Knowledge Matters Volume 6 Issue 4

Volume 6 Issue 4 October 2012 Welcome to Knowledge Matters Hello everyone and welcome to this very special edition of Knowledge Matters which celebrates an important day earlier this month. How many of you know that 10th October was ‘Bring a bear to work day’? Well you know now, so watch out for some bear features within this issue!!! It will be no news to readers of Knowledge Matters that we currently live in uncertain times with the NHS reforms in full swing. The team are continuing to develop new products to help front-line staff improve services (read more about these inside), but much of my time is being spent on trying to secure a ‘home’ for the Quality Observatory post March 2013. There are a variety of potential options available to us which I very much hope will translate into a secure future for the Quality Observatory for the foreseeable future. I am a firm believer that the importance of measurement to demonstrate the maintenance (and hopefully improvement) of high quality services and the best possible clinical outcomes is only going to increase over the coming years. It is not only me that believes this, we are regularly contacted by clinicians from a range of fields who support this view. This was very much reflected in the recent blog by Riaz Dharamshi, an ex Darzi fellow whom we were introduced to a number of years ago. Have a read of Riaz’s views on the importance of measurement: http://riazdharamshi.blogspot.co.uk/2012/10/where-have-observatories-gone.html and you may well want to sign up to his regular informative blog. I’ll provide an update on this next time. Finally, I have a couple of pieces of good news. Firstly congratulations to Rebecca Matthews who is now the proud mother of a beautiful baby girl (see the back page). Secondly, the paper written by myself and Kate on the benefits of utilising different sources of information on patient safety has now been published. This can be accessed (as can all other Quality Observatory publications) at the following website http://www.issuu.com/secqo

Inside This Issue : Respiratory dashboard

Skills Builder

Ask an Analyst

Health Visitors Dashboard

NICE Pathways

Update from bitjam

Effective Clinical Analysis Part 3

Analysis Ancient and Modern

Quest for Improvement

Website Updates

Meet the Observatory

News

twitter.com/SECSHAQO issuu.com/SECQO http://www.networks.nhs.uk/nhs-networks/sec-qo www.QualityObservatory.nhs.uk

South of England Respiratory Dashboard By Katherine Cheema, Specialist Information Analyst Breathing matters. Well it does, really, really matter, and as the population ages the prevalence of chronic respiratory disease is set to rise. According to the British Lung Foundation already one person in five in the UK are affected by lung disease. Chronic respiratory diseases have been a focus for improvement in the South of England region for some time; they make up a large volume of the disease burden suffered by patients with long term conditions and are particularly amenable to an integrated care approach that includes care planning with patient education and self management. The South of England respiratory dashboard presents key high level indicators for chronic obstructive pulmonary disease (COPD) and asthma. Local areas have more focused information products, including our very own Nikki Tizzard’s nationally recognised work in the form of the South East Coast COPD dashboard, so this dashboard is really designed to give a more general overview. Currently the data is split by CCG, and covers the whole South of England region, using the most recent mappings of practices to CCGs (available on the ODS website), and is split into two dashboards, one for asthma the other for COPD, and a notes page which explains the rationale for indicator inclusion. NHS South of England: Chronic Obstructive Pulmonary Disease (COPD) main indicators dashboard COPD QOF indicators key:

COPD QOF indicators 2010/11 100%

Estimated vs QOF prevalence

COPD08: Patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March

98%

SoE area:

Clinical Commissioning Group:

Emergency COPD 30-day readmissions 45%

4.0%

40%

3.5%

35%

COPD10: Patients with COPD with a record of FeV1 in the previous 15 months

92% COPD12: All patients with COPD diagnosed after 1st April 2008 in whom the diagnosis has been confirmed by post bronchodilator spirometry

90% 88%

3.0%

Readmission rate

94%

Prevalence

Underlying achievement

96%

2.5% 2.0%

84% 82%

Jun-12

Feb-12

Dec-11

Apr-12

Oct-11

Jun-11

Aug-11

Feb-11

Dec-10

Apr-11

Oct-10

Jun-10

Aug-10

South West SHA

Feb-10

Dorset CCG

Dec-09

0.0%

Apr-10

COPD 13

Oct-09

COPD 12

0.5%

Jun-09

COPD 10

10%

1.0%

Aug-09

COPD 08

20%

Apr-09

80%

25%

15%

1.5%

86% COPD13: Patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months

30%

Indicator South West SHA

Estimated prevalence

Emergency COPD admissions and admission rate

Readmission rate

QOF prevalence

Readmission rate: South West

Emergency COPD bed days and bed day rate

1,550

1,500

Admissions (count)

1,400

1,350 4

1,300

1,250

6,000

5,000

30 25

4,000 20 3,000 15 2,000 10

Bed day rate per 1,000

Admission rate per 1,000

1,450

Bed days (count)

Dorset CCG

1,200

1,150

Admission rate/1,000

Admission rate:South West

Jul-12 Jun-12 May-12 Apr-12 Mar-12 Feb-12 Jan-12 Dec-11 Nov-11 Oct-11 Sep-11 Aug-11 Jul-11 Jun-11 May-11 Apr-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 May-10 Apr-10 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09

1,000

12m rolling bed days

Bed day rate/ 1,000

Bed day rate: South West

As usual, where possible, the data is shown over time to help CCGs identify where change has occurred. A mix of primary care and secondary care indicators are used and include:

