible to calculate the adjusted opportunity. This provides a more realistic view as to how many patients could have a short stay when benefiting from ambulatory care. Using this method the adjusted opportunity across the patch is 37,000 admissions. Working in conjunction with Ian Sturgess (who was instrumental in the development of the Directory and is a clinician at East Kent Hospitals), I have created a new dashboard/benchmarking tool around the Directory. This enables you to compare quarterly data for all acute trusts in Kent, Surrey and Sussex across a range of measures selected by condition, chapter or totalled for all conditions. The following information can be viewed on the dashboards: -
• • • • •
Numbers of admissions; Bed days; PbR value of admissions; Adjusted opportunity; PbR value of adjusted opportunity
The dashboards are really useful in prompting key questions: - what variation exists across the patch? Are there opportunities to learn from other trusts and spread best practice? Which conditions have the greatest opportunity attached? This view shows the admissions/bed days data for chest pain, note that the potential for ambulatory care is shown at the top. In this case it’s moderate, 30-60%. The admissions are GM - Chest Pain, % Potential - Moderate 30-60% plotted on the left axis and the bed days on the right. Note that for all views in the dashboard all trusts are plotted to the same scale. Directory of Ambulatory Emergency Care for Adults Admissions & Bed Days Admissions - LH Axis Bed Days - RH Axis
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The dashboards will be updated on a regular basis and are available now in the downloads section of the Quality Observatory website. If you have any queries and need any help feel free to contact me at simon.berry@southeastcoast.nhs.uk
Range Upper - Lower Opportunity
Sussex
BSUH
Frimley
06/07 Q1
Surrey
ASPH
09/10 Q1
The blue line is the adjusted opportunity, the higher this is in this range the greater the potential at the trust. The adjusted opportunity can drop below the estimated range and this indicates that the trust is achieving better results than would be expected.
Directory of Ambulatory Emergency Care for Adults Admissions Opportunity GM - Chronic Obstructive Pulmonary Disease, % Potential - Low 10-30%
08/09 Q3
The orange / buff coloured range is a calculated range of the likely opportunity.
Below is the view of the adjusted opportunity for COPD, note that for this condition the potential for ambulatory care is low, 10-30%.
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This is useful to put things in context and throws up some interesting questions, for example, there seems to be strong seasonality in the data for ESHT for chest pain that’s not as evident for other trusts, why might that be? Also note that the bed days for EKHT is dropping noticeably but the admissions are remaining level, this indicates the average length of stay is dropping significantly.
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Page 6
Door of Acute Medical Unit to Doctor in 30 minutes Focus on Dr Gordon Caldwell and the Acute Medical Team, Worthing Hospital From late 2007 Dr Gordon Caldwell, was involved in work at Worthing Hospital to improve waiting times and quality of care provided to acute medical patients in the Acute Medical Unit (AMU). Dr Caldwell visited Canterbury and Brighton Hospitals and saw what they were doing to improve early and thorough patient assessment, treatment and timely discharge. He also read Juran’s seminal “Quality Handbook” as well as Taiichi Ohno’s “Toyota Production System; Beyond Large Scale Production”, which served as powerful introductions to modern thinking on quality, safety and reducing waste - especially cutting wasted non productive time. In July 2008, Dr Caldwell was in Boston with his wife and had the pleasure of spending the day in a shopping mall. It was here that he saw the “We know what you want when you are ill. Door to Doctor in 30 minutes” poster, which made the promise to patients attending Metrowest Medical Centre that they would receive an early assessment when attending the Emergency Department. It was as a result of seeing this poster that Dr Caldwell commenced on a mission to ensure timely assessment, decision making and treatment for all patients referred to the Acute Medical Team.
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The graph to the right shows the percentage of patients receiving an assessment within 30 minutes over the past 18 months.
Worthing Hospital - % Patients Seen in 30 Minutes from Arrival
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Over the past 18 months, there has been a significant improvement in the number of patients receiving an assessment within 30 minutes of arrival in AMU.
