Knowledge Matters Volume 7 Issue 2

Volume 7 Issue 2 June 2013 Welcome to Knowledge Matters It’s been 60 years since Edmund Hillary and Sherpa Tenzing conquered the summit of Everest, one of the greatest achievements in the history of exploration. The theme of all time firsts is an apt one for this issue of Knowledge Matters, as the new NHS plunges forward on a programme of work that is bringing so many new ideas and innovations together. The Commissioning Show, covered on page five, was an enormous event bringing stakeholders from all sectors together to network and develop their plans and products for a brighter commissioning future.

In a major step for transparency of data in the NHS, consultant level outcome measure data was published for the first time ever in the UK, and possibly the world; we have a few words to say on this significant milestone on page four. And the new-y newness doesn't stop there; by the time the next edition of Knowledge Matters is published, the first tranche of Friends and Family Test data will be published– have a look at what the Quality Observatory is planning to do with it on page three.

Amongst all this new stuff we sometimes forget about the useful things we’ve had all along; our favourite Director of Insight, Sam Riley reminds us of untapped riches on pages eight and nine.

It’s clear that we’re just in the foothills of the Everest of possibilities in the development of information tools and analyses that could help to revolutionise the delivery and experience of healthcare. Let’s start climbing!

Kate Cheema, Specialist Analyst

Inside This Issue : Casemix adjustment

2

Skills Builder

6

Ask an Analyst

12

Friends and Family analysis

3

The Biggest Survey…….?

8

News

14

Consultant level outcomes

4

Analysis Ancient & Modern

10

The Commissioning Show

5

The work of the QO

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

www.QualityObservatory.nhs.uk

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Casemix adjusted emergency admissions within a locality Chris Morris, Central Southern Commissioning Support Unit Adjusted Clinical Groups (ACGs) is a population/patient case-mix adjustment system developed by researchers at The Johns Hopkins University School of Hygiene and Public Health in Baltimore, USA. The ACG system measures health status by grouping diagnoses into clinically similar groups. The goal of the ACG system is to assign each individual a single, mutually exclusive ACG value, which is a relative measure of the individual's expected or actual consumption of health services. Through this mechanism, we can view healthcare usage adjusted for casemix which can result in fairer and more meaningful comparisons, for example, between practices.

In the above chart, the Practice Emergency Admission Rates (blue bars) and the PCT average (red line) represent standard methods of analysing activity, where Practice performance would be measured against the average (Confidence Intervals have not been included in this example for the sake of simplicity). By this method, you would assess each Practices performance according to its relative position to the PCT average.

The problem with the method is that it takes no account of the different case-mix that each Practice deals with. Analysis has shown, unequivocally, that there is an association between multi-morbidity and care utilisation, and consequently, much of the variation in activity can be explained by differences in case-mix.

When you bring case-mix into the analysis by using the information in ACGs to calculate ‘expected’ rates of activity (green triangles), a different picture can be seen. When case-mix is taken into account, some Practices with apparently high emergency admission rates are actually doing as well as, or even better than might be expected (the green oval) – and some with apparently low rates are doing only as well as, or in some cases, worse, than might be expected (the orange oval). ACGs facilitates a much fairer method of analysing variation in activity, and shows that opportunities for reducing activity are not necessarily always amongst the Practices with the highest activity levels.

Contact: chris.morris2@nhs.net Information Analyst, Central Southern Commissioning Support Unit

info@qualityobservatory.nhs.uk

www.QualityObservatory.nhs.uk

3

Analysing the Friends & Family Test data Charlene Atcherley-Steers, Analyst At the end of July 2013, the first tranche of Friends and Family Test data will be published, no doubt with much media interest! We understand that large sets of data can be bewildering and that analysing the data often seems like a job for experts. But the essence of the NHS Friends and Family Test is that the data can be used by patients and the public to help drive improvement in patients’ experience across the NHS. NHS England has commissioned the QO to develop an analysis site where the NHS Friends and Family Test data will be made available in a range of views to help with: •

Finding scores and response rates at organisational, ward, site, specialty, region and national level

•

Benchmarking

•

Viewing results over time to assess change and improvement

•

Mapping scores to see how things are going locally

•

Interpretation of data and what it means for you We’re in the process of developing all this functionality and can’t wait to see it all come together! Naturally there is a lot of interest in the results of the NHS Friends and Family Test and it is important that the data is as robust and as fully validated as possible.