•

Key QOF indicators

•

Recorded prevalence vs expected prevalence rates (to help understand the scale of the ‘missing millions’ issue)

•

Readmissions

•

Admissions

•

Length of stay

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Of course lung health isnâ&#x20AC;&#x2122;t all about the older generation, children are often sufferers of asthma, so the asthma dashboard shows admission counts and rates for under 18s as well as the other measures. SoE area:

NHS South of England: Asthma main indicators dashboard Estimated vs QOF prevalence

Asthma QOF indicators 2010/11

Emergency 30-day readmissions for asthma

7.0%

95%

90%

85%

30.0%

6.5% 25.0%

6.0%

Emergency readmission rate

Prevalence

100%

Underlying achievement

Clinical Commissioning Group:

5.5% 5.0% North West Surrey CCG

South East Coast SHA

80%

Asthma QOF indicators key:

20.0%

15.0%

10.0%

75%

ASTHMA03: The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months

5.0%

70%

ASTHMA06: The percentage of patients with asthma who have had an asthma review in the previous 15 months

0.0%

South East Coast SHA

Readmission rate

Emergency asthma bed days and bed day rate 450

400

3.5

350

2.5 200 2 150

1.5

100

0.5

0.7

140

300 250

200

150 2 100 50

0.5

100 0.4 80 0.3

0.2

0.1 0

Jun-12

Feb-12

Dec-11

Apr-12

Oct-11

Jun-11

Aug-11

Feb-11

Dec-10

Apr-11

Oct-10

Jun-10

Aug-10

Feb-10

Dec-09

Apr-10

Oct-09

Jun-12

Feb-12

Bed day rate/ 1,000

Apr-12

Dec-11

Oct-11

Jun-11

Aug-11

Feb-11

Dec-10

Apr-11

Oct-10

Jun-10

Aug-10

Feb-10

Apr-10

Dec-09

Oct-09

Jun-09

Aug-09

12m rolling bed days Bed day rate: South East Coast

0.6

120

Jun-09

Apr-09

Jun-12 Apr-12 Feb-12 Dec-11 Oct-11 Aug-11 Jun-11 Apr-11 Feb-11 Dec-10 Oct-10 Aug-10 Jun-10 Apr-10 Feb-10 Dec-09 Oct-09 Aug-09 Jun-09 Apr-09

12m rolling admissions Admission rate/1,000

0.8

160

Aug-09

180

Apr-09

6 5

Bed days (count)

250

Admission rate per 1,000

300

Bed day rate per 1,000

4.5

350

Bed day rate per 1,000

400

Readmission rate: South East Coast

Emergency asthma admissions <18 years and admission rate

Bed days (count)

Emergency asthma admissions and admission rate

Admissions (count)

Jun-12

Apr-12

Feb-12

Dec-11

Oct-11

Aug-11

Jun-11

Apr-11

Feb-11

Dec-10

Oct-10

Aug-10

Jun-10

Apr-10

Feb-10

Dec-09

North West Surrey CCG

Oct-09

ASTHMA08: The percentage of patients aged 8 years and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility

Jun-09

ASTHMA 08

Indicator

Aug-09

ASTHMA 06

Apr-09

ASTHMA 03

Admit <18yrs Admit <18yrs rate/1,000 Admit rate <18yrs: South East Coast

A range of different views are also available; as respiratory conditions are often subject to considerable seasonal variation, a 12 month rolling view can be seen, as well as rates and counts, with rates allowing crude comparisons between the chosen CCG and SHA benchmarks. And because the dashboard covers the whole region, the potential comparisons are considerable. What next for this dashboard then? Well, weâ&#x20AC;&#x2122;re working on getting some provider based views in as well, covering admissions, length of stay and, for COPD, in-hospital mortality. In the meantime, the dashboard is updated monthly and will shortly have the latest QOF results in as well! Get it from the usual place: nww.qualityobservatory.nhs.uk and as ever, any and all feedback gratefully received, just drop us a line at quality.observatory@southeastcoast.nhs.uk.

