knowledge matters volume 3 issue 3
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Taking the QIPP ChallengeTRANSCRIPT
Volume 3 Issue 3August 2009
http://nww.sec.nhs.uk/QualiityObservatory
Inside This Issue : Inpatient Survey Explorer Tool 2 Department of Health South East
update 6 Using data to evidence innovation
& variation 12
Clinical Quality Reports 3 Cancer Waiting Times Dashboard
7 Dementia Dashboard for Commis-sioners
14
NAO Report—Rheumatoid Arthiritis
4 Taking the QIPP Challenge 8 News 15
Stroke Dashboard Enhancements 5 A3: Ask an Analyst 10 Fun Fact, Quick Quiz, plus more! 16
Welcome to the first edition of the new look Knowledge Matters—the style may have changed, but the content (I hope) will continue to be informative and stimulating.
I thought that you might be interested to learn about some of the priorities for the Quality Observatory over the coming year. I mentioned last time that the clinical advisors for the Healthier People, Excellent Care (HPEC) pathways have been appointed (see page 15 for a list). The Quality Observatory has already developed effective links with each advi-sor and will be providing support with the development of quality metrics and subsequent provision of analysis and benchmarking. In addition, we aim to further develop our benchmarking for patient safety and patient experience. Clearly all of the analysis that we undertake will need to cover not only the quality angle, but also look at productivity and efficiency—both for a wide range of services and settings and also different segments of the workforce.
We have already undertaken some work to evidence innovative practice and the variation between different organisa-tions and teams. Working with the clinical advisors, we intend to work up case studies (similar to page 12) for each HPEC pathway which can then be used to help spread innovative practice. By the way, by mid September, South East Coast Chief Executives will have been notified of the bidding process for the regional Innovation Fund. Keep an eye on the NHS South East Coast website or e-mail [email protected] for further details.
We will of course continue to provide technical advice, support and training for analysts, clinicians and managers across South East Coast and will be holding quarterly ‘Meet the Quality Observatory’ sessions starting in October (see page 16). These sessions will provide an opportunity for you to find out more about the work that we have undertaken/have planned, and provide an opportunity for us to obtain feedback and ideas on how we can best support improvements in quality and productivity across South East Coast.
Welcome to the new look Knowledge Matters
The annual survey of inpatients is a key source in helping acute providers understand what their pa-tients really think of the services they provide. The survey also provides valuable information on how patients perceive progress in key areas such as safety, privacy and dignity and access to services. The
Inpatient Survey Explorer Tool By Katherine Cheema, Specialist Information Analyst
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patient survey provides commissioners with a rich source of patient feedback that they need to take into account when commissioning services for their population.
Whilst there can be no doubt that the survey is extremely useful, the amount of data accompanying it is tremendous, especially if there is a requirement for benchmarking against other Trusts or regional and national results. The Inpa-tient Survey Explorer Tool uses national data (making it of interest/use to all regions not just South East Coast) and allows users to look at scored results over three years, drilling down to individual questions or looking at data grouped according to theme. The tool is presented with a graphical front end separated into three parts, each with a different way of looking at the data, illustrated below..
Some additional functionality is included which allows users to select which series on the bar/line and radar plots they wish to view, a choice of bar or line charts for the benchmarker section, and the option to show average scores for the PSA domain questions (that’s in the ‘purple’ section!). An illustrated user guide is also included.
For more information, and to download the tool, log onto nww.sec.nhs.uk/qualityobservatory. Comments or feedback on the tool would be very welcome; e-mail [email protected]
Organisation selection: all England trusts are included in alphabetical order. Once one is selected, all data displayed is for that specific trust.
Save and print button. Saves the workbook to its current location and prints the dashboard to the default printer
Key themes section. This looks at subsets of questions relating to keythemes such as privacy and dignity, which can bviewed together in a radar plot.
PSA and forecasting section. This looks at the questions from the inpatient survey that are included in the assessment of the public sector agreement 19 and also used for Vital Signs indicator VSB_15, self-reported experience of patients. The three year's results are used to forecast the next three years with options for the user to input local plans.
Benchmarker. This sections enables the user to select a question from the survey and benchmark the results fo the chosen organisation against regional results and similar trusts.
Over the last year the South East Public Health Observatory (SEPHO) has prepared a set of reports on the quality of health care in South East Coast and South Central for a number of conditions which have a substantial impact on health, and on NHS spend. The purpose of the reports is to check whether there are significant issues in clinical qual-ity that can be identified from existing routine data. The analyses have been undertaken mainly at the level of PCT populations and where possible address health outcomes and proxy health outcomes like blood pressure or diabetes control. Some indicators within the reports reveal potential quality issues in PCTs which could require further discus-sion and investigation within individual PCTs and by the SHAs. Reports later in the series have specifically outlined issues that commissioners might want to consider. The report series covers:
• Diabetes;
• Cerebrovascular disease (stroke and transient ischaemic attack);
• Coronary heart disease;
• Chronic obstructive pulmonary disease (chronic bronchitis and emphysema);
• Mental health; and
• Specific cancers (part 1: lung, breast, colorectal; and part 2: gynaecological, upper gastrointestinal, urological).
