NHS Friends and Family test vs Staff Survey

I worked at Royal Free Hospital for one year. When the 1st National Friends and Family test was published at the end of July 2013, I was surprised that Royal Free Hospital had the lowest net promoter score. I have worked in many hospitals and I actually thought that patients were treated reasonably well. In fact in the 2012 National Staff Survey when asked:  ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation’, 72.5% answered ‘Agree/ Strongly Agree’ which was in the 4th quartile of performance.

So I asked myself a question, is there are correlation between the ‘Friends and Family test’ and the ‘NHS Staff Survey’?

I took both datasets, combined them and ran a linear regression analysis.

As you can see, the R-squared value is 0.1513 which represents a small positive correlation. I’m afraid that my statistics is not up to scratch to ask if this is statistically significant.

Interestingly, my old hospital does look to be an outlier.

I don’t know what this means but a few things but there are a few things to keep in mind

• The response rate for the friends and family tests for inpatients was only 10% at Royal Free Hospital
• The net promoter score is calculated very differently from the NHS Staff Survey (please see links above for an explanation).
  From the website:

Those that say they are ‘extremely likely’ are counted as promoters. ‘Likely’ is neutral, ‘neither unlikely nor likely’, ‘unlikely’ and ‘extremely unlikely’ are all counted as detractors.

I welcome others to analyse this data. The sources and methods on how the raw data was collected and calculated are available from the sources (links above).

You can download my Excel Spreadsheet: NHS Staff Survey vs Friends Family or LibreOffice Spreadsheet

Any thoughts?

Update: 0734 19/08/2013

This post has generated quite a bit of interest with a lot of talk about sample sizes and response rates.

I wonder if someone able to create dynamic graph where the user can filter by the sample size and when mouse-overed, the tooltip will show the hospital the data pointrefers too? Maybe the size of the data point can correspond to sample size too (like a bubble graph?). All help greatly appreciated.

7Breaths is born

Respiratory rate needs to be measured over one minute?

A fundamental part of medical practice is the measurement of primary physiology. For centuries heart and respiratory rates have been calculated to help identify disease and demonstrate response to treatment. However confidential enquiries, internal reviews and other studies frequently show that observations are poorly taken. This in part has lead to an inexorable rise in early warning scores and system to identify acute illness. A potential barrier to the recording of observations, whether by doctor, nurse or other health professional is the time taken to measure them. Traditionally a minute has been the gold standard in order to ensure reliability. Studies have supported the 60s approach (Simoes 1999) but with increasing pressures on health services and rapid advances in easy to access technologies the time has come for a review. Can you help?

Take part in a large scale observational trial using your smartphone

This idea was first in my previous post here, tweeted and published on the NHS Hackday googlegroup . This idea was quickly picked up by Neville Dastur, a Consultant Vascular Surgeon, software developer and owner of Clinical Software Solutions Ltd and 7breaths was born.

What are we going to do with the data?

The data will be openly available to data analysts and mathematicians to attempt to generate an algorithm that can be used in future version of 7breaths that will automatically report the respiratory rate once the software is ‘confident’ that it is able to predict within set level of confidence what the respiratory would be at 1 min.

We envision that this will take into consideration

• Inter-breath duration
• Variability and pattern of the Inter-breath duration

Why bother with this?

Ultimately this is a demonstration of the power of open source, collaborative healthcare innovation. While it is a bit of fun there is a real possibility that new methods to improve the accuracy of RR measurement and that can also save time could transpire. It’s also a demonstration that a simple piece of software may enable an economical way of gathering data at the point of care that does not require any form of duplication of efforts.

Want to take part?

Download the App

Register

When you first download the app, you have the option of registering the software. We would encourage this as it would allow us to acknowledge your contribution and also provides a degree of provenance for the data collected.

Start collecting data

When you are next counting a patient’s respiratory rate, use 7breaths instead. At the end of one minute it will report the respiratory rate and it will give you an option of sending the data to us. That’s it!

Who’s behind 7 breaths?