www.QualityObservatory.nhs.uk

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Health Visitors Dashboard for NHS South of England By David Harries, Public Health Anaylist The Health Visitors Minimum Data Set (HVMDS) has been set up to help support the governmentâ&#x20AC;&#x2122;s commitment to improve the health visiting service and recruit 4,200 more health visitors by 2015. This data is collected monthly via submissions by SHAs to the Information Centre for Health and Social Care. Whilst the HVMDS monitors the numbers of existing health visitors and those coming online, one of the key deliverables from the Health Visitor Implementation Plan 2011-15 (Department of Health, 2009) for aligning the delivery systems are developing outcomes measures in order to measure the impact of the increase in health visitor capacity. The 2012/13 NHS Operating Framework states an increased number of health visitors will ensure improved support for families through the delivery of the healthy child programme and the family nurse partnership programme. SHA and PCT Clusters should work together to achieve the 4,200 target by April 2015 and commissioners should ensure new health visitors are supported and deployed. Identifying sufficiently sensitive outcomes for work that is essentially health promotion and prevention is a challenge. Consequences of health visiting interventions may be long term and causality difficult or impossible to track in an environment of rapid change and multiple interventions The NHS South of England Health Visitor Dashboard has been setup as an initial attempt at identifying possible intermediate outcome measures (from existing data sources) that the increase in health visitor capacity maybe impacting on. Measures in the dashboard include, HV (WTE) per 100,000 population aged 0-4 years; Proportion of children aged 0-4 by deprivation quintile; Rates of Children in need and Children subject to child protection plan, Rates of A&E attendance for ages 0-4 years; Breastfeeding initiation, continuation and coverage (6-8 wks), Immunisation uptake at ages 2 and 5; and Prevalence of obese children in reception year (45 year olds). As well as an overall dashboard view, each measure is available to view separately comparing rates with the rest of South of England and England overall. By drawing together and linking existing data sources the HV Dashboard has provided Action on Health Visiting teams across the South of England with a starting point for measuring the impact of increase in HV capacity whilst it was also used to kick start discussions more widely. At a national level, a Health Visitor SHA Metrics Task & Finish Group has been set-up with the specific aim of working together to standardise data to measure a selection of indicators, evidencing service delivery and improvement in Health Visiting services, including its contribution towards the Healthy Child Programme outcomes. Using the South of England HV Dashboard as a starting point for discussions, 6 indicators have now been identified to measure improvement in health visiting services and coverage of the Healthy Child Programme (the core service). The chosen indicators include: Antenatal Contact with a HV; Breastfeeding prevalence and coverage (6-8 wks); New Birth Visits (NBV); Childhood Immunisations; Children receiving a review by the age of 2.5 years; and prevalence of obese children (Reception year). More information around the six indicators should be out shortly. In the meantime the NHS South of England HV Dashboard can be accessed from the QO website: http://nww.qualityobservatory.nhs.uk/index.php? option=com_cat&view=item&Itemid=2&cat_id=1315

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Effective clinical analysisâ&#x20AC;&#x201D;Part 3 By Simon Berry, Specialist Information Analyst Hello again everyone! As a result of my last article, I was pleased to be contacted by the Health and Social Care Information Centre asking for my advice. The HES service is currently being transitioned to the HSCIC as the contract with the current supplier is reaching an end. Whilst the primary aim of the project is to ensure continuity of supply, the HSCIC are also looking to make a number of improvements to the service. One of the improvements is to make as much progress as possible in reviewing the data cleaning rules and removing those that do not add value or detract from the value of the data - hence contacting me to advise on those rules which should be removed as a priority. In this article, I want to take a different slant and look at why we use discharge date rather than admission date when we analyse inpatient data. When we talk about hospital data we talk about admissions so, on the surface, it seems to make perfect logical sense that we should use the admission date, and therefore month, quarter, or year of admission to group up our data. Certainly its an easy mistake to make and one that I definitely made when I first started with the NHS 10 years ago!! Unfortunately, although it seems to make sense, it can actually result in skewing of your data and result in apparent reductions in measures like length of stay, numbers of admissions or readmissions that disappear when you refresh the data in the future. Why is this? Well, what it boils down to is that the source data you are analysing is almost certainly closed spells. This means that a spell is only included in the inpatient extract once the patient has been discharged from hospital so the extract is defined by the discharge date. Admission vs Discharge Date Last Month in Dataset 25 Discharge Date Admission Date 20

15 No of Spells

If you then choose to analyse this data by admission date, in the last couple of months of your data you will be missing all those patients admitted in those months who are yet to be discharged. Typically the numbers arenâ&#x20AC;&#x2122;t large, there may be many reasons as to why they have a long stay, delayed discharges for example, but they can have a significant effect on rates as they have long lengths of stay. If you are looking at specific conditions where the patient is very likely to have a long stay, FNoF of Stroke for example, the skewing effect on average length of stay can be considerable.

For example, this bar chart shows for a particular condition the total number of patients in bins of 5 days length of stay intervals for the last complete month in a dataset. You will note that there are no patients at all with lengths of stay 31 days+ in the data extracted by Admission Date.

0 0-5

6-10

11-15

16-20

21-25 26-30 Length of Stay

31-35

36-40

41+

And this line chart shows average length of stay over time using admission date and discharge date for the time series. Note the significant drop off in the last 2 months data!

Average Length of Stay 25 By Discharge Date By Admission Date

If you are calculating 30 day readmission rates using admission date you get hit with a double whammy, not only are some of the patients admitted in your reporting month still in hospital, and therefore not in the denominator, but the subsequent emergency readmissions for your numerator are more likely to be.

Days

Sep-12

Jul-12

Aug-12

Jun-12

Apr-12

May-12

Mar-12

Jan-12

www.QualityObservatory.nhs.uk

Feb-12

Dec-11

Oct-11

Nov-11

Sep-11

Jul-11

Aug-11

Jun-11

Apr-11

May-11

Mar-11

Jan-11

Feb-11

So, although we talk about admissions to a particular hospital the most sensible and accurate method is to group them based on their discharge date.

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Website update: New features on: http://nww.QualityObservatory.nhs.uk On the 5th of November the Quality Observatory website will be updated with some new features. We will update the side bar to make accessing the newest and most popular items easier. You will be able to create your own favourites list and will receive email alerts when ever your favourites are updated. Below is a little look at the new features and how to use them.

Updated sidebar. The updated sidebar includes: • Quick and easy access to the latest files. • A look at the most popular items in the catalogue. • Access to the most recently updated files in your favourites list.