Clinical Quality Reports By Alison Hill, Director, South East Public Health Observatory
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been included in the mental health report and in future will also be included in updates to the other reports. It is still early days but the reports are increasingly being used to initiate discussions within PCTs, with both primary and secondary care providers, to help explain any variation and address the issues raised.
Now that the first series of reports is nearing completion SEPHO is working with the two SHAs to establish the next steps. The reports contribute to the outputs of the South East Coast Quality Observatory, and the steering group for the Quality Observatory will be determining how they want to shape the indicators and their reporting into the future. A very first short term step will be to update the indicators used so far, and to make them available through the Quality Observatory and the SEPHO websites as dashboards and dynamic reports.
We will keep you posted on further developments.
Figure 1 All the South East Coast reports apart from the cancer re-ports (which will be published during the autumn) are avail-able on the SEPHO website at http://www.sepho.org.uk/viewResource.aspx?id=11478 . The indicators for these reports were agreed following con-sultation with relevant stakeholders. The data sources in-cluded the Quality and Outcomes Framework (QOF) (Figure 1), Hospital Episodes Statistics (HES), national clinical au-dits (see Table 1), and other relevant routinely collected and complete data sources. Programme budgeting data have
Table 1
The National Audit Office’s recently published study, Services for people with rheumatoid arthritis HC 823 2008-09 has revealed that there are significant opportunities for improvements in services which would result in fewer people be-coming permanently disabled by the condition and more people living relatively normal lives including staying in work. While this may require some investment or more likely redistribution of current funding, in the longer term, there would also be efficiency savings for the NHS
Rheumatoid arthritis is a lifelong progressive autoimmune disease. It is a very painful condition, can cause severe dis-ability and ultimately affects a person’s ability to carry out everyday tasks. The disease can progress very rapidly, causing swelling and damaging cartilage and bone around the joints. Any joint may be affected but it is commonly the hands, feet and wrists. It is a systemic disease which means that it can affect the whole body and internal organs such as the lungs, heart and eyes.
The key to successful outcomes with this condition is early diagnosis and swift referral to specialist care. Clinical con-sensus is that to be most effective, treatment should start within 12 weeks of symptom onset. However, our study found that there are currently several “opposing forces” preventing patients reaching specialists within this window of opportunity.
One of our report’s key recommendations is that the Department of Health should consider options to improve the low awareness among the general public. Many people who develop symptoms do not realise that they might have a con-dition which requires prompt medical attention and is treatable.
Once a referral has been made, the pathway to treatment is somewhat more straightforward. The Government’s 18 week referral to treatment standard has led to a significant increase in the percentage of rheumatology patients being seen and treated by a specialist within 12 weeks of referral (from 80 per cent in 2005 to 93 per cent in 2008). How-ever, the number of patients being seen within eight weeks of referral has decreased from 65 per cent in 2006 to 60 per cent in 2008. If one considers the delays in the patient presenting and GPs referral, even a few extra weeks be-tween referral and treatment can make all the difference in getting patients treated within that all important 12 week window of opportunity.
As well as ensuring that people with rheumatoid arthritis are treated as soon as possible after developing symptoms, it is vital to ensure that people with this condition have appropriate support in the long term. The nature of rheumatoid arthritis means that coordinated, multidisciplinary care is essential for optimising treatment outcomes. While our sur-vey of acute hospitals revealed that these joined up services are not available to many people with rheumatoid arthri-tis (only half of acute trusts responding to our census provide all their patients with rheumatoid arthritis with a care plan), our report includes some good practice examples. We visited one such example in the South East Coast SHA;
Improving the Lives of People with Long Term Conditions By Phillipa Dixon, Audit Principal, National Audit Office
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This issue of late presentation is compounded by low awareness among GPs. Our study found that many people who did present with symptoms of rheumatoid arthritis had to visit the GP multiple (on average, four and for 18 per cent, eight) times before being referred to specialist care. In addition, evidence from our study indicates that tests carried out by GPs prior to referral may result in unnecessary de-lays and costs as they are usually repeated by specialists following referral. We therefore rec-ommend in our report that PCTs should aim to improve awareness within primary care of the need for rapid referral, particularly among GPs. Our economic modelling work indicates that the use of a rapid referral system (such an Early Arthritis Clinic) can shorten the length of time taken for people to see a specialist by reducing the number of visits to GPs and avoid the duplication of diagnostic tests by GPs and specialists.
Rheumatoid Arthritis Key Facts and Figures
580,000 people in England with this condition
About 26,000 new cases every year
Affects more than twice as many women than men
Shortens life expectancy by 6-10 years
Costs the NHS £560m a year
Cost to the economy of sick leave and work-related disability is £1.8bn a year
A normal joint Early stages More advanced
A new revised and enhanced Stroke Provider dashboard, enabling a quick overview of a number of stroke measures down to hospital site level is now available from the Quality Observatory website, as well as including data up to Q4 2008/09 the following improvements have been incorporated.