Therefore, until the July 2013 public data release the website will be used to help validate results from individual organisations, who will be able to access and review all their scores on the site (e-mail

England.friendsandfamilytest@nhs.net to get an organisational log-on) but with the benchmarking facilities restricted.

N.E. WHERE HOSPITAL FFT score: 2 Response rate: 81%

After the data is made fully public in July 2013, the analysis site will be developed further to add real value to the data through the inclusion of case studies and links to organisations who have used the data to drive change, through the use of ‘treasure maps’ and geographical look ups.

So watch this space for more updates!

www.QualityObservatory.nhs.uk

info@quailtyobservatory.nhs.uk

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Consultant Level Outcome Measures

By Kate Cheema June 2013 represents a milestone in the transparency of data in the NHS; on the 28th of June key information on surgical outcomes will be published, not just at an organisational but individual consultant level. This is, according to Professor Sir Bruce Keogh, a work first and puts the NHS in the vanguard of transparency and patient choice.

For us it marks an important moment in the approach the NHS takes to data and how it uses it to interact with the public. There have been concerns raised from many quarters about whether or not publication of statistics at this level could be more of a harm to consultant practice than a help to patients. There are certainly compelling arguments concerning the appropriateness of potentially comparing surgeons who may undertake very different casemix, with very different patients across differing regions of the country. And, naturally, a lot of the usefulness of the data from a patient perspective will be dependent on the presentation of the data and how well the caveats surrounding it are described.

We’ve taken a look at the information that’s been published for vascular surgeons. This covers two major types of operation; elective repair of infra-renal abdominal aortic aneurysm (AAA) and carotid endarterectomy (or ‘stroke prevention’ procedure). There are one and two outcome measures associated with these operations respectively; in the case of elective repair of AAA, the proportion of patients who died in hospital after the surgery is reported. For carotid endarterectomy, the proportion of patients who died or had a stroke within 30 days of surgery is reported, as well as the median wait time between initial symptom onset and surgery. All the outcome measures were risk adjusted for age and gender, and some additional variables specific to the operation type.

The choice of measures was of particular interest to us, because we often think of death rates as being a rather crude approach to measuring outcomes, and that other outcomes, for example patient reported outcome measures or functional scoring, as being more relevant when it comes to quality. But communicating these to the public, could be tricky and adds additional challenge to an area already fraught with difficulty.

The method of presentation was also a fascinating issue for us; in the vascular example tables are presented with the key statistics for each surgeon, arranged by region and trust. This leads to a 55 page pdf document which, whilst very clear, is not perhaps as accessible as a publicly available dataset should be.

Nevertheless, the data is fascinating; one of the key findings is that no surgeon had any outcomes that were out of the expected boundaries. Have a look at the funnel plot , the only graphical presentation of the data so far, which shows lots of variation but no-one outside the control limits. However, there is a definite negative correlation between in hospital deaths and numbers of operations carried out.

There is no doubt that this is a revolutionary step in the use of information in healthcare, but maybe there is a way to go before patients can feel that they can use it to make choices about their healthcare.

Check out the vascular numbers via NHS Choices (www.nhs.uk)

info@qualityobservatory.nhs.uk

www.QualityObservatory.nhs.uk

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The Commissioning Show

By Adam Cook On the 12th & 13th of June the Commissioning Show was held at the Excel centre in London, and the Quality Observatory helped man the stand for our hosts at Central Southern CSU.

The Commissioning Show is the largest national event focussed on clinical commissioning, and amongst all the usual exhibitors it provided the best opportunity for the Commissioning Support Units to set out their stalls, and show what they plan, and how they hope to support clients in the future.

The Central Southern stand was right outside the CSU Pavilion where representatives from each CSU were talking throughout both days sharing their visions and their innovations. This not only meant that there was good footfall for our stand, it also meant we could listen to many of these thoughts and ideas without having to wander too far.

It was very easy to wander though, as not only were there hundreds of exhibitors and stands, there was a full programme of speakers, talking around such subjects as CCG business, Long-term conditions, technology, adapting to survive to the new NHS, facilitated learning, and rising to the challenge of Dementia.

Of course the main aim of any major exhibition like this is networking. There was plenty of opportunity to meet people from not just the NHS, but also social care and the private sector, to forge new relationships, a n d b u s i n e s s collaborations. It’s not just about the new – it provided an excellent platform to catch up with existing colleagues, or old contacts who have moved around the systems during the recent changes; thereby helping the spread of the softer knowledge and intelligence that comes out of these more informal meetings.