Key to achieving this improvement has been the gathering of the Acute Medical Team at the start of each day to review data from the previous day collected on the ‘AMU Whiteboard’ information system which was developed by Jeff Ashby and other Worthing Hospital IT staff and is now supported by Sussex HIS. This system enables a significant amount of information to be collected, including key timings for each patient. At the daily Acute Medical Team meeting, the team reviews data from the previous day including the number of cases referred to the team, the number sent home, number seen by the night team, the number with a thorough assessment starting within 30 minutes of arrival and the longest wait for assessment to start. Worthing Hospital - Average Time from Arrival to First Seen
Mark Dennis, the Trust’s Senior Information officer, has developed an automated delivery of the statistics extracted from the Whitebaord SQL tables. Data from these tables have subsequently been analysed by the South East Coast Quality Observatory (more about this later).
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The chart to the right shows the significant improvement that has been made in the time that patients wait for assessment—here we can see the average wait for assessment by the Acute Medical team once the referral to the team has been made.
Reviewing this data has become a key component of how the team works and by sharing the data, the team takes ownership of both the data and the associated care provided to patients. In addition to reviewing the data, Dr Caldwell’s devolved leadership style has resulted in really effective team working and individuals within the team developing their own leadership skills – Dr Caldwell does not run the daily meetings, members of his team do.
Page 7 Dr Caldwell explains : “When the data are presented to the team there are often useful discussions about the reasons for delays. For example the night shift for the F1 was changed from a 9pm to an 11pm start, and immediately delays built up around 9pm. We changed the shift back to a 9pm start, with an earlier finish the next morning, at a time that tends to be quiet. The team obviously feels good when the performance has been excellent. The SPRs are given the task of running the meeting, with the data provided for them. The meeting continues as a handover meeting. I can see the SPRs growing in confidence in running and controlling the meeting. They are now coming up with ideas to further improve patient safety. This week they have started a process for the day teams to be notified if any of their patients deteriorated over night and need early review in the morning.” % Patients First Seen in 30 Minutes
This graph shows for a week in February this year, how well the team did in their quest to assess patients within 30 minutes of referral. Green indicates the percentage of patients assessed within 30 minutes of referral, amber relates to waits between 30 minutes and an hour and red indicates the percentage of patients who waited more than an hour.
Limits Green up to 0.5 Hours
Week Ending 14/02/2010
Amber up to 1 Hours
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Dr Caldwell explains how well analysed data has supported his improvement efforts : -
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“By using run charts and other graphical representations of the data, we are able to see trends in delays. This in turn means that we can now start to plan to change our ways of working to address the issues identified through the analysis
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Delays are common at weekends when numbers of doctors are decreased. We need to find ways to help the weekend teams to be able to work more efficiently. During the week we need to co-ordinate rotas better to ensure steady numbers of doctors available to the take. We may need to establish a fixed AMU team rather than have individuals on a rota to come down a day at a time. This whole improvement in timely patient review has been achieved at zero cost. Simply and clearly stating a rational and pragmatic target “30 minutes Door (of AMU) to doctor” and reporting the performance daily makes our Juniors know that we really value this. This rational target makes sense to clinicians – if the patient is ill s/he gets treated sooner before there is time to deteriorate. If he is not ill, he is worried, gets early reassurance and is more likely to go home as an early discharge. This work has been successful because of the strong support and team working amongst the Consultants and Nursing Staff that work in AMU.”
Here we can see the waiting times for individual patients referred to the Acute Medical Team over the period of a week. Colour coding indicates the time of day that patients arrived. The left hand access indicates the waiting time in hours. The horizontal green line indicates the target (in this case 30 minutes) and the horizontal pink line indicates the average waiting time over the period. In this instance the average wait was 20 minutes.
Worthing Hospital Consecutive Attenders - Time to First Seen Week Ending 14/02/2010 2.5
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The Quality Observatory has introduced Dr Caldwell to alternative ways of presenting the data that is collected. Timing point data lends itself very well to using statistical process control charts which enable a greater understanding of the variation in patient waiting times and the ‘capability’ of the system to deliver a sustained assessment within half an hour.
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Note: UCL represents the time within which a patient can be guaranteed to be seen from time of arrival
If you would like to learn more about Dr Caldwell’s improvement efforts please e-mail Gordon.caldwell@wsht.nhs.uk
Page 8
Formula auditing in Excel Application: Microsoft Excel 2003 Q– In a previous article you explained how to use formula auditing, however I found it slightly confusing. Is there another way of breaking down my formulas? A- Yes there is, you can use the Evaluate Formula option which will show a break down of a nested formula for you.