• The time to MRI / CT scan chart now checks the first 12 operative procedures on the admitting patient episode rather than the first 4;
• Overall position from phase 2 of the 2008 Royal College of Physicians Stroke Sentinel Audit published in April this year is now shown at the top of the dashboard alongside the position from phase 1; A breakdown by area for the trust / site selected of their results in both phases of the Stroke Sentinel Audit and the corresponding national position is now included on an additional sheet.
Note that to download the dashboard you will need to register on our website. If you have any questions or would like an explanation of any aspects of the dashboard feel free to contact me on [email protected]
Stroke Dashboard updated and enhanced
St Peter’s Hospital in Chertsey (see figure 25 within the report) where staff tailor patient pathways and educational programmes to individuals’ needs.
Our report recommends that PCTs should identify the people with rheumatoid arthritis in their population so they can design and deliver services for these people accordingly, bearing in mind the guidelines for the management of rheu-matoid arthritis published by NICE in February of this year. PCTs should also carry out a needs-based assessment and cost-benefit analysis of how best to configure their services for people with rheumatoid arthritis and should work with providers to ensure that all people with rheumatoid arthritis are offered a personalised and holistic care plan.
The benefits of work for people’s health and wellbeing are well-established. Although three quarters of people are of working age when diagnosed, one third of people with rheumatoid arthritis currently give up work within a year of di-agnosis. Our patient survey found that only 20 per cent of people with rheumatoid arthritis receive sufficient informa-tion about employment issues.
Separate reports on different aspects of our methodology such as our acute trust census, patient survey. interna-tional comparison review, patient stories videos and economic modelling are published on our website : http://www.nao.org.uk/publications/0809/services_for_people_with_rheum.aspx
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A key strand of work was our economic modelling which reveals that productivity gains could be achieved and patient quality of life improved through better integra-tion and coordination of services, leading to quicker diagnosis and earlier treat-ment, although in the short-term costs to the NHS would increase. We recommend that the Department of Health and PCTs should build on the NAO’s economic analysis in order to optimise treatment and support for people with rheumatoid ar-thritis who wish to remain in work.
In conclusion, there are real opportunities to improve the efficiency and cost-effectiveness of the current model of commissioning for services for people with rheumatoid arthritis and indeed other long term conditions. There is often currently a lack of integration between primary care and secondary care. There may also be a lack of impetus or incentive for changing the way services are currently con-figured, with little shared knowledge and understanding about the extent of the dis-ease, or an evidence base as to the most cost-effective way of providing services to reflect different local needs.
PCTs should ask themselves if their current model of commissioning services for people with rheumatoid is effec-tive. If not, they should use the recommendations and good practice examples within our report to address how this model can be improved.
The Department of Health South East (DHSE) has undergone a number of changes in recent months. The existing regional public health group have been joined by a social care policy and programmes team. The new combined team continues to lead on the South East England Health Strategy (which covers a number of priorities including health inequalities, the health of children and young people, and health in later life), and is still responsible for the regional delivery of several national programmes including tobacco control, ‘Healthy Weight, Healthy Lives’ and re-ducing alcohol-related harm. But DHSE now also covers the implementation of adult social care policy across the region, including the National Dementia Strategy, Improving Access to Psychological Therapies (IAPT), and the transformation of adult social care (which includes improving choice and increasing self-directed support).
This change has meant that the DHSE information team has been extended to cover both public health and social care, and a number of new products are currently in development to support this widened remit, including joint health and social care profiles. More on this in a future edition of Knowledge Matters!
But in the meantime, the DHSE team is continuing to produce several analytical and information resources for the region including:
• the South East England Indicator Tool (aka SEEIT);
• the South East Health Inequalities Gap Measurement Tool; and
• a three-weekly health and social care information update (see page 15 for further details). SEEIT The South East England Indicator Tool is an interactive Excel-based tool displaying trends, projections and LAA tra-jectories and PCT plans for a range of public health and social care National Indicators and Vital Signs. SEEIT can be used to quickly visualise the ‘direction of travel’, evaluate local performance against comparator areas (local vs. local, local vs. regional and national, LA vs. PCT) and help guide target setting. It serves as a ‘one-stop shop’ bring-ing together data from a range of sources including the Data Interchange Hub, the Information Centre, NCHOD and the Department of Health.
A beta version of SEEIT has been distributed to a number of analysts across the region. The full version – which has been awaiting final sign-off the Vital Signs plans by Department of Health and which will be updated on a regular basis as new data is published – will be available on the SEPHO website (www.sepho.org.uk) from 7th September 2009.
Department of Health South East Update By Robert Kyffin, Senior Public Health Intelligence Officer, DHSE
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Health Inequalities Gap Measurement Tool Tackling health inequalities remains a key Depart-ment of Health and NHS priority. The South East Health Inequalities Gap Measurement Tool provides a standardised approach to analysing health inequali-ties across the region using mortality rates for depri-vation score-based quintiles of super output areas.
Specifically, for 2003 to 2007 combined, the tool dis-plays age-specific mortality rates for 17 cause of death categories, absolute and relative gaps in age and cause-specific mortality rates, and cause-specific mortality profiles for varying combinations of the Gov-ernment Office Region, two SHAs, 17 PCTs, 19 counties and unitary authorities, and 55 county dis-tricts in the South East.