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7 Add Items to you favourites. Adding items to your favourites couldn’t be simpler. Once you have logged in just click on the favourites icon (the star) next to the items and it’s done! Click it again to remove it from your favourites. The star will go orange and yellow when it’s one of your favourites and will be grey when it’s not. You will also automatically start getting e-mails for your favourite items though: Remember to add us to your SAFE SENDERS LIST! Otherwise you may find all your alerts in “junk” mail.

New Favourites View. We have also added a new view so you can view all your favourites together. Simple click on favourites in the search menu. Here you can remove favourites from your favourites list as well as turn on and off email alerts. To turn the email alerts on and off simple click on the envelope next to the item. If the envelope is orange then you are subscribing to email alerts.

You can also edit your email preferences and remove or add an item to your favourites in the item view. Again just click on the favourite and email icon next to the item name.

Access and registration to the N3 catalogue is free so why not check it out today and from the 5th November you can start adding your own favourites.

http://nww.qualityobservatory.nhs.uk

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Reading between the lines - understanding line graphs By Nazir Zarnosh, Performance Analyst In a previous edition of Knowledge Matters we had a look at bar charts and histograms. To carry on from this I thought that in this edition we could have a look at line graphs. The majority of the graphs used for visual representation in mine and many other dashboards produced by my colleagues in the QO are line graphs. The reason why? They can tell a story over time and make patterns easier to see. Lets start with taking a look at the history of line graphs. You may remember the name William Playfair from previous editions. He was a Scottish engineer who represented economical data in bar charts. He also used line charts to represent the economic conditions of the UK. Playfair first presented a line chart in his Commercial and Political Atlas. He used it to examine the imports and exports differences between Britain and other countries. The strength in using visual data representation like this was that it was easy to compare large numbers of variables and see trends.

Chart by William Playfair, 1786

So what is a Line graph? Line graphs show the relationship between two variables with each variable plotted along an axis. The line graph is used when there are a considerable number of data points to be plotted or when the data is continuous, for example plotting the number of patients seen at a ward every month over a year. These concepts are represented with the help of simple lines, vertically or horizontally drawn. There are a number of variations of line graphs from the high, low and shaded line graphs.

The characteristics of line graphs which make them useful are:

•

They are good at showing specific values of data, i.e. given one variable the other can be determined.

•

They show trends in data, they visually illustrate how one variable is affected by another. It is easy to spot patterns and to see if something has occurred out of the ordinary.

•

They enable us to make predictions about results of data not yet recorded and use this information to ensure that we can move resources around to help cover any predicted peaks and dips in demand.

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9 Letâ&#x20AC;&#x2122;s look at a set of example data and ways to represent the data using line graphs. This data set shows the number of patients visiting a hospital over four months (this doesnâ&#x20AC;&#x2122;t represent any actual figures).

Patients Seen

Hosp 1 Hosp 2 Hosp 3 Hosp 4 Hosp 5

Jan-12 500 770 250 1200 350

Feb-12 450 790 200 1050 390

Mar-12 580 940 280 1000 420

Apr-12 600 970 250 1090 400

There are several line graphs we can use to represent this data.

Line Graph: This displays the trend in patients seen over each of the months. Comparing each hospital as well as the months over which patients attended. This is also known as a comparison line graph.

Stacked/Compound Line Graph: This type of graph displays the trend of the contribution of each value (patients seen) over the given months. However this is not necessarily the best way to represent this type of analysis as it can be easy to think that hospital one has around 500 patients a month and hospital five has over 3000!

100% Stacked Line: This type of Graph displays the trend of the percentage each value contributes over the given months. Again this is not the best way to represent this type of analysis as again it could be confusing as to what it is actually representing.

Remember when using any kind of graph it is important to identify both the horizontal and vertical scales. The purpose of each of these is so we can derive values from the graph at any point. Never superimpose two vertical scales which are different as this can lead to misinterpretation. If you are comparing two data sets on two separate graphs (e.g. male vs female attendances) make sure you set the scale to the same so that the data is not misinterpreted.

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10 NICE Pathways –the fast and easy way to access NICE guidance and products By Sanjay Tanday - External Communications Writer, NICE Over the past decade, guidelines have increasingly become a familiar part of the clinical landscape. Every day, decisions on treatments and medications at the bedside, operations at hospitals, and commissioning decisions at NHS trusts are influenced by guidelines, many of which are from NICE. But reading through all the recommendations from NICE and identifying the accompanying quality standards or support tools can be a real challenge. And as the quantity and range of these products increases, busy healthcare professionals require new ways of identifying, accessing and using this guidance. Help is now at hand in the form of NICE Pathways, an online tool for health and social care professionals. Bringing it all together NICE Pathways brings together - for the first time - all related NICE guidance and associated products in a set of interactive topic-based flowcharts. It is a visual and interactive format that provides a way to quickly view and navigate guidance, including quality standards, and other tools from NICE on a given topic. Previously, there has been no easy way to see at a glance everything NICE has said on a specific condition across all its separate published guidance. NICE Pathways covers the entire range of NICE guidance, including health technology appraisals, clinical guidelines, public health and social care advice, quality standards and implementation tools. Pathways can be viewed on smart phones and on IPads allowing easy access while on the move. Users are also able to print out the Pathways and save them for future reference. “NICE Pathways is for anyone who needs to use NICE guidance. Starting with a broad overview allows the user to explore in increasing detail NICE recommendations and advice,” explains Dr Gillian Leng, NICE Deputy Chief Executive. “For example, you may be interested in finding out what NICE has said on stroke. There might be technology appraisal guidance, clinical guidelines and perhaps a quality standard as well. NICE Pathways will connect all of this advice together in one place. “NICE Pathways will provide a useful starting point for users new to a topic, while giving specialists confidence that they are up to date with everything NICE has recommended.” This new resource will also greatly facilitate access to NICE guidance for commissioners, who need to commission care across a whole pathway. Users do not need to understand how NICE classifies different types of guidance to view everything NICE has said on a particular topic. For example, you may be interested in finding out what NICE has said on say advanced breast cancer. There might be technology appraisal guidance, clinical guidelines and perhaps a quality standard as well. NICE Pathways will synthesise all of this guidance together in one place. From alcohol disorders to venous thromboembolisms Over 80 pathways have been produced so far that can be browsed by A to Z or by the following clinical areas; Cancer, Cardiovascular disease, Endocrine disease, Eye disease, Kidney disease, Mental disorders, Infections and infectious diseases, Metabolic diseases, Nervous system diseases, Pregnancy and childbirth and Respiratory diseases.