Solution: Complexity 2/5 — Uses Built in Evaluate Formula Functions 1. Click on View > Toolbars and ensure that Formula Auditing is ticked.
2. Evaluate formula Click on the cell you would like to evaluate, then click on the Evaluate Formula icon (magnifying glass with fx). Unlike the formula auditing buttons, this option will bring up a box with the formula listed. By clicking on ‘Evaluate’ in the box excel will run through the underlined area. Each time you click on ‘Evaluate’ you will see the cell reference is replaced by the constant value in that cell. By clicking on ‘Evaluate’ again you will see the calculation performed, and finally the result will be shown. Please note that the Formula Evaluator shows you how the existing formula is being evaluated and will not suggest corrections.
3. Step in/Step out If you would like to observe the evaluation of cells that contain other formulas as well as constants, you can use the ’Step in’ button. Click on ’Evaluate’ until you the cell reference you are interested in is underlined. Then click on ’Step in’. The formula or value will appear in a separate box. You can evaluate this further by clicking on the ’Evaluate’ button. To return to the original formula simply click on ’Step out’.
For more information on Evaluate formula please contact a member of the Quality Observatory team Quality.Observatory@southeastcoast.nhs.uk
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Project Planning in Excel Application: Microsoft Excel 2003 Q– I need to plan a project and be able to see if I’m meeting planned timescales and adjust deadlines where necessary. Microsoft Project would be the obvious solution to this, but I don’t have this on my PC. Can you suggest an alternative?
Excel, of course! I have produced a tool to do this in Excel. My project timeline is simply a sequence of project tasks arranged by date in chronological order and displayed in rows by using conditional formatting. By entering basic project data into the Timeline such as the Project Task, Task Owner, Start Date and End Date the Timeline will automatically show the planned activity in green cells, activity completed in blue cells and any overruns are shown in red cells with respect to today’s date. I created the timeline to be easily adjustable, especially for printing and am happy to help if you have any further questions. The Project Timeline is available to download from the Knowledge Management website and you can contact me on 01403 227000, ext 7612 or email me— robert.leiper@westsussexpct.nhs.uk
The 2010 Health and Social Care Awards are now open The overall Awards are run in partnership between the NHS Institute for Innovation and Improvement and the Department of Health. Each Strategic Health Authority hosts a regional awards scheme and forms the regional strategic partners along with the Social Care, Local Government and Care Partnerships Directorate at the Department of Health. Applications for the National Health and Social Care Awards can only be made via the Regional level. The winning applications from each national category in all ten regions will automatically be considered for the National Awards, however only three will be short-listed. Winners of the regional-specific categories are not eligible for the National Awards. There are 6 national categories this year which are accessible to anyone working in health and/or social care in England. The categories are focused around the four core principals of QIPP (Quality, Innovation, Productivity and Prevention) and include:
• • • • • •
Success in Partnership Working Award Mental Health and Wellbeing Award Primary Care and Community Based Integration Award Support for Independence Award Acute Care Award Excellence in Commissioning Award
The regional awards for NHS South East Coast are:
• • •
Unsung Hero Health and Social Care Professional of the year Outstanding contribution to Healthier people, excellent care
Now in their 9th year, these flagship Awards are endorsed by the Department of Health and the Awards is the largest peer-to-peer scheme of its kind. The scheme is run at regional and national level giving teams well-deserved recognition both in their own patch as well as nationally. Applications close on 18 June 2010, so don't delay—apply on-line at www.healthandsocialcareawards.org.uk
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Understanding activity data - SUS vs HES By Adam Cook, Specialist Information Analyst (and Cookie Monster) I’m often asked about sources of data, in particular around patient level activity. SUS and HES are the main sources of this data, but what are SUS and HES? Where does SUS and HES data come from? And what’s the difference between the two? I feel that I need to warn readers of a nervous disposition that this article contains intensive use of three letter abbreviations—you have been warned! I hope that you are brave enough to read on—you may learn something! Let’s take inpatient data as an example, but the process is similar around outpatients, A&E, and to a certain extent mental health. When a patient is admitted to a hospital, their details are entered on the trust’s Patient Administration System (PAS). This has personal demographic data, clinical information about what the patient was diagnosed and treated for, and administrative information such as when and how the patient was admitted. Every trust has a legal obligation to send this data up to a central repository in the form of a Commissioning Data Set (CDS). The CDS has an exact specification detailing which data is included, and these data items are defined in detail in the data dictionary. This central repository is the Secondary Uses Service (SUS). SUS is a large data warehouse – one of the largest databases in the world. New data is being added at the rate of about 10 terabytes per month! This equates to 1,462 DVDs (or 243 “Lord of the Rings” trilogy extended editions!) The SUS data warehouse contains extracts from all NHS trusts, and those independent sector organisations providing NHS services. Trust PAS data undergoes some processing before being imported in SUS – this includes creating derived fields (e.g. age, spell and episode durations, and some geographical data), and also some ‘sense checking’ to make sure that the data is in an acceptable format. Outpatients