The tool also provides information on health inequali-ties trends. For 2001 to 2007 (for all causes of death,
all circulatory diseases and all cancers), the tool displays the annual trends and mortality rate gaps between differ-ent combinations of areas. A range of data export and print options are available, as are full source and methodo-logical notes, and maps showing the deprivation quintiles.
An updated version of the gap measurement tool will be available to NHS users on the SEPHO website from 7th September 2009, as will a web-based version which has been developed in conjunction with SEPHO.
For further information contact: Robert Kyffin ([email protected])
A new dashboard has been developed to show the performance of South East Coast organisations against the new cancer targets, as detailed in the Department of Health paper, ‘Going Further on Cancer Waits’. The 2 week, 31 day and 62 day targets have been extended to cover patients with breast symptoms, subsequent treatments and patients referred via screening centres and upgraded by consultants.
The national cancer waiting times database was updated in January and actual data against the new targets is available for March 2009 onwards for the monthly reports and quarter 4 2008/09 for the quarterly.
The dashboard is updated monthly and quarterly from the reports available to download from the Open Exeter system (on the 25th working day after month end). Both commissioner and provider views of the data are shown.
The dashboard has charts for the monthly data alongside those for the quarterly, allowing the two sets of data to be compared. There are six charts on the dashboard:
Chart 1: monthly data, numbers of patients seen within target and outside of the target time
Chart 2: monthly data, performance against the selected target and the England performance
Chart 3: quarterly data, numbers of patients seen within target and outside of the target time
Chart 4: quarterly data, performance against the selected target and the England performance
Chart 5: monthly data, a snapshot of the latest month showing performance for all trusts
Chart 6: quarterly data, a snapshot of the latest quarter showing performance for all trusts
For each chart it is possible to select organisation, indicator, and admitted, non-admitted or total data. The operational standards for the majority of the new targets have recently been finalised and these are also shown on the performance charts.
This dashboard is available to download from the Quality Observatory website. Please let me know if you have any queries or comments: [email protected]
Cancer Waiting Times Dashboard By Rebecca Owen, Performance and Planning Analyst
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£15-20 billion. That’s how much the NHS has to plan to save by 2013/14.
Why? It’s all to do with the state of the economy. It is affecting countries around the world and this country is no ex-
ception. The impact will be felt right across the economy, including our public services. There are still too many uncer-
tainties to know exactly what this will mean for the NHS. But as David Nicholson set out in his annual report1 back in
May, it makes sense to start preparing now by focusing on how we can go further in improving quality and productiv-
ity.
What does this mean in practice? Providing high quality care is the organising principle of the NHS – confirmed by
High Quality Care for All2, the final report on the NHS Next Stage Review (NSR) led by Ara Darzi. So improving qual-
ity – making care safer, more effective and providing as positive as possible an experience for patients and users –
has to remain the basis for all of our work.
But in more constrained financial times, the care the NHS provides also has to be consistently good value for money.
It also means seeking to spread innovative practice wherever possible and, over the medium term, doing all we can to
help people stay healthy and prevent ill-health.
So the challenge is to deliver against each of these 4 themes together – focusing on improving Quality, Innovation,
Productivity and Prevention (QIPP). QIPP is a challenge for the whole NHS system. It cannot be a national pro-
gramme or set of top-down initiatives. The real changes this requires can only be delivered locally – within and across
NHS organisations – with the centre supporting those changes.
David Nicholson, supported by Jim Easton, the new NHS National Director for Improvement and Efficiency, has re-
cently asked NHS leaders to focus on 4 elements of this challenge:
• engaging widely so everyone knows what this is about – inside the service to reach every team and beyond to
partners in Local Authorities for example;
• getting the right leadership in place – especially clinical leaders;
• being clear what needs to be done – what changes have to be made to deliver on the QIPP challenge; and
• being clear what national policy changes are needed to help
Thinking about what needs to be done has to start with the evidence. The work done during the NSR was based on
evidence for the best pathways of care. It is important that we support the same evidence-based approach to meeting
the QIPP challenge. It is not always the case that improving quality automatically increases efficiency. But there are
many examples of improvements that achieve both of these things – often where teams have adopted innovative
work from another part of the NHS. To take just two examples:
Taking the QIPP Challenge By Dominic Hardy, Director, Quality Framework Programme
1 The Year – NHS Chief Executive’s annual report 2008/09, Department of Health 2 High Quality Care for All – the final report of the NHS Next Stage Review, Department of Health June 2008
• Work to reduce healthcare associated infections has improved the quality of care across the NHS - and the Na-tional Audit Office has recently estimated that it has saved up to £143m3.
• The NHS Institute’s Productive Ward initiative has helped staff across the acute sector improve the efficiency with which they work – and improved the quality of care provided.