As, ever with these kind of events it finished with delegates tired and footsore, but with good contacts and fresh ideas to help ensure that he business thrives in the future.

www.QualityObservatory.nhs.uk

info@qualityobservatory.nhs.uk

6

Excel Masterclass : pulling data from web pages So there is some particularly useful data sitting in a table on a web page that is updated every month that you want in your dashboard, and you don’t want to have to copy and paste the data into your spreadsheet each month, is there a better way?

Here is a friendly web page with a nice table in it.

The first thing we need to do is select the URL address of the web page

In Excel 2003 select “Data” from the main toolbar then “Import External Data” then “New Web Query…”

In Excel 2007 & 2010 Select the Data Option from the menu and select “From Web”

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In the address box paste the address of the website / webpage you are interested in. You can navigate and interact with the page as you would in a web browser.

Excel will process the webpage and automatically recognise the parts of the page that it can process.

These bits will be highlighted by yellow boxes with arrows in them.

Hovering over the icons will highlight the area that Excel can import. Clicking on the icons will turn them green and select the area for import into the Excel workbook.

Select where you want the data in your workbook and Excel will do the rest .

To refresh the data just right click on the table and select “Refresh Data” this will reload the data from the website .

You can even set up Excel to refresh from the website automatically when you open the workbook. Right click on the table and select “edit properties”. There is an option to “refresh data on file open”

www.QualityObservatory.nhs.uk

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IS THIS THE LARGEST SURVEY IN EUROPE? Samantha Riley, Director of Insight, NHS England Hello Knowledge Matters readers – it’s great to see you again!

Last time, I provided you with an overview of the results from the Inpatient Survey…… This time I want to focus on another of the annual surveys. This survey was at one point the largest postal survey undertaken in the whole of Europe!!! On this basis, I imagine that Ipsos Mori (the survey supplier) is in the ‘good books’ of the Royal Mail!

So….. which survey am I referring to? The GP Patient Survey – the results of which were published on 13th June.

So, let’s start with an introduction to the GP Patient Survey (fondly known as GPPS). This is a vast survey which has now been undertaken for 7 years. Every year, 2.7 million patients are provided with the opportunity to complete the survey and (although of course response rates do vary year on year), approximately between 930,000 and 1.1 million patients complete the survey every year. This makes it one of the largest surveys across England.

The GP Patient Survey is a detailed survey asking patients about their experiences with GP services and other NHS Primary Care services. A number of indicators from the survey support indicators within the NHS Outcomes Framework. Here’s the link to the GPPS website for those of you who are interested http://www.gp-patient.co.uk/ So, what are the headline national figures from these recently published results? Lets start by looking at GP services…..

• 86.7% of patients rate their overall experience of their GP practice as good, a decrease of 1.5 percentage points since the 2011-12 aggregated survey results.

• 76.3% of patients rate their overall experience of making an appointment as good, a decrease of 2.8 percentage points since the aggregated 2011-12 survey results.

• 75.0% of patients find that it is easy to get through to their GP surgery on the phone, a decrease of 3.0 percentage points since the 2011-12 survey results.

• 92.6% of patients have at least some level of confidence and trust in the last GP they saw, a decrease of 0.4 percentage points since the aggregated 2011-12 survey results.

• 79.6% of patients are satisfied with their GP surgery opening hours, a decrease of 1.3 percentage points since the aggregated 2011-12 survey results.

info@quailtyobservatory.nhs.uk

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9 The highlights related to helping people manage their health are as follows: • 64.0% of people with a long-standing health condition feel they have enough support from local services to help them manage their condition. This shows no significant change since the 2011-12 survey results.

• 92.7% of people with a long-standing health condition feel they are confident that they can manage their own health, a decrease of 0.2 percentage points since the aggregated 2011-12 survey results.

• 88.7% of patients with a long-standing health condition rate their overall experience of their GP surgery as ‘good’, a decrease of 1.5 percentage points since the aggregated 2011-12 survey results.

In terms of out of hours services: • 70.2% of patients describe their experience of out-of-hours GP services as good, a decrease of 0.7 percentage points since the aggregated 2011-12 survey results.

• 81.4% of patients reported that they have at least some level of confidence and trust in Out-of-Hours clinicians. This shows no significant change since the aggregated 2011-12 survey results.

