Knowledge Matters Volume 8, Issue 3

issuu.com/SECQO

twitter.com/SECSHAQO

www.QualityObservatory.nhs.uk http://www.networks.nhs.uk/nhs-networks/sec-qo

Volume 8 Issue 3 August 2014

Welcome to the August (well, -ish) special holiday edition of Knowledge Matters!

This month we have an update on the Friends and Family Test from Samantha Riley, Director of Insights at NHS England, and its forthcoming major rollout across GP practices, mental and community health services, dental practices, patient transport services, day cases and outpatients (phew!).

We also have a fairly topical Analysis Ancient and Modern around improvements in treatment of the injured up to the Great War, an update from the Association of Professional Healthcare Analysts and an interesting article on the Bayesian Approach in statistics from one of our new team members, Trishna.

For those looking to build their knowledge of using R, a handy free tool for statistical analysis much in use in academia and statistics, I would strongly recommend looking at the News section for details of a free course being run by edX.

I’m off to relax by the pool with a cheeky cocktail now so cheers and see you next edition!

Simon

Welcome to Knowledge Matters

Inside This Issue :

Making Connections - FFT 2 Skills Builder 6

Analysis Ancient and Modern 4 Ask an Analyst 8

Making Connections - AphA 5 News 10

2

[email protected] www.QualityObservatory.nhs.uk

The Friends and Family Test is coming to a place near you SOON

By Samantha Riley, Director of Insight, NHS England

Hello Knowledge Matters readers. I’m hoping that

most of you are aware of the Friends and Family

Test (FFT), that it is coming to a place near you

very soon and also that you are starting to hear

about the significant benefits that it is bringing to

both staff and patients. There have already been

3 million responses received to the FFT – that

compares to 65,000 responses per year from the

annual inpatient survey. Anyway, just in case you

aren’t familiar with FFT, let’s start with some

basics…….

So, the Friends and Family Test is a feedback tool

which supports the fundamental principle that people

who use NHS services should have the opportunity to

provide feedback on their experience that can be used

to improve services. All patients should have the

opportunity to provide feedback through the FFT at any

time. The important thing to stress here is that ALL

patients should be provided with the opportunity

regardless of their needs – children need to be

communicated with in a different way to someone who

has hearing loss. It is important that steps are taken to

ensure that all patients are given a voice.

Approximately a quarter of the recently published guidance is dedicated to providing advice on how to make

the FFT more inclusive, allowing people of all ages and from all parts of our community to provide feedback.

The FFT was introduced to inpatients and A&E in April 2013 and to maternity services in October 2013. FFT

is now being rolled out to all NHS services to the timetable below: -

GP practices from 1st December 2014

Community and mental health services from 1st January 2015

Dental practices, patient transport services, day cases and outpatients from 1st April 2015

Clearly there are big differences in how care is delivered in different settings and we have given a lot of

thought to how FFT is now approached to ensure that it works for patients and NHS staff. A review was

undertaken to look at what had worked well in inpatients and A&E and what could have been better. In

addition, a number of ‘pathfinder’ sites tested FFT in a range of new settings and provided evidence on

which approaches worked best. The review documents can be accessed here : http://www.england.nhs.uk/

ourwork/pe/fft/fft-test-review/ Key findings from the review were as follows:

3

[email protected] www.QualityObservatory.nhs.uk

The FFT has made a positive impact on the NHS, with

78 per cent of trusts saying it had increased the em-

phasis on patient experience in their trust;

The FFT was also seen to have an important role in

driving local service improvements, as well as boosting

staff morale when positive comments are received.

The net promoter score was not easily understood and,

as a result, the FFT will move to a more transparent

presentation of the data which both patients and staff

will find easier to understand and use. As a result of

this we are changing the way in which FFT data will be

presented.

On 21st July, the long awaited guidance on how to imple-

ment the Friends and Family Test in all care settings was

published. This marked a really important step in ensuring

that every patient will have the opportunity to provide feed-

back on the services they have received, enabling the pub-

lic to make better informed choices about the services they

use. The introduction of FFT to all settings also means

providers will be able to design care services based on the

feedback and around the needs of patients.

The new guidance mirrors the format of the Participation

Guidance which was published by NHS England last au-

tumn and which received very

good feedback from the NHS and key stakeholders. The new guidance is inter-

active and contains advice, videos, supporting materials and case studies. I

hope that the interactive nature of the guidance helps to bring FFT alive for peo-

ple and that the videos (which I highly recommend) help describe the benefits

experienced by both patients and staff.