And nationally the policy framework needs to support this, including through the quality framework that Lord Darzi set
out in High Quality Care for All. The quality framework is designed to show how policy can support quality improvement
across 7 key elements:
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Bring clarity to quality
Measure quality
Publish quality perform-ance
Recog-nise and reward quality
Clinical leader-ship
Safeguard quality
Stay ahead
The aim is to make sure that existing policies, such as the Quality and Outcomes Framework, and new ones – including
Indicators for Quality Improvement (IQI), Quality Accounts and NICE Quality Standards – are designed as effectively
and coherently as possible. No single policy can help improve quality on its own – we need to make sure that they work
together to support NHS staff in improving quality.
We consulted widely with the NHS before we began implementing the quality framework. People told us the priority
should be to support clinical teams to measure what they do as a basis for improvement. We therefore made Measuring
for Quality Improvement the cornerstone of our work. The previous issue of Knowledge Matters covered this area in
some detail—see the Information Centre website for further details on the IQI (www.ic.nhs.uk/mqi).
Using this information as the basis for improvement will be vital in meeting the QIPP challenge. Quality Observatories
are already playing a key role in making information and analysis available for teams to use. Here in NHS South East
Coast, for example, the Quality Observatory has developed new clinical indicators for dementia care, and created
dashboards for stroke care and primary care prescribing.
Knowing what the evidence is for high quality care will also be crucial. That is why we are working with colleagues at
NICE to develop new quality standards. These standards will bring greater clarity to what high quality care looks like for
different conditions and pathways and will cover a wide range of clinical topics, starting with four pilot areas – stroke
care, dementia, venous thombo-embolism and neo-natal care. Indicators for these standards will be part of IQI.
Ensuring we keep quality as the organising principle, even when finances are tighter, means making it the priority for
every organisation’s Board. Quality Accounts – new annual reports that all provider organisations will have to publish
alongside their financial accounts – have been developed this year with organisations in NHS East of England and with
Monitor and NHS Foundation Trusts across the country. We will be consulting in the autumn on their content so look out
for further details.
We are committed to supporting NHS organisations in retaining quality as their organising principle. Meeting the QIPP
challenge will not be easy, but the enthusiasm, innovative practice and commitment to do so are already in place across
the NHS.
3 Reducing Healthcare Associated Infections in hospitals in England, National Audit Office June 2009
Dear Quality Observatory, I am trying to split the following text into separate Columns, I’ve added in commas in an attempt to split it but can’t figure it out?
For example I want to split the contents of cell A12 which contains :
1738. Difficulty Breathing N145.Backache_unspecifed
into two separate cells.
I’m hoping that you can help me out with this—any ideas?
- Vince O’Mahoney Information Analyst
Surrey PCT
Hi Vince The problem you are having is due to the Cells containing Line Break Characters between the two entries. Line break characters cause problems in some functions like the text to columns because they are not read properly
The solution to problem has 2 steps:
Step 1 - Convert the text string to one which does not contain a line break character.
The line break character is char(10) you can use the =SUBSTITUTE() function to create a string without the line break like so:
=SUBSTITUTE(A12,CHAR(10),”#”)
This will create a string in which the line break is replaced by ”#” Resulting in the following string:
1738. Difficulty Breathing # N145.Backache_unspecifed This formula result cannot still cannot be used as it stands you will need to copy the formula and use the Edit > Paste Special >Paste Value to turn the cell contents into the required string
Step 2 - Split the string into multiple columns
Select the cell/columns with the New text strings that you have created. From worksheet menu bar select : DATA > Text to columns If you have not pasted the string value you will see the =SUBSTITUTE() Formula in the preview area
How do I Split text out into separate columns in Excel ?
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You should see the string Value in the preview Area. Ensure you have the Delimited Option Selected Click Next
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From the delimiters Options select “Other” and Type “#” in the text box Click Next /Finish to complete the process Your text string should now be split into 2 separate cells
Vince’s Query was posted to the forums at our website.
Each Issue we will be scouring the forums and the Quality Observatory Mailbox for questions/interesting articles.
If your query (or solution) is chosen for publication in Knowledge Matters
We will send you an exclusive limited Edition Notebook and MUG!
The National Patient Safety Agency (NPSA) recently launched a consultation on a National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (previously known as Serious Untoward Incidents or SUIs).
This document is the first release of a proposed new National Framework for the management of serious incidents occurring in the NHS and those parts of the Independent Sector which provide NHS services in England .
The purpose of the framework is to provide a nationally consistent definition of serious incidents, to clarify roles, re-sponsibilities and requirements, and; to highlight tools and resources that support good practice.
Documents can be downloaded from: http://www.npsa.nhs.uk/nrls/reporting/patient-safety-direct/
Consultation closes on 13 November 2009. Responses should be sent to [email protected]
NPSA Launches National Consultation
Well presented data can be a really powerful tool for both identifying and sharing innovative practice.
A key aim of the Quality Observatory is to provide comparative analysis which evidences variation in practice across and within organisations. Having heard the story (which I referred to in my editorial last time) of Hugh Apthorp and his team who have for some time been pioneering short stay hip replacement surgery for suitable patients (approximately 50% of cases), we decided to have a look at the data associated with this.