A&E
Inpatients
“...the NHS should use SUS as the standard repository for activity for performance monitoring, reconciliation and payments”
SUS PbR
The data in SUS is available in two versions. There is a PbR mart where all activity that goes through PbR is stored and used. The second version of the data includes all activity regardless of whether it is PbR or not – this is known as the extract mart. The 2008/09 national NHS operating framework explicitly stated that:
Extract
The key meaning of which is – if it’s not on SUS you won’t get paid for it. This means that it is crucial for providers and commissioners alike that this data is up-to-date and accurate. For many analysts outside of trusts SUS, is the coalface of information, and the basis of all their analysis. However a more refined version of this data set is available Hospital Episode Statistics (HES).
HES is another national data warehouse of trust data, built up from regular extracts from SUS. The audience for HES is wider that just the NHS, it is used by many academic and research organisations. One of the major clients for HES data is central government, and in particular the Department of Health. This is one of the reasons that HES is generally considered the ultimate NHS patient level data source. HES
Page 11 The other reason for this is that HES data has undergone a cleaning process, which removes or cleans any of the poor data quality records and data items that may come in from SUS. Data on HES will differ from data on SUS; this is partly due to the cleaning process, and partly due to timing issues. Extracts taken from SUS for HES are fixed at the moment of extract, and so won’t change on HES, but because SUS is more of a living, working databases, some of this data may change, and these changes will not be reflected in HES. (There are also other issues around the reconciliation and post reconciliation dates—but that’s a whole other article!) The other consequence of this is that HES records lag behind SUS by a period of up to several months, whereas SUS is up-to-date from the moment a trust PAS extracted is accepted. Trusts submit between weekly and monthly data to SUS. It’s down to an individual analysts choice, and purpose that the data is required for, which they use – SUS is more up-to-date but has more data quality issues, HES is cleaner but more out of date. In the end though both are good quality, valid sources of patient level data for the NHS analyst. Access to SUS is via a smartcard and restricted to a certain number of users per organisation, whereas there are two points of access for HES—a website with a variety of freely available information, or organisations can buy in access to HES data to do their own analysis via a Business Objects front end. The Quality Observatory at South East Coast SHA has access to SUS for our patch and the national HES system. We use SUS for the majority of our activity based analysis, and use HES data for national comparators and benchmarking For more information on SUS see: http://www.connectingforhealth.nhs.uk/systemsandservices/sus For more information on HES see: http://www.hesonline.nhs.uk If you are still confused or have questions that I have not answered in this article, please do get in touch!
The Future of Informatics 2010 The annual BCS Health Informatics congress was held this April in Birmingham. The Quality Observatory was there presenting a poster around the story of the development of Dementia metrics. The stall was manned by David, Samantha, & Adam. Samantha was also one of the guest speakers and on the second day of the conference delivered a well received talk on using data to drive quality improvements. Samantha’s presentation covered a number of examples of how the Quality Observatory has effectively worked with front-line clinicians to develop meaningful measures, dashboards and tools to help reduce variation and drive improvement.
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Analysis in Action…………………………….. On 18th March 2010, the SHA hosted a successful and fully attended event focusing on healthcare associated infections (HCAIs). The event brought together analysts and information managers with clinicians and specialist infection prevention and control practitioners, PCT Commissioners, Community and Acute Trust providers and the Health Protection Agency. The aims of the day were to highlight and share how the wealth of data and information available can be used to improve patient safety and experience of health care through informing the sustainable reduction of HCAIs. The importance of interrogating data and information, triangulating and cross correlating it in meaningful ways were investigated and discussed from both the analytical and clinical perspectives. Putting this learning into action, groups undertook group work to design and present HCAI Dashboards for different stakeholder groups, including those for patients, clinicians, Trust Board and the public. This highlighted the different levels of information appropriate for different purposes and resulted in some really creative ways to present key elements of information as you can see below.