The guidance can be accessed here http://www.england.nhs.uk/wp-content/

uploads/2014/07/fft-imp-guid-14.pdf

If you have any queries on the guidance or would like to provide feedback you

can email [email protected] or phone 0113 824 9494. For

those of you using twitter, we use #nhsfft to mark any relevant tweets.

The last thing to say for now is that the first set of results for staff FFT will be

published towards the end of next month. As always the data will be available

on the NHS England statistics page and on NHS Choices. More about staff FFT

next time!

4

[email protected] www.QualityObservatory.nhs.uk

It is generally acknowledged that

the Great War was one of the

most costly conflicts in history in

terms of human life. But

throughout history war has

generally provided at least one

small up-side in the form of

innovations in medical treatment.

World War One was no exception,

but the impact was perhaps more

evident than in previous conflicts.

Take a look at the chart on the

right. The proportion of deaths

due to disease rather than combat practically reverses compared to relatively contemporaneous conflicts

(although of course we should bear in mind a range of caveats such as the theatre of war, where hotter

climates abroad were likely to give rise to nasty diseases that British soldiers at any rate were unlikely to

have encountered before). So why did we see this apparent reversal happen?

World War One had a direct impact on a range of medical innovations which would have affected this

figure. Blood storage and transfusion is a famous example but advances were made also made in wound

care. The incidence of trench foot and obviously the impact of wounds from combat led to significant

changes in how wounds were initially treated, including the more extensive use of antiseptics in cleaning

wounds and improved techniques for the debridement of wounds to improve healing. There were various

technological advances which had an impact too; for example the development of the Thomas splint was

widely credited with reducing mortality rates from

fractured neck of femur from a staggering 80% to just

20%.

And then there were the basics; hand hygiene, short

hair cuts and regular delousing, and keeping toilets

well away from water sources drastically reduced

some of the big killers such as typhus and dysentery.

The ‘sanitary committee’ and the Sanitary Section (a

kind of hygiene hit squad) were instrumental in

ensuring that some of the basics of disease

prevention were adhered to. A Sanitary Section (consisting of a Lieutenant or Second-Lieutenant, 2

Sergeants, 2 Corporals, 20 Privates and 1 batman) was tasked to maintain as far as possible clean water

supplies, cooking facilities and billets, de-lousing stations and similar facilities. It couldn’t have been pretty,

but was no doubt critical in the reduction of disease casualties.

Analysis Ancient & Modern

5

[email protected] www.QualityObservatory.nhs.uk

To paraphrase the famous line, “It is a truth

(almost) universally acknowledged that there

is a lack of development and networking

opportunities for people involved in

healthcare analysis”. We have a bit of a bee

in our bonnet here at QO Towers about the

training and development (or lack thereof)

available to healthcare analysts who, when

all is said and done, provide the bedrock on

which proper decision making stands in the

NHS. So we’re very chuffed to see the

Association of Professional Healthcare

Analysts (AphA) help to fill the void. Created just last year AphA has a number of ambitious aims:

Support information specialists/analysts working across the healthcare sector

Promote best practice and innovation amongst all NHS staff involved in analysis and interpretation

of data

Support professional and personal development

Promote the highest standards in healthcare analysis

AphA are set to act alongside other Health Informatics professional bodies such as UKCHIP and BCS Assist

(see the news section for an update on their latest activities) to provide opportunities for all healthcare

analysts to network with each other, share learning and best practice and, of course, training opportunities.

AphA are a membership organisation (£30 per year) with members offered access to an online community

and resources to promote personal and professional development and of course the chance to network with

fellow analysts from across the country.

AphA also have an annual conference, the next one just around the corner on the 16th September. The event

is designed for members to come and exchange ideas, hear all about the latest developments in the field and

the opportunity to showcase all the exciting and (naturally) innovative work you’ve been up to!

For more information take a look at the AphA website at www.aphamembers.org or drop them a tweet

@apha_members

Association of Professional Healthcare Analysts

6

[email protected] www.QualityObservatory.nhs.uk

As a Statistics student, I would learn theorems, their proofs, other theorems to contradict or support previously

learnt theorems and of course, their proofs too. The first year went by in utter incomprehension of the subject

matter and a constant questioning of – Why am I studying Statistics? Will I ever appreciate these symbols from

another planet? My ‘Wow’ moment showed up in my second academic year when I met Thomas Bayes – and

no, he is not alive! He was a British mathematician and minister who described a process for adjusting and

updating the likelihood of an event based on data, as the data is generated. In simpler terms, it could be

synonymous to - reality changes with new information. Does it not?