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11 Latest Pathways include topics such as headaches, crohn’s disease, preventing type 2 diabetes, osteoporosis fragility fracture and the use of antibiotics for early-onset neonatal infection. There is also a back catalogue of NICE Pathways on a host of common conditions such as depression, COPD, chronic kidney disease, dementia, hypertension and food allergies. There are public health topics covering behavioural issues such as diet, physical activity and smoking, as well as maternal health, mental health and preventative medicine. Individual pathways also link to other related pathways - for example the diet pathway links with the physical activity pathway. NICE Pathways will continue to develop by including more content and more topics as new NICE guidance is published and by adding new features such as linking to the evidence behind NICE recommendations One of our most recent pathways, the headaches Pathway (below) sets out the routes for diagnosing and managing headaches - one of the most common complaints presented to GPs and neurologists, with more than 10 million people in the UK experiencing them frequently or at regular intervals. Headaches Pathway Following the path for diagnosis guides you through the options for patients presenting with a tension-type headache, a migraine or a medication overuse headache. Medication overuse headaches are on the rise as the use of drugs and different combinations increases. Clicking on the medication overuse headaches nodule on the Pathway reveals the guidance recommendations which advise GPs to be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

•

triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or

•

paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more.

The management section of the Pathway splits into two sections to offer advice on the management of headaches and the management of migraines (with or without aura). Venous thromboembolism Pathway This NICE Pathway for reducing the risk of venous thromboembolisms in patients admitted to hospital is a good example of how other aspects of a piece of guidance, such as the implementation tools, can be brought together in one place. Currently, it is estimated that 25,000 people who are admitted to hospital in England die from preventable venous thromboembolism each year. This has led the Department of Health to make the prevention of this “silent killer” across the NHS a priority for the forthcoming years. NICE estimates that around 10,000 lives could be saved each year if patients are assessed for their risk of developing blood clots as soon as they are admitted to hospital, and has produced a suite of support tools to help put the guidance into practice. There are baseline and self-assessment tools which can be used by organisations to identify if they are in line with practice recommended by NICE and to help them plan activity that will help them meet the recommendations. Audit and costing templates along with educational tools and slide sets are also available and highlighted in this Pathway.

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Analysis Ancient and Modern: Paul Meier (1924 - 2011) By Katherine Cheema, Specialist Information Analyst I get asked a lot about sample size and sampling generally, usually by clinical colleagues who are conducting research. Most of the time, this research is what you might call opportunistic, using data from the patients that walk (metaphorically or otherwise!) through the door. But if we were testing a new procedure or drug, ideally we’d want to carry out a full clinical trial, with carefully controlled groups of participants either on a specific treatment or on a placebo. This kind of controlled trial is regarded as ‘gold standard’ evidence, but those readers familiar with this area may realise that I’ve missed a word off; randomised. Our statistician this edition of Knowledge Matters is Paul Meier, the man who was arguably the first proponent of randomisation in clinical trials (although Bradford Hill, the biostatistician so involved in the proof that smoking was bad for you, advocated randomisation in a study of streptomycin for the treatment of tuberculosis). Prior to Meier’s involvement in medical statistics, clinical trials could often be skewed; researchers would provide the new treatment to those who they thought would benefit, and compare them against untreated samples of patients, thus introducing bias and therefore unreliable results. In any case, Meier’s influence had a significant impact on the received wisdom on quality of evidence, and these days nothing gets past the USA’s Food and Drug Administration without a randomised control trial (RCT) supporting it. Not that getting his clinical colleagues to randomise their patients was easy: “When I said “Randomize” in breast cancer trials, I was looked at with amazement by my medical colleagues. “Randomize? We know that this treatment is better than that one.” I said “Not really.””- Paul Meier, 2004