Public Dashboard
Staff Dashboard
Patient Dashboard
Dashboards in Action at St Richard’s Hospital In conjunction with Jackie Hole, productive ward facilitator at St. Richard’s Hospital, Adam Cook has developed a suite of ward level dashboards with a wide range of outcome and staffing indicators. These are displayed on every ward, so that all staff, patients and visitors can see how the hospital is doing. Jackie explains how the dashboards have added value : -
Sam Channell, Senior Staff Nurse, with Ward level dashboard for Petworth ward, St.Richard’s hospital.
“We have been using the dashboards for about 8 months now and they have really improved the way we use the data we collect. The Productive Ward Programme enabled us to organise them and ensure consistency across the hospital. This means that whichever ward is visited the Productive Ward board looks the same so everyone can find the data easily. The dashboards are updated monthly by the ward sister and displayed publically on the ward, so that staff, patients and visitors can see the performance of that ward. The ward sisters use this to feed back to their staff both positive improvements and data with may be causing concern. It allows staff to see their progress month on month and take ownership of their performance. We are currently updating the dashboards to include more data and the plan is to roll this out to the other 2 hospitals within the Trust. One of the biggest advantages to using the dashboard is that all of the data collected by the ward is available in one place instead of in several different departments. ”
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NICE News By Steve Sparks, Implementation Consultant South East The National Institute for Health and Clinical Excellence is the independent organisation that provides national advice to the NHS and local government on the promotion of good health and the prevention and treatment of ill health. We produce guidance in three main areas: Public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector Health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS Clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS. There’s a whole variety of support that NICE provides to help the NHS implement our guidance and increasingly importantly to help the NHS to meet the quality, innovation, productivity and prevention challenge. As the local NICE Implementation Consultant for South East Coast my role is to help the NHS and partners in local government to work with our guidance and also to provide feedback to NICE on what we can do to make it easier for you to use our guidance. Over the last four years I’ve developed extensive links with trusts and PCTs across the SHA. If you would like to meet with me to discuss the support we can offer, please drop me a line at steve.sparks@nice.org.uk. I wanted to take the opportunity of some space in Knowledge Matters to introduce you to three of the newer products and services that we have developed over the last year or so. Fed up with the junk you get returned when you do a Google search on a clinical term? Well one of the most exciting developments at NICE in the last 10 years was the launch of NHS Evidence last April. This free web based resource is rapidly becoming the first port of call for clinical and managerial professionals looking for the most up to date information from accredited sources. It includes all the resources you previously accessed through the National Library for Health and special sections for commissioning and public health. There’s now a customisable home page so that you can have the latest news that you’re interested in at the moment you sign on. In addition we recently launched a widget which enables the NHS Evidence search bar to be embedded in your trust or PCT’s intranet home page. If it’s not on your intranet yet ask your IT lead to download it from www.evidence.nhs.uk. We’ve also been asked by the National Quality Board to develop quality standards to help the NHS demonstrate the quality of services based upon the best available evidence. This new programme takes NICE guidance and other high quality sources of evidence and develops a series of statements that describe a really high quality service for the clinical area concerned. Each statement is underpinned with measures to enable you to assess your performance against it. We have produced three draft standards; for stroke, venous thromboembolism and dementia and these are available on our website. The final standards for these three areas were due to be published in April but will now come out after the general election. Over the next year we will be working on an additional 10 standards and we hope that they will become a really powerful resource for trusts and PCTs to demonstrate the quality of services available in their area. Finally, we know that NICE has a really important role in helping the NHS meet the tough challenges that the squeeze on public finances has placed upon us all. We now have a section of our website dedicated to cost saving. In here you can find pointers towards our existing guidance that identifies potential national savings of £600m. Alongside this we also list all the areas where we have made recommendations in relation to ineffective practice. These form a really good start point for simple trust-wide audits to identify opportunities to reduce cost and ineffective practice. If you would like any more information on any of these initiatives or would like to find out anything else about how NICE guidance and tools can help you in your work, please give me a call on 07785 951202.