Let’s have a go at it – I am turning 30, I have a great job, I have lots of friends, a pleasant partner and my

parents are rich. Oops, the pleasant partner and great job suddenly are no longer part of this equation. Boom!

Reality changes.

Using the terms I learnt back in the days, Bayes’ Theorem is a formula for revising prior probabilities after

receiving new information. The revised probabilities are called posterior probabilities.

Consider the probability that you will develop a specific cancer in the next year. An estimate of this probability

based on general population data would be a prior estimate; a revised/posterior estimate would be based on

both on the population data and the results of a specific test for cancer.

The formula for Bayes Theorem is as follows:

Yes, the formula did not say much to me either!

Let's put Bayes' Theorem to practical use.

Let's say that cancer is known to have a prevalence of 1 out of every 1000 people in a given population. This

gives us our prior estimate. Let's also say that we have a test for cancer that is very sensitive, but has an

inherent false positive rate of 10%.

Now, we need to use the test on 1000 individuals to determine if they have the disease.

The pre-test probability that any one of the individuals has the disease is 1/1000, or 0.001. When we test 1000

people, we may find (on average) the 1 person in 1000 that has the disease. But we also find 100 people who

test positive but do not have cancer (10% false positive x 1000 people = 100 false positives). So, we may

expect on average to find 101 people that test positive out of the 1000 people tested (1 true positive and 100

false positives).

Therefore, of these 101 suspects, each of them only has a 1/101 chance of having the disease. The

denominator, 101, represents the sum of our 2 possible hypotheses (101 positive tests = true positives and

false positives).

The Bayesian Approach By Trishna Julha, Programme Support Analyst

7

[email protected] www.QualityObservatory.nhs.uk

Without understanding that we need to combine the new data with the prior probability, a clinician may tend to

raise an unwarranted amount of fear in these 101 patients even though it is likely that only 1 of them has can-

cer. Without the Bayesian perspective, these 101 people will likely all become convinced that they have cancer.

We can turn the process above into an equation, which is Bayes’ Theorem. It lets you take the test results and

correct for the skew introduced by false positives to get the real chance of having the event.

Going back to the Bayes theorem formula,

Pr(A|X) = Chance of having cancer given a positive test (X). This is what we want to know: How likely is it to

have cancer with a positive result?

Pr(X|A) = Chance of a positive test (X) given that you had cancer (A). This is the chance of a true positive, 10%

in our case.

Pr(A) = Chance of having cancer (0.001).

Pr(~A) = Chance of not having cancer.

Pr(X|~A) = Chance of a positive test (X) given that you didn’t have cancer (~A). This is a false positive.

This exercise demonstrates how we gain a much clearer perspective about test results by combining prior

knowledge with new data and updating our position. It demonstrates how we arrive at the positive predictive

value of a test. However, the Bayesian methodology was often shunned, with much debate between Bayesians

and frequentists: The Bayesian methodology begins with uncertainty and corrects itself with each new observa-

tion towards the likely truth. Meanwhile, in frequentist statistics, probabilities are determined only after all data is

collected. Conclusions tend to be binary, that is, we either reject the null hypothesis in favour of the pet hypoth-

esis, or we do not.

With new technology, especially in the IT and phone industries, Bayesian methodology has been revisited and

appreciated. Prior probabilities are now calculated from prior scientific knowledge, specialized expertise or by

recently developed statistical techniques.

Debates over the supremacy of each school of thought have lasted centuries and to date, they seem

unfinished. We cannot know what goes on in a scientist’s mind and which methodology will be favoured.

But the Bayes formula still remains for me, a ‘Wow’ theorem.