We started by looking at the average length of stay for patients admitted for an elective hip replacement for each of the Trusts within South East Coast. Looking at the graphs below, we can see the average length of stay for each Trust over the past 10 quarters (red line). The blue line indicates the SHA average. The grey bars indicate the level of ac-tivity during each quarter—more about why this is important in a moment.
Using Data to Evidence Innovation and Variation By Samantha Riley, Head of the Quality Observatory
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8 Q
3
08/0
9 Q
1
08/0
9 Q
3
0
20
40
60
80
100
120
140
160
180
Elective Length of Stay - Primary Hip Replacement (OPCS W371, W381,W391)
Trust 7
2
4
6
8
10
12
14
16
18
04/0
5 Q
1
04/0
5 Q
3
05/0
6 Q
1
05/0
6 Q
3
06/0
7 Q
1
06/0
7 Q
3
07/0
8 Q
1
07/0
8 Q
3
08/0
9 Q
1
08/0
9 Q
3
0
20
40
60
80
100
120
140
160
180
Trust 5
2
4
6
8
10
12
14
16
18
04/0
5 Q
1
04/0
5 Q
3
05/0
6 Q
1
05/0
6 Q
3
06/0
7 Q
1
06/0
7 Q
3
07/0
8 Q
1
07/0
8 Q
3
08/0
9 Q
1
08/0
9 Q
3
0
20
40
60
80
100
120
140
160
180
Trust 6
2
4
6
8
10
12
14
16
18
04/0
5 Q
1
04/0
5 Q
3
05/0
6 Q
1
05/0
6 Q
3
06/0
7 Q
1
06/0
7 Q
3
07/0
8 Q
1
07/0
8 Q
3
08/0
9 Q
1
08/0
9 Q
30
20
40
60
80
100
120
140
160
180
Trust 11
2
4
6
8
10
12
14
16
18
04/0
5 Q
1
04/0
5 Q
3
05/0
6 Q
1
05/0
6 Q
3
06/0
7 Q
1
06/0
7 Q
3
07/0
8 Q
1
07/0
8 Q
3
08/0
9 Q
1
08/0
9 Q
3
0
20
40
60
80
100
120
140
160
180
Trust 12
2
4
6
8
10
12
14
16
18
04/0
5 Q
1
04/0
5 Q
3
05/0
6 Q
1
05/0
6 Q
3
06/0
7 Q
1
06/0
7 Q
3
07/0
8 Q
1
07/0
8 Q
3
08/0
9 Q
1
08/0
9 Q
3
0
20
40
60
80
100
120
140
160
180
Patch 1 Patch 2 Patch 3
Source: SUS / Trust Extracts Spells - RH AxisTrust LoS - LH AxisSHA LoS - LH Axis
ence. Maybe the case-mix for each site is very different, maybe one site undertakes all of the complex operations or maybe the care processes at each site differ. It can be very easy to jump to a conclusion when looking at this type of information—often the wrong conclusion. Analysis doesn’t provide you with the answers—it points to where questions need to be asked. We do our best to provide as much relevant information as possible to ensure that wrong conclusions are not jumped to.
Trust 4 has seen the most signifi-cant reduction in length of stay – the average length of stay for patients having their hip replaced is currently just below 4 days. This is Mr Ap-thorp’s Trust. The Trust does have two hospital sites, however, and Mr Apthorp operates at one of them.
So the next thing we had a look at was the length of stay for the indi-vidual sites. We found that one site had an average length of stay of just over three days. The other site had an average of almost five and a half days. Of course a number of reasons could explain this differ-
This is why the grey bars in the above charts are important. The reaction of many people when looking at the charts was not to identify the Trust where the most improvement had been achieved, it was to identify the Trust (Trust 3) where the graph looked very different—’What an earth is happening there?’ was a common reaction. If we look at the grey bars, we can see quite a step change in activity—a significant reduction. It may well be that this Trust is sending a signifi-cant amount of activity elsewhere—maybe to an independent sector treatment centre? So the Trust may be undertaking all of the complex cases…..and patients would need to spend longer in hospital. It would be dangerous to assume that this is the case of course—the analysis should prompt these questions to be asked. But equally jumping to the conclusion that Trust 3 is ‘bad’ would be unfair.
Clearly all Trusts should be using this type of analysis to challenge themselves, to look at how they compare to neighbouring organisations and also how they are performing over time.
Quality Observatories have access to a really rich range of datasets. As it is possible to access Consultant level data, this was the next bit of analysis undertaken by the team. Dependent on the data set, different statistical techniques can help you glean a lot more than you might think possible.
Had we identified a data quality issue? How many other surgeons were undertaking apparent low levels of activ-ity?
In the graph to the right, we have used colour coding to differentiate between Consultants undertaking less than and more than 20 procedures over the period of a year. The lighter green is used for less than 20 procedures. So the data is telling us that around 50% of surgeons are un-dertaking very few procedures. This of course raises a whole range of new questions related to quality, safety and data quality that need to be investigated.