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Normalising Birth By Tony Kelly, Consultant Obstetrician & Gynaecologist, Brighton & University Hospitals NHS Trust In the last issue of Knowledge Matters, you will have seen a list of the bids which recently funded from the Regional Innovation Fund. As a successful bidder myself (submitted on behalf of midwives and Obstetricians across the region), I thought that I would take this opportunity to tell you a bit about the programme that I am leading (with lots of support from colleagues) and explain what we hope to achieve. The Normalising Birth programme was officially launched on 31st March 2010 at the Royal Sussex County Hospital in Brighton with 30 attendees from clinical teams from across the region, key individuals from the SHA and NHS Institute The programme formally commenced a day after the launch on 1st April 2010. So, what is the Normalising Birth programme about? Over recent years, there has been increased national focus on the rising caesarean section rates. Following on from the national Sentinel caesarean section audit in 1999 and the subsequent NICE guidelines in 2004, various initiatives have been proposed to reduce these rates. Caesarean section rates are used as a surrogate against which to measure the quality of maternity care. By reducing caesarean section rates we reduce the clinical impact on mothers and reduce direct costs of delivering maternity care. Caesarean births are also associated with more complications than vaginal deliveries. So, what does the situation across South East Coast look like currently? The graph below shows C-section rates for each of our Trusts compared to the national average, SHA target and WHO recommendation. Current caesarean section rates across NHS SEC vary between 22-31% with a median rate of 27%. The World Health Organisation (WHO) recommends a C-section level of 15%. The initial target that we have set across South East Coast is to reduce rates to a median of 23% Trust Actual SHA Target
C-Section Rate by Quarter 2004/05 -2008/09
WHO HES Actual
Trust data from PAS extracts Pre-2007, from SUS Post 2007. HES Annual Data from HES
50%
50%
45%
45%
45%
30% 25%
2008/09 Q3
2008/09 Q1
2007/08 Q3
2007/08 Q1
2006/07 Q3
2006/07 Q1
2005/06 Q3
2005/06 Q1
2004/05 Q3
2004/05 Q1
2008/09 Q3
2007/08 Q4
2007/08 Q1
2006/07 Q2
0%
2005/06 Q3
0% 2004/05 Q4
0% 2004/05 Q1
0% 2008/09 Q3
0%
2008/09 Q1
5%
0%
2007/08 Q3
5%
2007/08 Q1
5%
2006/07 Q3
5%
2006/07 Q1
5%
2005/06 Q3
10%
5%
2005/06 Q1
10%
2004/05 Q3
10%
2004/05 Q1
10%
2008/09 Q3
10%
2008/09 Q1
15%
10%
2007/08 Q3
15%
2007/08 Q1
15%
2006/07 Q3
15%
2006/07 Q1
15%
2005/06 Q3
20%
15%
2005/06 Q1
20%
2004/05 Q3
20%
2004/05 Q1
20%
2008/09 Q3
20%
2007/08 Q4
20%
2007/08 Q1
2007/08 Q3
25%
25%
2006/07 Q2
2007/08 Q1
30%
25%
2005/06 Q3
2006/07 Q3
35%
25%
25%
2007/08 Q3
35%
30%
2007/08 Q1
40%
35%
30%
2006/07 Q3
40%
35%
30%
2006/07 Q1
40%
35%
30%
40%
2005/06 Q3
40%
35%
2004/05 Q4
2006/07 Q1
2004/05 Q1
Medway Foundation 50% 45%
40%
2004/05 Q1
2008/09 Q1
50%
45%
2008/09 Q3
50%
45%
2008/09 Q1
Maidstone & Tunbridge Wells
50%
2008/09 Q3
Worthing & Southlands
Royal West Sussex
2008/09 Q3
2008/09 Q3
2004/05 Q1
Surrey & Sussex Healthcare
Royal Surrey County
2008/09 Q1
0% 2007/08 Q3
0% 2007/08 Q1
0%
2006/07 Q3
0%
2006/07 Q1
0%
2005/06 Q3
5%
0%
2005/06 Q1
5%
2004/05 Q3
5%
2004/05 Q1
5%
2007/08 Q4
5%
2007/08 Q1
10%
5%
2006/07 Q2
10%
2005/06 Q3
10%
2004/05 Q4
10%
2004/05 Q1
15%
10%
2008/09 Q3
15%
2008/09 Q1
15%
2007/08 Q3
15%
2007/08 Q1
15%
10%
2006/07 Q3
20%
15%
2006/07 Q1
20%
2005/06 Q3
20%
2005/06 Q1
20%
2004/05 Q3
20%
2004/05 Q1
25%
20%
2008/09 Q3
25%
2007/08 Q4
25%
2007/08 Q1
25%
2006/07 Q2
25%
2005/06 Q3
30%
25%
2004/05 Q4
35%
30%
2008/09 Q3
40%
35%
30%
2007/08 Q4
40%
35%
30%
2007/08 Q1
40%
35%
30%
2006/07 Q2
40%
35%
30%
2005/06 Q3
40%
35%
2004/05 Q4
40%
2004/05 Q1
45%
2005/06 Q3
East Kent Hospitals Foundation
50%
45%
2005/06 Q1
Dartford & Gravesham
50%
45%
2004/05 Q3
East Sussex Hospitals
50%
45%
2005/06 Q1
Brighton & Sussex University
50%
45%
2004/05 Q3
Frimley Park Foundation
50%
45%
2004/05 Q1
Ashford & St Peters 50%