References and Links

Bayesian methodology

https://sites.google.com/site/skepticalmedicine//bayesian-methodology

An intuitive and short explanation of Bayes Theorem

http://betterexplained.com/articles/an-intuitive-and-short-explanation-of-bayes-theorem/

The Bayes theorem, explained to an above-average squirrel

http://blogs.sas.com/content/sastraining/2011/01/31/the-bayes-theorem-explained-to-an-above-average-squirrel/

8

[email protected] www.QualityObservatory.nhs.uk

Calculations and Textbox masking Input Forms

Application: Excel 2007/2010 (xlsm)

Solution:

Complexity 3/5 — Form validations with event based VBA

Hi Eloise Thanks for getting in touch. With Excel you can format and validate cells on a spreadsheet easily, but there is no direct option to format mask or validate the data that is input into the textbox. The closest option to a validation you have readily available in Excel is the “MaxLength” property to set the maximum number of characters. To ensure that people can only add numbers to the textbox we will need to use some event based VBA. There are 3 potential textbox events that we can use to trigger our input checking code; these are KeyDown, KeyPress and KeyUp. There are some differences between these events. KeyDown and KeyUp events return an MS KeyCode value, and KeyPress returns the Ascii code for the key that has been pressed. In this example we are going to use the KeyPress event to run some VBA code that will check the input data. In your Developer tab switch into Design Mode. I have created 4 textboxes named TextBox26-29 (as below).

Dear Ask an Analyst I am trying to create a user form in Excel and have gotten a bit stuck. Half way down the form I have the following 4 fields: 1. Income 2. Expected Costs 3. Margin 4. Margin % I need to make sure that the input is numeric only and I need number 4 to be calculated as number 3 divided by number 1. Is the textbox the right control to use or is there a better one that allows you to format mask, like in Access?

Eloise Armstrong Business Analyst

NHS Central Southern

TextBox26

TextBox27

TextBox28

TextBox29

9

[email protected] www.QualityObservatory.nhs.uk

Select the first textbox on the form and right click and select View Code to pop up the VBA Editor.

The editor will load with the default “Change” event. We want to utilise the “KeyPress” event so from the drop down at the top right of the editor window select “KeyPress” The KeyPress event makes the “KeyAscii” variable available to us to use in our code.

This variable holds the Ascii value of the key that is pressed e.g. the numbers 0-9 have Ascii values of 48-57. This gives us the basis for the logic we can use to evaluate if the data being input is a number or not. In this example I transform the KeyAscii value back to the character that it represents with chr() and use the IsNumeric() function to evaluate it. Setting the KeyAscii value to 0 in the False evaluation step will stop the character being displayed in the textbox. In the finished example I have used an If statement but you could use Select Case for multiple validation rules Private Sub TextBox26_KeyPress(ByVal KeyAscii As MSForms.ReturnInteger) If IsNumeric(Chr(KeyAscii)) Then ‘action to do if is a number i.e. let it through Else ‘action to do if is anything else i.e. don’t do anything KeyAscii = 0 End If End Sub For the calculated value in Textbox29 we want to divide the value of Textbox28 with the value of TextBox26. We probably only want to perform this calculation when the value of the textbox changes so we can utilise the Change event, and for Textbox26 we probably want to check that Textbox28 is not blank. So we can add something like :

Private Sub TextBox26_Change() On Error Resume Next ‘ this is just in case the system tries to divide by zero (and other errors!) If TextBox28.Value = "" Then

‘do nothing Else

TextBox29.Value = TextBox28.Value / TextBox26.Value End If End Sub

You will need to repeat this for Textbox28 as well, don’t forget that on the Textbox28_Change() event you will want to check if TextBox26 is blank. You may also want to set Textbox 29’s “Enabled” property to False to stop people overwriting the calculation.

10

[email protected] www.QualityObservatory.nhs.uk

NEWS

New Starters

We have had 3 new starters since the last

newsletter. I’ll let them introduce themselves!

Becki Ehren

Hi I’m Becki, the second newest

recruit to the Quality

Observatory. My role is the

Team Administrator, so I am the

‘go to’ person for organising the

team for meetings etc.

I have previously worked in

pensions administration and as

cabin crew (two very different

industries!), and I am enjoying

working for an organisation as

interesting as the NHS.

Dani Collier

Hello, I’m Dani. I joined

the team at the Quality

Observatory in July 2014.

I am helping out on the

Friends and Family Test

Project.

I have worked in the NHS

for nearly 4 years. I was

previously working as a

Healthcare Assistant on a

mixed sex 19 bed inpatient ward in acute

psychiatry. I’m really enjoying the work and it is

great using the data to see why things are changing

on the wards. It really is an eye opener!