Damian Roland – Paediatrican (@damian_roland)
Wai Keong Keong – Haematology Registrar (@wai2k) <- ME
Neville Dastur – Vascular Surgeon (Clinical Software Solutions) <- He built the app! (Sourcecode on GitHub)

Staff Administration System (SAS): A Vital Missing Piece in Hospital IT systems

Reflect on the current state of affairs

1. Patient
   Who is the junior doctor looking after me at this moment in time? Who is my nurse? Who is my Physio?
2. Radiologist
   I am reporting a CT Scan on Mr Some Body. There is something not right here, I need to speak to the doctors looking at this patient now. Who is it? How I can make contact?
3. Haematologist
   I have some really abnormal blood results for Mr Some Body. I need to tell someone in charge of this patient’s care, but I do not know who it is? The contact number on the form is not working.
4. GP
   I have a vital piece of information I need communicate to the doctors looking after my patient, but I don’t even know where to start.
5. Nurse
   I need a doctor to see this patient as she is in pain. Doctors change around all the time and it’s 530pm already, who should I call?
6. Patient relative
   I want to tell the physiotherapist something really important about my dad to help discharge. I do not know who to get in touch with.
7. Ward Junior Doctor
   I want whoever is taking over my shift to be notified if a patient does not get a CT Scan by 10pm. It is 6pm and I’m going home now.
8. Site Manager
   I wonder what medical and nursing levels are tonight.
9. Director of Operations and Workforce
   I wonder if we are deploying the right skill mix of doctors, nurses, physics, occupational therapists. Are we matching the clinical services to clinical need?
10. Medical and Nursing Directors
    I really need to understand if we are providing safe enough levels of care in our hospital all the time. I need live up-to-date information. I hear concerns all the time but I do not have any data to backup it up to guide decision-making and strategy.
11. Chief Executive and Financial Director
    The Workforce is our most valuable and expensive resource and patients are the focus of our organisation. I have never had an objective way to bring these two together.

This is a problem

Speak to any nurse, ward doctor, lab technicians, GP or patient (or relative). This is a problem. I have been to 4 NHS Hackdays now and spoken to others attending other health IT events and the following are recurring themes.

• Bleep Bleep – The problem with intra-hospital communication between professionals
• Patient Lists – Making Information to the right person as the right time and keeping track of patients
• Notifications – Making sure important information get to the right person
• Task Management Software – Making sure things get done 24 hours a day
• Rota Management Software – Management staffing, leave, ensuring the right skill mix
• Medical and Nursing Handover Software – Making sure things get done and right information gets transferred (I actually see this as an amalgamation of patient list + task management software)

SAS – The Vital piece of IT infrastructure that is missing

Imagine a hospital EPR running without a PAS (patient administration system) system.

That’s essentially the situation now with managing staff in hospitals. Let’s call this system the Staff Administration System (SAS) for now; I know this is not a great name!

Like a PAS, SAS will form the backbone to any application that requires coordination or communication between staff. For example, a lab system will just have to send a message out a notification application that says, ‘please inform the junior doctor looking after a particular patient about this result.’ The notification system will then query the SAS to find out the right person(s) to send the notification on.

It will be system to let’s every other system know, who is on duty and when, what their grade and skill sets are. For example a rota management system will use data from this system to ensure that there is someone on duty on all time that can perform a cardiac pacemaker or chest drain in an emergency out of hours situation.

Without a SAS every piece of software that does any form of staff management will require its own database that is not coordinated with any other. This is not sustainable nor safe in the long run.

It is not just about the IT

A SAS is not going improve the care coordination for people do not change the way they work. A SAS will require people to login to work and logoff. It will require staff nurses to assign themselves to a particular patient. It requires teams to clearly define their roles and ensure that it is recorded electronically.