Knowledge Matters readers will know very well that my passion is utilising data to drive improvement in care – this has been for many years the focus of work for the Quality Observatory and I am pleased to see that this continues to be the case. When I was at the Observatory, I have to be honest and admit that I was unaware of how vast this data set was. It’s only now (that I have responsibility for the whole of the survey programme) that I am understanding the true potential of data sets which are sometimes not valued on the basis that they are annual. The GPPS provides a huge wealth of data related to patient experience of primary care. We have a considerable number of years of data. My question is, how well is this data used?

Are there other people like me who have previously been unaware of the extent of this data set? Do people know how to access the data? Do people have the skills to interpret the data and understand the key messages which could prompt an action to improve the experience of patients? With the most recent data release, an online tool has been made available to allow comparisons of multiple practices, trend analysis and crosstabulations, making access to the data even easier. No doubt there are practices which use the data to improve services – my question is what more could be done to encourage and support this? Fundamentally, this is what my job is about. I would be really keen to hear from Knowledge Matters readers for a couple of reasons. Firstly, please do send me examples where survey data has been used to drive improvement. Secondly, I would love to hear your thoughts on how the NHS England Insight Team could best support the NHS to use the data and evidence available through research to inform decision making. I would love to hear from you…….. Please contact me on samanthariley@nhs.net I look forward to seeing you next time!

PS By the time the next edition of Knowledge Matters is published the first publication of the Friends and Family Test data will have been published so this will probably be the topic for next time!

www.QualityObservatory.nhs.uk

info@qualityobservatory.nhs.uk

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Analysis Ancient and Modern Katherine Cheema Judging by the number of measures we have around mortality and death, you might suppose that we’re slightly obsessed. But measuring deaths and rates of deaths is not only the ultimate in outcome measures, it is also one that has been recorded for a very long time and can reflect many aspects of social history and development. These pages have described before the parish records of deaths in the plague outbreaks of the 17th Century, and how patterns of deaths have helped to understand the epidemiology of disease (and how to avoid it!). Anyone who has tried to track down their family history will be grateful for records of deaths!

As a national exercise we’ve been recording death rates since at least 1841, and thanks to our friends at the Office of National Statistics we can see how crude death rates have fallen, and plot key historical events in the world of public health and world events. Have a look at the chart to the left; in 1841 crude mortality was at around 23%, slightly lower in females (red line) than males.

The Broad Street cholera epidemic, a key outbreak in terms of understanding the disease and its waterborne nature, occurred around this time and not long after the development of London’s first sewerage system began. Such events have a significant effect on death rates and as the country introduces health checks in schools and brings newly developed vaccinations to the public they continue to slide downwards. The tragic spikes in deaths in males (blue line) concurrent with the two world wars can be clearly seen. But one of the most fascinating mortality statistics, viewed historically, which shows a clear societal change, is infant mortality, split by whether the baby was born in (blue line) or out (red line) of wedlock. The chart to the right clearly shows our changing attitude to marital status and the gradual liberalisation of outlook. The massive disparity between these groups at the beginning of the 20th century doesn’t really begin to reduce until the 1950s and doesn’t close right up until the 2000s. It also serves to show that measurement of outcomes is not only helpful in managing health services, but can tell us something about ourselves.

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The work of the QO The QO provides support at many levels within the NHS: National, regional and sub-regional benchmarking products -These are designed for organisations and regional networks including HR directors, Medical directors, workforce planning, Directors of Nursing, pathway specific networks e.g. stoke, cardiac, dementia and other professional bodies.

Using a range of data, from central repositories to bespoke collections the team has built up an array of tools that can be used to compare organisations against their peers. Depending on requirements these tools have been designed to provide analysis at both commissioner and provider level and if necessary drill down to the individual GP practice or hospital site. These tools are updated on a regular basis to ensure the most up to date and relevant information is available.

Analytical / statistical support to projects and programmes—The QO have supported regional research and innovation programmes and support direct to organisations and individual clinicians, clinical teams and other NHS programmes (e.g. Enhancing Quality, NHS Quest ). The team also currently provides an analytical service to a CCG. We create bespoke tools and dashboards to support a variety of programmes, both long term and one-off to inform decision-makers implementing service improvement projects and large-scale change.

A named contact will be provided to the project. They will be an who will be able to guide and advise on the data that is available, and how to best utilise and present the data, and most importantly how to interpret the results in a fair and unbiased way.

experienced information professional

Core Principles of the QO Key to the successful engagement with clinicians is the fact that analysts work in partnership with clinical experts to co-design products.