The other famous contribution to the medical sciences that Meier pioneered was his input into the KaplanMeier estimator. This was the use of a statistical method to estimate the survival rate of patients in a clinical trial, accounting for the fact that some will die over the course of a trial, and others will survive beyond it. It means that if you were measuring the effect of a treatment on 5-year survival rates, you don’t have to discount the data from a patient who died at, for example, two years after the start of the trial. The use of the estimator results in a Kaplan-Meier curve, which can be seen in literally thousands of clinical trials today (the original paper has been cited over 30,000 times!). The curve enables the researcher to show the proportion of patients alive at any point in the trial. Paul Meier is a great example of how effective use of information and application of statistical techniques can be applied to help advance medical knowledge. Refs: Marks, M (2004), A conversation with Paul Meier, Clinical Trials, 1, 131-138

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Meet the Quality Observatory – Susan Chartwell interviews Samantha Riley With 10th October being ‘Bring a Bear to Work Day’, our new surgeon Susan Chartwell took the opportunity to interview Clive and Barnie (Samantha’s closest bears) to bring Knowledge Matters readers the truth about the Boss…… Clive and Barnie, it is a real pleasure to meet you having heard you mentioned so often Hi Susan (hope you don’t mind us calling you that), it’s a real privilege to be visiting again. We haven’t visited QO Towers since December 2010 when we made a guest appearance in the hugely popular QIPP Hop video http://www.youtube.com/watch? v=N-WoVIbC2-M So, tell us a bit about Samantha and her work history then? Well, Sam has worked for the NHS since 1997. She has done lots of different roles, all of which have had a focus on improvement. She used to change jobs pretty frequently so we’re rather surprised to find that she has been working in Horley for approaching 8 years (we think the silver jewellery shop has a big part in that). Over the years she has increasingly become a bit obsessive about data. We might get in trouble for this, but we would say she has become quite a geek (no offence intended). Sometimes she talks in her sleep, often muttering about a run of seven points all above or all below the centre line, or all increasing or decreasing. We’ve got no idea what she is on about! And what does Samantha’s current role actually entail? Now that is a very good question. We know that she goes to lots of meetings, LOTS!!! and spends lots of time on motorways. And clearly she has to ‘crack the whip’ to make sure the team delivers, but more than that we really couldn’t say. Now there is much talk about Samantha’s shoe collection and rumour that her nickname is Sam The Shoe – can you comment on this? We can confirm that there is truth in the rumour. Ms Riley is named Sam The Shoe for a reason! We often have to clamber over shoes to get into bed. We do sometimes ‘relocate’ shoes just to wind Sam up if she has bought us cheap honey. And recent sightings of Sam have seen her with a collection of thermos flasks – what’s that all about? A few months ago, Sam did a fruit juice detox and since then to be honest has been a bit odd. She has been ordering boxes of organic vegetables, making lots of soup (sometimes it feels like we’re living in a soup kitchen!), has constructed a food safe in the garden and started composting. The flasks contain herbal tea and home made soup. Next thing she will be buying vegetarian shoes and wearing thick brown tights! And are there any other aspects to Samantha which you think would interest Knowledge Matters readers? Well, for a special birthday several years ago the team had all of the Knowledge Matters issues published to date bound in red leather. This has pride of place in a silk pillow case under Sam’s pillow. She sneaks a look most nights.

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Making my macros copy graphs to PowerPoint. Application: Excel 2003/2007/2010 Dear Quality Observatory, I have been trying to write a macro to copy graphs from my excel workbook into a PowerPoint presentation with one graph on each slide. I have looked on the internet and found some code that looks like it should work! But No matter what I try it just doesn’t work! It does nothing! Can you advise? Anonymous analyst NHS hospital trust

Solution:

Complexity 3/5 — Check your code /

library

Hmm this sounds like a puzzler! Firstly lets have a look at the code … below is an example of code up a new powerpoint presentation and add a slide. You can add the copy and paste, and any other specific functions that are required.

that should open more code to do

Sub ExcelToNewPowerPoint() Dim PPApp As PowerPoint.Application Dim PPPres As PowerPoint.Presentation Dim PPSlide As PowerPoint.Slide Set PPApp = CreateObject("Powerpoint.Application") ' Create instance of PowerPoint PPApp.Visible = True visible

' For automation to work, PowerPoint must be

Set PPPres = PPApp.Presentations.Add

' Create a presentation

PPApp.ActiveWindow.ViewType = ppViewSlide ' Some PowerPoint actions work best in normal slide view Set PPSlide = PPPres.Slides.Add(1, ppLayoutTitleOnly)

' Add first slide to presentation

''Do Some Stuff Here like copy / paste With PPPres .SaveAs "C:\My Documents\MyPreso.ppt" ‘specify file path for save *optional .Close End With ‘Save and close presentation *optional PPApp.Quit

' Quit PowerPoint

Set PPSlide = Nothing ' Clean up Set PPPres = Nothing Set PPApp = Nothing

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End Sub This code has been tried and tested so if this isn’t working then you will need to check your “reference library” This is a common mistake that lots of people (including us here at the QO) make, you need to add the PowerPoint reference to your project to be able to manipulate PowerPoint. To check your reference library in visual basic editor go to -> TOOLS -> References In the popup box scroll down the list until you find the “Microsoft PowerPoint” Object Library. Make sure that you select this and that it has a “tick” in the box!. Click Ok and you should be good to go! If this doesn’t fix your problem let us know!

Update from By Carl Plant , Managing director Bitjam.org.uk Its been a busy summer launching my new company bitjam. The work I have been involved in over the last few years have helped to shape the company. We are focusing on digital engagement and data to intelligence with much of our work involving health, cultural projects, education, research and community engagement.