Imagine what things could be like

1. Patient
   Who is the junior doctor looking after me at this moment in time? Who is my nurse? Who is my Physio?
   > I can just look this up on my Patient Information System. It is reassuring to know the names and faces of the people overseeing my care.
2. Radiologist
   I am reporting a CT Scan on Mr Some Body. There is something not right here, I need to speak to the doctors looking at this patient now. Who is it? How I can make contact?
   > I’ll just click this button on my radiology information system and it will contact the doctor in charge of the patient now and we are connected!
3. Haematologist
   I have some really abnormal blood results for Mr Some Body. I need to tell someone in charge of this patient’s care, but I do not know who it is? The contact number on the form is not working.
   > Same as no.2
4. GP
   I have a vital piece of information I need communicate to the doctors looking after my patient, but I don’t even know where to start.
   > I can just login into my portal in my local hospital and click contact the team 
5. Nurse
   I need a doctor to see this patient as she is in pain. Doctors change around all the time and it’s 530pm already, who should I call?
   > I just click ‘contact the doctor’. 
6. Patient relative
   I want to tell the physiotherapist something really important about my dad to help discharge. I do not know who to get in touch with.
   > Log in to Patient Portal.. Contact my physiotherapist… Done
7. Ward Junior Doctor
   I want whoever is taking over my shift to be notified if a patient does not get a CT Scan by 10pm. It is 6pm and I’m going home now.
   > Add a task linked to the patient record to send a notification to the whoever the looking after that patient at 10pm. 
8. Site Manager
   I wonder what medical and nursing levels are tonight.
   > Let me just look at the dashboard to see the live staffing levels linked to live patient levels.
9. Director of Operations and Workforce
   I wonder if we are deploying the right skill mix of doctors, nurses, physics, occupational therapists. Are we matching the clinical services to clinical need?
   > Another dashboard? 
10. Medical and Nursing Directors
    I really need to understand if we are providing safe enough levels of care in our hospital all the time. I need live up-to-date information. I hear concerns all the time but I do not have any data to backup it up to guide decision-making and strategy.
    > I can finally target the training requirements of my staff. I can finally have some data on staffing that I can link to patient level data to try to understand the link between patient care and staffing. This was not possible before.
11. Chief Executive and Financial Director
    The Workforce is our most valuable and expensive resource and patients are the focus of our organisation. I have never had an objective way to bring these two together.
    > We are not going to able to increase efficiency and quality without changing the way we work. We need to re-design pathways of care and get people working better together as a time. I want to use IT to make this happen. Current IT system don’t understand or manage our most expensive and valuable resource. 

This must happen

IT is only an enabler of new innovative processes for care delivery. Healthcare staff are the key and most important components to these processes. He can we design patient pathways and have no way of digitally representing the staff members that are key components of that pathway. Without this, how can we move forward?

What can YOU do about it?

1. NHS Trusts. Build your own and share it – Currently NHS England are making funds for projects just like this. I ask that you run it as an open source project and share your learnings and code with others. Make sure you truly understand the care delivery process and reflect it in the design and data structure.
2. Software Vendors: Build it, make sure it is interoperable with open APIs. Run it as an open source project. Sell it as a service. This will encourage uptake and constant improve to it. Partner with an NHS Trust and work together and access the £260 million fund.

Let me know what you think. Are people addressing this already?

This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.

Essential Reading on why OpenSource software is the only sustainable answer to NHS IT woes

It is rather surprising that it is only this week that I have come across the writings of Eric S. Raymond who’s seminal paper ‘The Cathedral and the Bazaar’ in 1997 was credited with accelerating the open source movement and was an important factor in Netscape’s decision to opensource its browser.

I highly recommend reading the following essays all which can be found here. I’ve provided pdf versions below.

1. The Cathedral and the Bazaar [pdf]
2. Homesteading the Noosphere [pdf]
3. The Magic Cauldron [pdf]

In combination these 3 papers set out the sociological, economical and philosophical arguments for open source.

After reading them, I more convinced than ever that it is in the interest of the NHS to create/ procure opensource software by default. It is the *only* way that the quality, reliability, security, longevity and affordability can be assured.

Most posts to follow….

 

 

A simple app for counting Respiratory Rate

The respiratory rate (how many times you breathe in one minute) is a very sensitive indicator on whether a patient is well or unwell. It is a vital part in all early warning scores. Indeed, it is often the first parameter that becomes abnormal.

Unfortunately, this is also a parameter is measured inaccurately and often omitted by healthcare professionals.

Reasons (and excuses) include:-

1. Most bedside observation machines do not produce a number that people can write down unlike the Heart Rate, Blood Pressure, Oxygen Saturations
2. Requires the clinicians (often healthcare assistants) to count how many breaths a patient takes per minute. Over 30 patients, this observation along can take 30mins. (people get lazy). The one minute is recommended is because unlike our pulse our respiratory rate can be quire irregular. (unless you are breathing very fast then it becomes more regular.)
3. You need a watch with a secondhand/ stopwatch

As more and more hospitals progress towards digital collection of observations on smartphones, I’m proposing a simple application that counts respiratory rates that is accurate and that will require minimal ‘skill’ and training.