Page 13
Trust 4 Site A Primary Hip Replacement Patients Last 100 Discharged for Consultant A by Discharge Date
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
11/0
6/08
13/0
6/08
26/0
6/08
27/0
6/08
28/0
6/08
03/0
7/08
16/0
7/08
25/0
7/08
26/0
7/08
11/0
8/08
16/0
8/08
12/0
9/08
27/0
9/08
10/1
0/08
23/1
0/08
07/1
1/08
14/1
1/08
18/1
1/08
27/1
1/08
29/1
1/08
02/1
2/08
09/1
2/08
15/1
2/08
19/1
2/08
25/1
2/08
27/1
2/08
15/0
1/09
17/0
1/09
01/0
2/09
08/0
2/09
12/0
2/09
14/0
2/09
19/0
2/09
26/0
2/09
13/0
3/09
21/0
3/09
23/0
3/09
Leng
th o
f Sta
y (D
ays)
MeanUCL
5.9
5.0
4.0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14> 20 Patients<=20 PatientsSEC Top DecileSEC Top QuartileMedian
Elective Admissions, OPCS W371, W381, W391, source: SUS extract
Primary Hip Replacement Length of Stay by SEC Consultant 2008/09
We initially looked at the length of stay for Mr Ap-thorp’s patients. You will have read in previous editions of Knowledge Matters that using an aver-age can be quite limiting and mask a lot of what is going on.
So, instead of looking at an average, we plotted the actual length of stay for the most recently dis-charged 100 patients in a run chart. Each line on the graph opposite shows the length of stay for individual patients. Quite a few patients did have a one day length of stay over the period of time that we looked at—probably around 50%. Of course some patients stay a lot longer due to clini-cal reasons, that is to be expected—no two pa-tients are the same.
This technique is much more useful in evidencing what is happening to individual patients—an average masks this valu-able set of data. The same charts for other Consultants (in the same Trust and within other Trusts) look quite different. We are currently developing a tool which will enable organisations to have a look at this type of data for individual clini-cians in different specialities.
5.9
5.0
4.0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14SEC Top DecileSEC Top QuartileMedian
Elective Admissions, OPCS W371, W381, W391, source: SUS extract
Primary Hip Replacement Length of Stay by SEC Consultant 2008/09Looking at the average length of stay for all of the ortho-paedic surgeons across South East Coast, we see a wide distribution (see left). Mr Apthorp does have the shortest length of stay. At the other end of the spectrum, one consultant has an average length of stay which is five times that of Mr Apthorp—this may of course be re-lated to a significantly different case-mix. There is a wide range of length of stay in between. Two Consultants appear to also have a very short length of stay—hardly longer than My Apthorp. We were inter-ested to know where these clinicians were based—had we un-covered more innovative practice? After investi-gation, we learnt that both Consultants had only under-taken one elective hip replacement over the period of a year. This highlighted a range of other issues/questions.
Our Quality Board will be considering this type of analysis and agreeing how the data can be used to challenge practice, encourage the spread of innovation and support improvements in both quality and productivity.
The Quality Observatory will be developing further case studies similar to this and we will share these with you in future editions of Knowledge Matters. If you have any queries or suggestions, please do contact me: [email protected]
Looking at Dementia in a secondary care setting is easy because the data is there and understood. However it is such a small part of the Dementia story that we cannot use this in isolation. With this in mind we have developed a dashboard to complement the existing secondary care one. This new dashboard focuses more on primary care.
The new dashboard looks at a range of measures, some of which are famil-iar from our initial clinical metrics work. Some of the measures are the same as on the secondary care dashboard, but they are cut by commissioner.
The two QOF measures — numbers on Dementia Registers, and numbers hav-ing a review in the past 15 months are included. The first by practice, and the second aggregated up to PCT level. They both show data for the two years that are available to us.
The numbers of patients on a register (at PCT level) is also compared, in another chart, to the actual prevelance from the Alzheimers Society Dementia UK report. This chart also shows the predicted numbers of Dementia sufferers up to 2025. This data was only available at local authority district level, so some work had to be done to match these up with PCTs.
The fourth chart shows the Program Budget for spend on or-ganic mental health disorders is looked at along with compari-sons to relevant ONS cluster groups over a three year period.
The first three charts at the bottom of the dashboard are based around admissions to secondary care. They look at to-tal numbers and estimated cost of admissions, total numbers of bed days consumed, and the rate of admissions per 10,000 population.
Dementia Dashboard for Commissioners By Adam Cook, Specialist Information Analyst
Page 14
The final chart shows prescribing data derived from ePACT. This shows the numbers of prescriptions and associated costs for the 3 NICE recommended dementia drugs: Donepezil, Galantamine, and Rivastigmine.
The dashboard is available to download from our website in the Dementia part of the clinical metrics section.
This, however, is not the last of dementia metrics. Much of the care of the patients comes under the aegis of social care, and work is
currently under way to produce a dementia dashboard for social care, based on the annual Referrals, Assessments and Packages of care survey. I will keep you updated on progress with this work in future issues.
For further information please contact Adam Cook: [email protected] 01293778846
PCT Procurement and GP Extended Hours Returns The PCT Procurement and GP Extended Hours returns how now been suspended until further notice. From imme-diate effect, PCTs will not be required to upload data to Unify for these 2 collections.