We wanted to develop services that made better use of data, multimedia and digital technologies with a strong focus on training as well as providing the services. So for example we are currently developing a project with a local university using these techniques for peer to peer wellbeing 'asset mapping' (mapping the voluntary and informal support networks). This piece of research will use social media data mining, crowdsourcing and digital engagement to map the informal peer to peer networks and support infrastructures in a specified location. We feel this approach is quite unique and taps into the rich stream of information contained in forums, blogs, Twitter and Facebook etc. There's a lot of work to do yet, mainly funding the project however we hope that working with the University we have a strong funding application. Much of my past data work has involved data mining and analysis so I hope to use these techniques as part of a bigger project. You can find out what bitjam are doing by following @bitjam on Twitter or www.bitjam.org.uk

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Quest for improvement: What do we mean by 'good'? Using Strategic Dashboards to measure Quality NHS QUEST is the first member-convened network for Foundation Trusts who wish to focus relentlessly on improving quality and safety. NHS QUEST members, together, want to find the ways of improving more and faster so that they can provide the best care possible for their patients. Here take a look at their view on measurement and what is ‘good’. The topic of measurement is not surprising as divisive as marmite – healthcare professionals either find charts and data tables a rabbit warren that they want to explore and ask questions of or run away from in a chorus of “I don’t do data!”. However, more and more staff delivering NHS funded care are asking one vital question to support quality improvement – how will I know that my ward, staff treating this caseload, or even my organisation as a whole is getting better at delivering quality and safety? The answer: we just don’t know unless we measure. This simple principle is taken from the three questions that form the basis of the Model for Improvement developed by the Associates for Process Improvement, a methodology to support quality improvement that has been used extensively in the NHS. At the level of the provider organisation there are numerous ‘key performance indicators’ of interest that provide a level of understanding of the level of quality being delivered, although often in a fragmented or specialised form. The Health Protection Agency publishes helpful data on mandatory surveillance of infection, but how do we reconcile this with the Summary Hospital Mortality Indicator (SHMI)? And how can we use these to understand how ‘good’ our organisation is? The question here is obviously what we mean by ‘good’ – again another point of measurement. But this is not a philosophical discussion, and with 11% (7456) of patients reported as suffering from harm from a survey of over 70,000 nationally in last month’s NHS Safety Thermometer a practical response to this question is as pressing as ever. NHS QUEST are just starting a journey of understanding. Research, experience and results from nationally reported indicators highlight there are some measures every healthcare provider organisation should want to review on a regular basis. As a network they have been developing an NHS QUEST Strategic Dashboard - a focus on 6 buckets of strategic measures: Mortality, Readmission, Length of Stay, Harm, Infection and Patient/Staff Experience. It reviews data over time for each measure group supporting local understanding of improvement, as well as highlight data sources nationally as a lens or perspective. The key here is that there are hundreds of measures that could give a signal of ‘quality’ – but unless we utilise simple dashboard design principles the noise of data can debilitate our success in using it to impact patient care. An excellent example of this is the Royal College of Physicians Stroke Sentinel Audit. There are a plethora of stroke measures but through careful analysis 9 indicators were understood to be key to supporting good outcomes. So what is the answer? We can’t say that we have the answer, but by developing a dashboard of measures in this way, reviewing national data sources alongside local measures we have a mechanism for understanding improvement and placement. How is your organisation challenging it’s understanding of quality? How are you as an individual utilising measurement to inform your own work in patient safety? You can give your comments to Quest, they’re contact details are available on their site: http://www.quest.nhs.uk/welcome/ This article was adapted from the Ian Chappell post on the Quest website: http://www.quest.nhs.uk/about-us/ blog/?blogpost=15

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17 The Teddy Bears Day Job (you know the tune!) by Adam C. Cook When you go into your work today

Clocking on for teddy bears,

You're sure of a big surprise.

The little teddy bears are booting up their PCs.

If you go into your work today

Watch them, writing e-mails,

You won't see suits or ties.

And see them using their spreadsheets. See them gaily dial-in.

For every bear that ever there was

They love their WebExing.

Will gather there for certain, because

They're filling in questionnaires.

Today's the day the teddy bears do their day job.

At close of play their mummies and daddies Will take them home to bed

Clocking on for teddy bears,

Because they're tired little teddy bears.

The little teddy bears are booting up their PCs. Watch them, writing e-mails,

Every teddy bear, that's come to work

And see them using their spreadsheets.

Is sure of a meeting today

See them gaily dial-in.

There's lots of wonderful minutes to take

They love their WebExing.

And the right to get sick pay.

They're filling in questionnaires. At close of play their mummies and daddies

At their desks, where everyone sees

Will take them home to bed

They'll copy and paste as long as they please

Because they're tired little teddy bears.

Today's the day the teddy bears do their day job.

If you go into the office today,

Clocking on for teddy bears,

You'll find it has come alive.

The little teddy bears are booting up their PCs.

It's lovely in the office today,

Watch them, writing e-mails,

It's home to Barnie and Clive.

And see them using their spreadsheets. See them gaily dial-in.

For every bear that ever there was

They love their WebExing.

Will gather there for certain, because

They're filling in questionnaires.

Today's the day the teddy bears do their day job.