Increasing normal birth rates will have direct effects on mothers as they are more mobile, able to bond quicker with their babies and have higher breastfeeding rates than mothers who undergo caesarean births. Crude rates are currently collected in most units which often only indicate that a caesarean was an elective or an emergency. Many of the factors that influence the decision to perform a caesarean section are complex: They may involve clinical issues relating to individual circumstance; communication issues between mother and health professionals; clinical ability and training of junior doctors involved with the care of the woman; availability of supervision of both junior medical and midwifery staff; availability of reliable testing equipment and preconceived ideas of patients and other staff members.
Our central project aim is to establish a robust central data collection portal utilising expertise at the Quality Observatory and combine this with local champions to facilitate best practice through use of the NHS institute toolkit for normalising birth. The data set collected and entered (in real time) will provide much more detail than information currently collected in most units. Through the portal it will be possible to collect clinical details of the delivery and those relating to the woman’s labour and pregnancy. The dataset will allow each caesarean section to be categorised into 1 of 12 defined clinical subgroups. This data can be used both within individual units and across the SHA to identify clinical variation, identify reasons for this variation, share challenges and solutions and learn from units undertaking best practice. The approximate annual cost of C-sections within South East Coast at current rates is £30.5 million. With an overall SHA reduction to 23%, we would attract direct savings of £2.3 million. By reducing caesarean section rates and subsequently increasing the normal births, proportional reinvestment will be required in staffing, equipment and training to realise the full benefits and support the South East Coast HPEC pledges being realised as well as support the NHS improvement programme with the Quality, Innovation Productivity and Prevention (QIPP) agenda . If you would like to learn more about the programme please contact our newly appointed Project Manager Emma Luhr (Emma.Luhr@nhs.net)
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NEWS NHS Institute develops QIPP tool The NHS Institute for Innovation and Improvement is currently developing a website tool that will identify key products and services that the NHS Institute for Innovation and Improvement has available to support the NHS to deliver QIPP. Once up-and-running the QIPP tool will identify tools and resources to support the NHS with a wide range of challenges, whether you are from a PCT, SHA, general practice or other National Health Service provider. To receive notification of when this new tool becomes available please register at the following link : http://www.institute.nhs.uk/cost_and_quality/qipp/ quipp_tool_notification.html Kidney Disease PCT Profiles EMPHO, in collaboration with NHS Kidney Care, have produced a Kidney Disease PCT Profile for all 152 English PCTs.
Older People Profiles This interactive mapping tool has been produced by WMPHO using Instant Atlas™ from Geowise and allows the user to view selected indicators relating to older people at local authority and regional level for the whole of England. The tool shows the selected indicators in map, chart and tabular formats. The information is provided for several different geographies including lower tier and single tier authorities. http://www.wmpho.org.uk/olderpeopleprofiles/ Realising the Benefits—Better Care, Better Value Indicators The NHS Institute for Innovation and Improvement has recently developed a set of guides designed to support Commissioners and Providers in realising the benefits associated with the Better Care, Better Value Indicators. These guides contain ten steps that commissioners/ providers can take to use the BCBV indicators to maximum effect to improve quality and increase productivity.