Trishna Julha

Hi. I am Trishna Julha,

the latest fresher to

tune into the Quality

Observatory

bandwidth. For the

coming months, my

editorials will focus on

the Friends and

Family Test’s cuttings!

After having spent years in front and behind a

camera to present probed information, and with

prior experience in market research and media

audience insight, I will be making thorough use of

my Statistics educational training and analytical

mind to process, analyse and report programme

related data at the Quality Observatory. Five, four,

three, two, one … On Air!

New Office Update

The saga

continues…….. It

seems that we

were overly

optimistic in our

projection that we

would have moved

to our new home

by this issue, especially with our new arrivals!

It’s not all bad news, contracts have been signed

and we are now able to gaze over the road at our

future new premises at The Gables, Massett’s

Road, Horley while we wait for the seemingly

correct stars and planets to align for the fit out works

to be carried out and N3 connection installed.

In the interim it acts as a meeting space for us when

York House is full!

11

[email protected] www.QualityObservatory.nhs.uk

Birthdays

A quiet couple of months

since the last issue with

only Amit and Becky

celebrating getting a year

older (apparently fuelled

entirely by gin and

bubbly respectively)

Update on the Federation of Health Informatics

It’s a great time to be in health information. Never

before has the profession had so many channels for

professional development (take a look at the article

from ApHA on page 5) but there is still work to be

done to improve awareness and underline just how

critical high quality information is to improving care.

You may remember last time we mentioned the

consultation on the creation of a Federation of

Health Informatics, to provide a new and strong

voice for health informatics professionals.

The results of the initial consultation are now

available to view here: http://www.bcs.org/upload/

pdf/assist-federation-consultation.pdf

The main message is that respondents believe that

we need leaders in the health sector who

understand the importance of Health Informatics

and appreciate the value of Health Informatics

professionalism to patient safety and public trust.

The consultation doesn’t end until October so there

is still plenty of time to get involved in this work.

BCS Assist members can take a look at http://

www.bcs.org/content/conWebDoc/52449 to answer

the initial consultation.

Free Course: Explore Statistics with R

I’ve been made aware of a free EDX Massive Open

Online Course (MOOC) called “Explore Statistics

with R” being run over 5 weeks starting on the 9th of

September with an estimated effort of 8 hours a

week. It’s being run in English by the Karolinska

Insituet in Sweden .

“In this course you will learn the basics of R, a

powerful open source statistical programming

language. Why has R become the tool of choice in

bioinformatics, the health sciences and many other

fields? One reason is surely that it’s powerful and

that you can download it for free right now. But more

importantly, it’s supported by an active user

community. In this course you will learn how to use

peer reviewed packages for solving problems at the

frontline of health science research. Commercial

actors just can’t keep up implementing the latest

algorithms and methods. When algorithms are first

published, they are already implemented in R. Join

us in a gold digging expedition. Explore statistics

with R. “

If you do go for it let us know what you think!

More details are available on

https://www.edx.org/course/kix/kix-kiexplorx-explore-statistics-r-1524#.U_3fdsVdWO5

NEWS

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 us.

Hosted by: Central Southern Commissioning Support Unit

E-mail: [email protected]

To contact a team member: [email protected]

Fascinating Facts

Babies’ kneecaps don't form and properly harden till they are around 5 years old. Having seen how often my little one falls over I can say that’s a very handy thing!

I've heard of the postcode lottery,

It's been in the news quite a lot

Says it's dependent where you live,

whether you get treated or not.

This causes a bit of a worry,

In some cases rightly so,

But sometimes there are good reasons,

Which we do not yet know.

Demographics is part of the answer

You might live among weak and old,

You may live in somewhere that gets sickly,

Whenever the weather is cold.

I know when we're sick and we're poorly,

It doesn't seem just or quite fair,

Traveling miles to get our treatment,

But you can't have it all everywhere.

So don't worry if you live where mortality's high

For cancer or defenestration,

It doesn't mean you'll die that way,

Remember correlation isn't causation.

Simon says…….

Having spent time recently navigating bureaucracy, red tape and all too often having to “wait for the next meeting”, it has sometimes felt like processes and procedures are used as a convenient shield to not to take personal responsibility for decisions and take action! Being able to take responsibility and make decisions and quickly take action is one of the behaviours, I feel, we will need to encourage to allow us all to provide a responsive service to our customers, and ultimately will be reflected in the services delivered to patients!

The Postcode Lottery