At close of play their mummies and daddies Will take them home to bed

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18 NEWS The Quality, Innovation, Productivity and Prevention (QIPP) Evidence Collection The QIPP c ollec tion on NHS Evidence (www.evidence.nhs.uk/QIPP) provides quality-assured, real life examples of how things can be done differently in health and social care, whilst still providing optimal standards of care to patients. This includes evidencebased examples that have been shown to improve quality and save money (the QIPP Evidence Collection), plus areas of potential disinvestment from NICE guidance and Cochrane reviews.

If you have good examples that have been shown to or have the potential to work, and which can help the NHS nationally meet its challenge, NICE want to hear from you. If you have already submitted a case study, please consider whether you have any new examples to provide.

New approved information standard The Information Standards Board for Health and Social Care (ISB) approved two new information standard at its meeting on the 26th September. The first standard is ISB 1570 HIV and Aids Reporting System (HARS). More information about it can be found on the ISB website: http://www.isb.nhs.uk/documents/isb-1570/amd-1642010/index_html The second is ISB 0134 Surveillance of Healthcare Associated Infections (Amd 7/2012 Version 2). Again more information about this standard can be found on the ISB website: http://www.isb.nhs.uk/documents/isb-0134/amd-7-2012/ index_html Digital Innovation Fund

For your QIPP initiative to be considered for inclusion on NHS Evidence, you will need to complete an online form which you can find at http://www.evidence.nhs.uk/QIPP together with the QIPP Submission User Guide outlining what types of supporting information the assessment team is looking for. Send your completed submission to NHSevidenceqipp@nice.org.uk. Once your submission has been processed, a member of the assessment team will contact you. Protecting people, promoting health A new report about the roles of public health and health care services in reducing the levels of violence across the country has been released by the North West Public Health Observatory. The report details the extent and nature of the violence, its impact on short and long term health and wellbeing, education and antisocial behaviour, risk and protective factors for involvement in violence, the range of evidence based approaches for dealing with violence and related national policy and programmes. The report along side other publications for the NWPHO is available from the thier website: www.nwpho.org.uk

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The Department of Health has set up a fund from which local NHS organisations could now be awarded funding to develop new digital services that improve patient care ,including information sharing more easily across the NHS. More information can be found on their website: http://www.dh.gov.uk/health/2012/08/information-sharingchallenge/

Information Centre It is understood that the Health & Social Care Information Centre is to be replaced with a new Health & Social Care Information Centre. The new organisation will operate as an “arm’s length” body (similar to NICE) and will have a wider remit taking on the remaining functions of NHS Connecting for Health. Replacement of NHSmail The NHSmail 2 project has been established to look at options for when the current NHSmail (national e-mail system) contract ceases. Despite the name of the project, no assumptions have yet been made about the solution. Information will be published as it becomes available at:http://www.connectingforhealth.nhs.uk/ systemsandservices/nhsmail/nhsmail2.

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19 NEWS New MH Discharge Summary

Our latest twitter feed……

A new Mental Health Discharge Summary has been developed to help standardise the data items and information that GPs receive when a patient is discharged from inpatient mental health care. For details see: http:// www.connectingforhealth.nhs.uk/systemsandservices/ clinrecords/mhds/intromhds.pdf N4

The contract for N3 – the NHS national network – is due to come to an end in the next couple of years. An “N4” project has been initiated to develop options for what happens next. These options will be driven by the requirements of health and care organisations in consultation with potential suppliers. More information: http:// www.connectingforhealth.nhs.uk/systemsandservices/n3/ n4. Quality Observatory Birthdays

We have celebrated two birthdays in the Quality Observartory since the last edition. Nikki was treated to some Crabtree and Evelyn smellies from the team. Whilst Fats received a car kit. Make a contribution to the newsletter

If you have an article you would like to submit or a topic you would like to write about, please get in contact with us: quality.obersvatory@southeastcoast.nhs.uk. Trolley Dolly Update As always we have been filling the tea trolley with lots of goodies since our last edition. We have had the usual biscuits and sweets. Rebecca treated us all to some leaving cakes. Fats and Nikki also treated us with birthday goodies. We also had a taste of Christmas with some chocolate covered gingerbread. To keep us going Sam treated the team to some Halloween doughnuts.

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SHMI Poem by Adam C. Cook The time, at last has come, full of fear and dread Summary Hospital-level Mortality Indicator The final reckoning and totting up of the dead A nationwide death index derived from fine SUS data

Baby News! We are happy to announce that Rebecca Matthews (Performance and Planning Analyst) gave birth to Rosie Emily Matthews on Tuesday 16th October. She weighed 7.95lbs. Congratulations Rebecca and Robin. In keeping with the bear theme here is Rosie in her Winnie the Pooh outfit:

Showing observed against expected Which inpatients have gone to meet their creator? A test to help the trusts manage expectations, Does the reaper come to often, Is all within the norm or are there aberrations. There is still one problem that needs to be decided, A cause of great academic debate, It would be a service if a solution were provided Is it pronounced "SHMI" like Darth Vader's Mum, It's time the truth were told, Or is it really "SHIMMY" like when you wiggle yer bum

Fascinating Facts 40% of adults keep hold of their childhood bear.

Simon says……. Chickens with white ear lobes lay white eggs, whereas chickens with red ear lobes lay brown eggs.

The first teddy bear museum in England was set up in Hampshire in 1984. Unfortunately it closed down in 2006 and all the bears were sold off.

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