These profiles provide an overview of the key areas of kidney disease care, highlighting areas of good practice and inequalities.
The guides can be access from the Institute website :
Information within each profile includes:
Quarter 3 data has now been published and updated pdfs can be accessed from www.productivity.nhs.uk
•
Maps indicating 30 minute drive time to nearest Kidney Care centre • An overview of the demography and kidney disease risk factors in the PCT • Summaries of CKD Quality and Outcomes Framework information • Renal Replacement Therapy information • Standardised mortality rate from chronic renal failure • An indication of renal spend compared with need The profiles provide benchmarking against similar PCTs (both geographically and demographically) and highlight areas for further investigation. They also provide a starting point for any renal needs assessment work. The PCT profiles are available to download from the NHS Kidney Care website. An accompanying data guide, which provides more detailed information on the data presented in the profiles, including details of the data sources, the definitions used, and notes on interpretation, is also available to download. http://www.kidneycare.nhs.uk/OurworkprogrammesK i d n e y D i s e a s e i n P r i m a r y C a r e CKDmappingsandprofiles.cms Sport & Activity planning tool A new tool developed by the London Health Observatory and Make Sport Fun and based on Sport England’s proprietary Market Segmentation tool has been launched. See http://www.lho.org.uk/LHO_Topics/Analytic_Tools/ sportandactivityplanningtool.aspx
http://www.institute.nhs.uk/quality_and_value/high_volume_care/ better_care_better_value_indicators.html
New reports from SEPHO/DTMU The 2008/09 Drug and Alcohol Action Team (DAAT) data profiles are two page summary reports for each DAAT in the South East for adults and for young people in drug treatment. The reports contain analysis of data from the National Drug Treatment Monitoring System (NDTMS) and from other relevant sources. The new reports and guidance documents can be downloaded from the DTMU website http://www.dtmu.org.uk/Reports.html. The annual report Drug Treatment in the South East: Analysis of the 2008/09 NDTMS dataset can also be downloaded from the DTMU website using the link above. This report contains analysis of the 2008/09 NDTMS dataset for adults and young people resident in the South East in treatment for drug misuse. It examines client demographics, drug use, and treatment journeys. A methodology document has also been published which outlines the methodology used for the analysis of the 2008/09 NDTMS dataset. Unify 2 training As part of the Unify2 enhancement project, the Unify2 team will shortly be training SHA users in training others to use the new website. If you would like to attend a training session at the SHA please contact rebecca.matthews@southeastcoast.nhs.uk . Training will also include the opportunity to use a test environment to
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Productive Printing
Welcome to Nikki Tizzard….. Who will be joining the Quality Observatory in June as a Quality, Innovation and Productivity Analyst. Nikki will be joining the Quality Observatory on secondment from East Sussex PCTs where she is currently a Health Planning Analyst. Nikki will be supporting a number of the teams who had bids successfully funded from the regional Innovation Fund.
Do you need to print it out, Don’t do it if you’re undecided, If you really need to do it Make sure it’s doubled-sided. Many pages on one side, Or print out in booklet style,
…. and Welcome back to David Harries
Do you need it rainbow-hued, Monochrome is versatile.
Who is making an early part-time return to the Quality Observatory as Health Analyst from his secondment to East Sussex County Council. David will be working for the Observatory 2 days a week until returning full time in the summer.
When you print, collect it quick, Don’t let it pile up high. Or confidential documents May be seen by passers-by.
Fascinating Fact
Do you need to print it out,
We all know cleanliness is next to godliness, but it can go too far— last year 21 people in the South East Coast are were hospitalised from Toxic effect of soaps and detergents!
Before you do you it stop and think. You can save costs, and paper, Toner, trees, energy and ink.
The Quality Observatory’s most recent outing was to the ‘London Bridge Experience’. As well as an educational experience with the opportunity to learn about London Bridge through the ages, the team also journeyed through the London Tombs (formerly a plague pit) and rubbed shoulders with zombies and other weird and wonderful creatures!
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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: NHS South East Coast York House 18-20 Massetts Road Horley,Surrey, RH6 7DE Phone:
01293 778899
E-mail: Quality.Observatory@southeastcoast.nhs.uk To contact a team member: firstname.surname@southeastcoast.nhs.uk