In all areas we work to minimise the burden of data collection through the utilisation of existing data sources.

However, there are occasions when new information is needed to be collected and we will advise on the best ways to do this with the minimum of burden on the system.

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Highlighting a row when date is more than a year in the past.

Application: Excel 2003/7 Dear Ask an Analyst I have a spreadsheet that contains registration dates. I want the sheet to automatically highlight rows that contain dates that are more than 1 year old. I know that there is a way to do this, but I’m just not sure how to make it work?

Kind regards Colin Uju Public Health team Surrey and Sussex Area Team

Solution: Complexity 2/5 — Date/Time formulae and conditional formatting The solution to this problem requires a number of steps.

First let’s consider the logic required to solve this problem:

Calculate the Date 1 year after the registration date

Do Nothing

Seems straight forward enough…

Is calculated date less than todays date?

Turn Row RED

Surely the first step would be to just add 365 days to the registration date?

A simple formula like =(datevalue)+ 365 should do the trick surely?

Well let’s give it a go with a sample dataset: In column A we have some sample dates and in cell B2 we have added the formula “=A2+365” and copied it down column B .

At first glance this seems to have done the trick and incremented the date value by 1 year e.g. 05/07/2012 increments to 05/07/2013.

info@qualityobservatory.nhs.uk

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13 However as we look down the data set we see that there is a small issue with some dates, for example the +365 days formula increments 20/1/2012 to 19/1/2013 - it is one day out!

This is because 2012 was a leap year and every date before 1st march 2012 will appear to be “out by 1” this may appear trivial but in this case you can almost guarantee that someone will complain about it!

We can compensate for this by incrementing the “year” component of the date .

Excel has a number of functions that can help us : Year(date) will bring back the year component of a date field and can you guess what the day() and month() functions do?

We could do something like: =day(date) & “/” & month(date) & “/” & (year(date)+1) This would convert 20/01/2012 into 20/01/2013 This feels better right? There are 2 problems with this, firstly 29/02/2012 will appear as 29/02/2013 (an impossible date) and Excel will recognise the output of the above formula as a “Text String” making it difficult to use in the next evaluation step.

A better function to use is : =DATE( (YEAR(date)+1), MONTH(date),DAY(date)) The last thing we need to do is to add an evaluation step so that we can add conditional formatting to highlight the rows that have registration dates more than one year in the past.

We can use <today() or <=today() depending on the situation.

All we now need to do is create a conditional format , highlight the range to which we want to apply the condition.

In excel 2003 goto format > conditional formatting select the “formula is” option In excel 2007/2010 Home > conditional formatting > New rule and select the “use a formula to determine which cells to format” option.

Add in the formula referencing the first cell in the range e.g: =DATE( (YEAR(A1)+1), MONTH(A1),DAY(A1))<TODAY() And remember to use an absolute reference for the column (e.g. $A1) if you want to apply the conditional format to the whole row.

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NEWS CQC Indicator Consultation

Consultant level outcome measures Consultant level outcomes have been, or are about to be, published for a range of specialties:

The CQC are undertaking a consultation on the indicators and the approach to their development they have undertaken with a view to using them for the ‘intelligent monitoring’ of acute trusts. This is part of the wider consultation on changes to the way the CQC inspect, regulate and monitor care services. View the consultation document relevant to the monitoring of acute trusts at

•

Cardiac surgery

•

Vascular surgery

•

Thyroid and endocrine surgery

•

Bariatric surgery

•

Interventional cardiology

•

Orthopaedic surgery

http://www.cqc.org.uk//sites/default/files/media/ documents/qc_consultationannex_2013_tagged.pdf

•

Urological surgery

The consultation closes on the 12th August 2013

Further surgical areas will be published in the Autumn. You can access all the published data via NHS Choices (www.nhs.uk).

CCG outcome indicators: new release The latest release of the CCG outcomes framework has been published by the HSCIC. This release sees the publication of the underlying GP registered patient counts, as well as aggregated CCG figures, that are used in the calculations of a number of indicators in the CCG Outcomes Indicator Set. The published data captures over 55 million registered patients presented with breakdowns for GP practice, age and gender.

Data Linkage Stakeholder Forum The forum will be held on 10th July 2013, in Leeds.