This is how it works:-

1. Start the app
2. It will have a BIG button in the middle of it that just says ‘Press here every time the patient breaths’
3. The program will *figure* out how regular the patient is breathing to determine the length of time the observer needs to count. For eg. if the patient is taking 5 secs btw breaths and is very regular, 30 secs may be enough. But if it is 10secs, 1 min or more is required. Conversely if something is breathing every 2 secs, 15 secs of observation is more than enough. The accuracy of this algorithm can be refined in a field study.
4. The app, gives you a respiratory rate
5. THAT’s it

This will be simple enough to integrate into a observation recording tools like WardWare.

It is also simple enough to teach patients and their relatives how to do this themselves.

There are apps out there that can use the iPhone camera and/or motion sensors to do the same but that is much more complicated, less accurate and will require clearly defined hardware requirements. They will also have infection control issues.

Who wants to have a go, else I’m going to be proposing this for the next NHS Hackday

 

 

 

VitalVis Project Update: Coding the Vision

Since my last post about VitalVis the Superteam has been hard at work and you can find the latest screenshots below.

These are dynamically generated graphs pulling *real* patient data provided by Wardware .

It immensely satisfying to see the *real* version getting to close to the mock-up.

VitalVis – Re-imagining the Observation Chart for the Digital Age [NHS Hackday 4 – London Edition]

For NHS Hackday 4 – London Edition. I wanted to work on a design hack to solve the following challenge.

How to display 5 days worth of patient bedside observation data on a small smartphone sized screen.

Digital collection of routine observations (Blood pressure, Heart Rate, Respiratory Rate, Oxygen Saturations and Temperature) is becoming more common place in the acute hospital setting. The advantages of automated calculation of Early Warning Scores (EWS) and automated notifications to the clinical team and Patient At Risk Team (and related early intervention teams) are undeniable.

However, displaying of a large amount of patient observations to allow comparison of trends in a small smartphone sized screen remains problematic. Doctors are very used looking at patterns and trends very quickly. The way this is represented on smartphone sized screens currently makes this difficult.

The example above is taken from a leading provider of bedside observations systems. As you can see, the number of observations is quite limited and getting previous observations require a significant amount of scrolling and does not allow direct comparison with the current set of observations. This is a significant disadvantage compared to paper.

Inspired by Edward Tufte

Inspired by the father of data visualisation, Edward Tufte and his paper co-authored by Seth Powsner article (“Graphical Summary of Patient Status”, The Lancet 344 (August 6, 1994), 386-389), the Superteam (see below) produced the following solution:-

This design shows:-

• A total of 5 days of observational data:- The last 24 hours is shown in the right half where as the previous 4 days is shown on the left hand side of the screen.
• The right  area of the screen shows the most recent set of observations
• Horizontal Gray bars demonstrate ‘safe ranges’
• Numbers incorporated in the middle divider helps orientates viewer

Principles of the design:-

• Minimal use of colours
• Maximising the data-to-ink (pixel ratio)
• Variable X-axis with emphasise on the last 24 hours
• Use of dots or lines to represent trends instead of ‘artificial’ lines
• Relies of the natural ability of the human mind to quickly process large amount of information using pattern recognition

This also allows:-

• In a larger screen like a tablet or computer monitor, this allows one to view observations from multiple patients at the same time, allowing a quick overview of multiple patients
• Incorporation into a patient dashboard

The technical implementation

To turn this idea into reality, we were fortunate to have anonymised real patient level data collected by Wardware provided by Rob Dyke (@robdykedotcom) of Taxtix4 in the form of an mySQL database. In the short amount of time available to create the, the Superteam managed to create a webapp that can query this database and display it on a webpage. The technology stack: Python, Django, Mathlib library. Screenshot below. [30/05/2013: An updated version 48 hours post hackday could be found here ]

To my knowledge this is the 1st ever project at any of the previous NHS Hackday to use actual patient data. I strongly believe that one cannot build good systems without using realistic data.

The Superteam

This project would not be possible without the skills, professionalism and dedication of the following amazing people:-

• Martin Green – Radiation Physicist and Coder
• Alan Beebe – Coder
• Chris Pritchard (@chriscpritchard) – Student paramedic and Coder
• Ayesha Garrett (@londonlime) – Designer
• Amanda (@complexitytamer) – User Experience Designer
• Wai Keong Wong (@wai2k) – Haematologist <- ME!

Collaborate and other Resources

The code if available on GitHub

Presentation is available on SlideShare

Using NHS.net Email to store notes using the Drafts folder

I realised that I needed to keep some working notes with patient identifiable information with me that I can access on any computer.