Change to Direct Access Audiology timetable The direct access audiology timetable has now been re-vised to bring it line with the monthly 18 weeks collection. A full list of submission, sign-off and publication dates can be found on Unify2.
Proposed changes to inpatient and outpatient waiting time collections (MMR) Lord Darzi’s report ‘High Quality Care for All, Our Journey So Far’ set out the intention of removing obsolete targets and commitments, starting with the 13-week outpatient and 26-week inpatient targets and it is being proposed that the MMR collection should be dropped from April 2010. A con-sultation exercise has been launched to collect comments on this - the deadline for responses is 23rd October 2009. Documentation for this can be found in the statistics sec-tion of the DH website. There is also a link on the front page of Unify2.
Reminder: Unify2 training sessions, 3rd November There is currently a project underway to enhance and up-grade the Unify2 website. This is due to go live towards the end of the year and there will be 2 training sessions for the new website on 3rd November at the SHA, York House, Horley. If you are interested in attending please email your contact details to [email protected] stating whether you would prefer to attend the morning or afternoon session.
Health and Social Care Information Update
Every three weeks, DHSE publish an information update which provides a signpost to new public health and social care policy, evidence, news, consultations and events. The update includes national resources, but particular empha-sis is placed on news specific to the South East region. You can receive the update by email or visit the archive on the SEPHO website.
For further information contact: Anh Tran ([email protected])
Better Care, Better Value Indicators Data for quarter 4 2008/9 has now been published. Infor-mation can be accessed from www.productivity.nhs.uk
World Class Commissioning The Information Centre will be issuing their on-line World Class Commissioning Data Pack on 11th September. See www.ic.nhs.uk for further details.
NEWS
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Analytical Fair The fourth analytical fair will be taking place on 9th September in Leeds. The focus will be world class commissioning. Further information is again available on the Information Centre’s website.
Clinical Advisors appointed All clinical advisors to the HPEC pathways have now been appointed and Quality Observatory links identified to work with each lead (see below):
Yvonne Arthurs—Children & Young People (Adam Cook)
Beverly Castleton—Long Term Conditions (Kate Cheema)
Amit Bhargava—Staying Healthy) (Kate Cheema)
Tim Ojo—Mental Health (Adam Cook)
John Omany—End of Life Care (Adam Cook)
Stephen Pollock—Acute Care (Simon Berry)
Ryan Watkins—New Born (Kate Cheema)
Helen O’Dell—Maternity (Adam Cook)
Jackie Spiby—Planned Care (Simon Berry)
Forthcoming health reports The National Audit Office is planning to publish the following reports within the next 6 months: -
• Chlamydia screening - October
• Dementia follow-up - November
• Stroke follow-up - December
• Trauma services - November/December
• Health Inequalities—January
Informatics Trainee to join the Quality Observatory David Graham will be joining the Observatory from November for a period of nine months. David is one of the national Informatics Graduate trainees.
Medway NHS Foundation Trust has an exciting opportunity available for a dynamic individual. Initially to cover a 6 month secondment they have a vacancy for Assistant Information Manager to join their Information Department. For further information log on to www.jobs.nhs.uk or contact Karl Peters (01634 830000 ext 3216 or [email protected]
The Quality Observatory at NHS South East Coast has a vacancy for a Health Analyst for a period of 12 months. Further information is available from Samantha Riley, Head of the Quality Observatory (07966 249957 or [email protected]). Applications are also via nhs jobs.
Job Opportunities
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: [email protected]
To contact a team member: [email protected]
Once was Knowledge Management, A bold and noble crew, With info at their fingertips Designing dashboards just for you. Time stands still for no one, And Knowledge Management has gone; And now the Quality Observatory Begins its shining dawn. The Quality Observatory stands firm, Bigger, better, brighter, bolder than before. What once was there remains, But has grown into something more. Quality information, dashboards, Advice on data flows, Knowledge Management has gone, But the Quality Observatory grows & grows.
The Quality Observatory
Do you want to learn more about the work of the Quality Observatory? Are you aware of the breadth of tools and products that have been de-veloped to date? Would you like to learn more about developments in the pipe-line? Would you like to provide the team with feedback or made suggestions for the development of future products?
The Quality Observatory will be holding quarterly sessions where you can come along to learn about/inform the work of the team.
All we ask is that confirm your attendance with Suzanne Gregg ([email protected]) at least a week in advance to enable us to plan for the number of attendees.
Meet the Quality Observatory
All sessions will be held in the Board Room at York House, 18-20 Massetts Road, Horley, RH6 7DE
22nd October 2009 13.00—16.00 21st January 2010 12.30—15.30 14th April 2010 12.30—15.30 14th July 2010 12.30—15.30
To date, roughly 30,000 people worldwide have been infected with Swine Flu. How-ever in 1918-1919, over a period of just 18 months the Spanish Flu pandemic infected over 500 Million people.
Fascinating Fact
HoNOS scores are increasingly being referred to as a potentially useful Mental Health outcome measure. What does HoNOS stand for? See the next issue for the answer…..
Quick Quiz
Page 16
Next time…..
Read about the new Quality Observatory website hosted by NHS South East Coast on behalf of all Quality Observatories