The Data Linkage Stakeholder Forum provides an opportunity to learn about the HSCIC's Data Linkage and Extract Service, hear about future development of the service and explore the benefits of linked data. It also gives delegates the chance to network with members of the service, the wider HSCIC, and representatives from a range of organisations and industries.

See: http://www.hscic.gov.uk/dlsforum details.

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for more

Unify2 Accounts Don’t forget that if you’re still using a Unify2 account for an old organisation (SHA or PCT) then you’ll need to apply for a new account under your new organisation to make sure you can still access the website. All Unify2 accounts will give access to published data for the whole of the country (make sure you run the queries labelled PUBLIC though); CCG level accounts can access unpublished data for the CCG only plus any provider data submitted against them as the commissioner on prov-comm returns; NHS England Area Team and Region accounts have similar levels of access to the old SHA accounts and can access unpublished data for all organisations in their geographical area. Area Teams that co-ordinate specialised commissioning can also access data submitted against NHS England for the providers in their area. Commissioning Support Units can access anything their constituent CCGs can see. Any queries can be sent to the Unify2 mailbox: unify2@dh.gsi.gov.uk IPMR 2013/14 Data for the Q1 2013/14 Integrated Performance Measures Return (IPMR) will not be collected in July. Instead both Q1 and Q2 data will be collected following the end of Quarter 2. Diabetes, Stroke and TIA and NHS Health Checks data will not be collected on the IPMR this year. Further details will be posted on Unify once available.

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NEWS Accessing Friends and Family Test Data

New arrival

If you work for a Trust or a Local Area Team you can access your Friends and Family Test data and get your local area and national ranking now. To request your organisational log in email:

David Harries’ partner gave birth to a little boy on 22nd May. Here is a picture of Aaran with his big sister Jasmine:

england.friendsandfamilytest@nhs.net New NHS Architecture If you are confused about the new NHS architecture then the King’s fund alternative guide may be of some help. You can find it here: http://www.kingsfund.org.uk/projects/nhs-65/ alternative-guide-new-nhs-england New AHSNs On the 23rd May 2013 NHS England confirmed the designation of 15 new Academic Health Science Networks. More information on this can be found here:

Congratulations David!

Trolley Dolly update

http://www.england.nhs.uk/2013/05/23/acc-healthsci-ntwrk/ A map of where the AHSNs are based can be found here: http://www.emahsn.ac.uk/emahsn/documents/ national-ahsn-map.pdf

With all the birthdays we have had at QO towers the trolley has been filled with lots of goodies including lots of different brownies, rocky road bites, muffins and flapjacks. We also had some “Happy Germany” sweets from Austria!

Our latest tweets

QO birthdays We have been busy with birthdays in the last couple of months at QO towers.

Simon received a fine selection of ales and enjoyed spending his birthday in the pub garden with his family.

Rebecca received wine and some lovely soaps from the team.

Kiran received a nice selection of beers and celebrated with his usual birthday BBQ! Hope you all had great days!

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ODE TO THE F.F.T.

WELL DONE!

I hear you've been to hospital, I wish you a swift recovery, But there's a question that needs asking On our road to self-discovery.

If your friends or family Needed treatment the same way Would you recommend this ward to them, Please help with our survey.

Put a mark upon the scale, In response to what we pose,

On 15th June Kate conquered her own, slightly smaller peak, on Mt. Snowdon, in aid of Khalsa Aid, a charity working with sick and deprived people across the world. You can still sponsor Kate at www.justgiving.com/Kate-Cheema1

If you'd let your friends come here, or wouldn't even recommend to foes.

Fascinating Facts Don't worry, it's anonymous, You've not been singled out, We're asking all the patients, So we'll know without a doubt, If we're doing all the right things, or where we've got it wrong, So that we can make improvements, and make our service strong.

The world’s second highest building, Taipei 101 in Taiwan, which held the record between 2004 and 2010 at 509 metres, would need to be stacked up more than 17 times over to reach the peak of Everest.

The results will not be secret, and kept out of patients view,

Simon says…….

We'll put them on the website, Where the public can examine and review So help us help the system, and improve our future care, Just answer one small question,

The word "lethologic a" describes the state of not being able to remember the word you want ...

And make us more aware.

Knowledge Matters is the newsletter of the Quality Observatory, to discuss any items raised in this publication, for further information or to be added to our distribution list, please contact: Hosted by: Central Southern Commissioning Support Unit

E-mail: info@qualityobservatory.nhs.uk

To contact a team member: firstname.surname@qualityobservatory.nhs.uk