Given that NHS.net is the only way to store patient information securely, I thought of a simple solution that might work for you.

Use the ‘Drafts’ Folder

To create a draft

1. Create a new message but don’t put anyone in the To: Cc: field
2. Give your note a Subject
3. Create your note in the body
4. Click ‘Save’

That’s it.

When you want to access the notes again

1. Go to your ‘Drafts’ folder
2. Open the ’email’
3. Update your notes
4. Click ‘Save’

As NHS.net doesn’t currently provide a way of storing files, this is a quick ‘hack’ that is IG compliant.

What about text formatting?

If you do not access your NHS.net using IE or Outlook, you loose the ability to use formatting for your text. As an alternative, I suggest using ‘Markdown‘. If you ever choose to format the text, you can convert the markdown text into PDFs, HTML etc…

What about getting this on my phone?

You can access your ‘Drafts’ on your iOS device if you are linked to NHS Mail using Exchange. However, you won’t be able to edit mail in your drafts folder. However, what you can do is create an email, send it to yourself, and then move it into the ‘Drafts’ folder. (Don’t make the mistake of moving it into the ‘Drafts’ folder for phone but the ‘Drafts’ of your NHS.net account.

Hope this helps

Why NHS hospitals don’t utilise modern telecommunication technologies. A response to Prof Jonathan Kay, CCIO, NHS Commissioning Board

Professor Jonathan Kay, CCIO for the NHS Commissioning Boards asks on this NHS Hackday Google Group thread:  why so few NHS hospitals utilise modern telecommunication technologies such as the mobile phone, SMS to improve communications within and between medical teams.

Below are my observations:-

• Communication and care coordination within the hospital is not on the radar on most hospital’s IM&T strategy: PAS, PACS, Electronic Prescribing, Clinical Correspondence (incl. discharge summaries), Clinical Notation (incl. Bedside observations) are.
• Internal referrals and internal communication is often a problem for junior doctors and nurses on the frontline, who often do not have a seat at the table when it comes to influencing organisational strategy. We are the silent and transitionary workforce (junior docs).
• Revolutionising communication requires investment on new platforms such as smartphones and other mobiles devices and staff skilled to manage their deployment on a large scale. (I’m not referring to Blackberrys that are relatively simple).
• Due to points above there aren’t many people selling solutions. Those that exist require both a hardware and software investment. And often, the hardware is tied to the software instead of treating the hardware as a platform, a general purpose computer, that enables all sorts of other possibilities. Examples of this includes things like Wardware, VitalPAC, and various handover software.

I’m waiting for a forward thinking organisation to tackle the issues of intra-hospital communication head-on to solve the bleep bleep (pagers), patient list and guidelines at point-of-care problem that have been discussed in great detail on the NHS Hackday Google Group and on a series of podcast that a few of us junior doctors record: http://thedigitaldoc.co.uk/podcasts

In conclusion, the people that decides how the money is spent is blind to the problem -> resources are not allocated -> No one  steps forward to offer solutions.

Getting Google Chrome (sort of) working on NHS computers

As we are all aware, more NHS computers run on IE7 and some even on IE6.

I would like to share with you how I managed to get Chromium working on my NHS computer without having admin rights.

This is made possible by SRWare Iron: A browser that is based on the free Sourcecode “Chromium” that powers Google’s Chrome browser.

Download the Portable-Version for USB-Sticks and as it says on the website, “no Installation; no Admin-rights needed; Profiles in the same folder”

Unzip it in the directory of your choice, click on ironportable.exe and aware you go! Yup, it is really that easy.

Another advantage of using SRWare Iron is that there is no privacy concern. Read more Chrome vs Iron.

Potential pitfalls and suggestions:-

1. SRware website may be blocked by your web filters.
2. Even if you saved it to your Dropbox or alternative, those websites may be blocked too (my hospital does not block dropbox and this is how I managed to get the zip onto my work computer.
3. You could email the zip file to you computer but some NHS email filters may block that too!
4. You could use your work’s encrypted USB stick but your personal unencrypted USB stick will probably not work.

Tips:-

1. ‘Installing’ SRware’s Iron onto your personal directory allows you to use it on any computer that you login into.

What I’ve yet to figure out

1. Does installing it on your personal directory start bloating your personal directory and fill it up?

Thank you to @haematologic for sharing this with me.