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Posted by Rowan Gill on October 13th 2022
East London NHS Foundation Trust’s approach to quality improvement is deeply rooted in data, both to understand the opportunities for improvement and to test the impact of any interventions.
“Around ten years ago, we decided we were going to shift away from being a traditional, assurance minded organisation,” explains Amar Shah, “We wanted to flip the power so that decisions can be made closer to the point of care. By our patients and staff working together to solve the problems they experience day to day, we can keep making care better. We knew that was a better way to harness people’s experience, wisdom and ideas because it’s much better coming from people closest to the issues.”
Over the last decade, the Trust has made huge strides, but is still very much on that journey.
A clear ambition for the use of data
“Data is a creator of power imbalance in organisations. Too often, the people who have access to data are the people in leadership roles not the people delivering care,” suggests Amar Shah, “We recognised that we needed to completely transform the way we make data available to people.”
Mohammad Forid Alom, Strategic Lead for Information Analytics at East London NHS Foundation Trust, explains, “We developed a set of principles based on feedback from staff: a single place to access all data; being able to access it anywhere; and reflecting our Statistical Process Control (SPC) methodology.”
Based on these requirements, the team chose to use Microsoft Power BI for data visualisation. Cost and ease of use were important factors in the decision. Choosing a Microsoft solution also fitted well with the Trust’s overall digital strategy; a lot of the infrastructure already centres around Microsoft, including Microsoft 365. Furthermore, says Mohammad Forid Alom, “Power BI gives our users the power to use data without having to have specialist skill sets.”
“Microsoft Power BI has been transformational in itself,” says Amar Shah. “Having a single place where people access their data is a big shift for us. It’s accessible in real time. It’s accessible from any device, including mobile. And it is securely available off the network without going through loads of security hoops. We can build intuitive, real-time analytics that give people integrated data.”
Real world impacts on patient care
The Trust’s early focus has been on developing an Inpatient Mental Health Integrated System, to create a master patient index. This is already being used widely on wards in some boroughs.
Borough Lead Nurse, Rebecca Lingard, says, “I was really interested and excited about this project from the very start. I’m always keen to think about how we do things smarter and to help nurses release time from mundane tasks. None of us train to be nurses to sit doing audits.”
“Back when we started it, we were reliant on other parts of the Trust providing data to us before we could understand what we should do or what we should change or test next,” she continues, “Suddenly, having all this different data live means that we can dip into it at different levels and have those discussions in a lot freer and quicker way. For example, it’s really helpful for us to track our capacity. That’s important because we know if we go over 80 percent capacity we will have more incidents of violence and aggression on our wards.”
The team also use Power BI during their “time to think” sessions in which clinicians come together to look at issues and develop and share learnings. This used to mean a ten-day wait to get the data.
Proactively using information to improve the delivery of care
The information in Power BI helps staff to see what’s happening in the service, to sense check, to monitor metrics and to look at trends. Samson Uwimana, a Modern Matron at ELFT, enthuses, “For me, I’ve been checking in every morning when I come in to get some sense of what’s happening on the ward. It’s been very useful. And it’s great to be able to so easily get data to present during away-days.”
In City and Hackney, one transformative use case centres on the use of Power BI to audit patient-specific paperwork. This audit is completed each week on each ward.
“Power BI has massively reduced our workload in terms of the audit,” reports Alice Jefferson-Perry, Clinical Practice Lead at City and Hackney. “It used to take four hours on a night shift to complete. Now, the information is all available in the task view in Power BI. It now takes me about an hour.”
These savings of around two-thirds to three-quarters of the time taken to complete the audit have been released to deliver care.
“The nurses that do complete our audits have found it very helpful,” agrees Maham Shahzad, Clinical Nurse Manager at City and Hackney. “We’re still in our Power BI training period, so it’s early days on my ward. We are using it for audits and to spot patterns. We’re able to identify issues and plan what we are going to do.”
She continues, “We’re able to breathe into the information a bit more: to bring back these learning lessons and discuss them in our away-days with our staff and understand what they think about it too. It’s been useful, for example, when we noticed that the use of rapid tranquiliser had reduced a lot on the ward, but the incidents of violence and aggression were still the same. We asked ‘why have we not used so much rapid tranquiliser?’ It turned out that staff were fearful of using it because of the policy had changed. So we were able to provide training on the new policy so staff felt more confident about the procedure.”
“We can understand the trends and see if there is anything we need to change,” adds Maham Shahzad. “We notice when we have a high influx of admissions, the incident of violence and aggression increases. It has prompted us to ask whether there is anything we need to do a bit earlier with the patients who are admitted.”
“We’ve had five COVID-19 outbreaks on my ward now and we can see that, when we have more people isolating, we have a higher incidence of violence and aggression. People are frustrated, they can’t go out, we’re asking them to wear masks. It does give us an idea: we’re going to have an outbreak – we need to prepare ourselves, send out for more staff. It helps us to prepare.”
Maham Shahzad concludes, “Although it’s still early on for us, we’re already getting into discussions about why these things are happening, and the data will also enable us to plot the impact of our interventions.”
Making data more freely available helps to drive data quality
Even on wards where the use of Power BI is in its infancy, staff are using the information to drive improvement. Richard Ward, a Ward Administrator at Tower Hamlets, explains, “The data in Power BI is only as good as it is in our EPR system. If we are not updating that, then Power BI is never going to give a true perspective. That then becomes an internal issue around who’s responsible for data update in the EPR system.”
This feedback loop can be used to drive data quality – creating a virtuous circle of data quality improvement.
“We’ve found on our Power BI journey that making the data available helps with data quality. Staff used to complain that they entered data into a black hole. When they wanted to get it out again, it was impossible,” Mohammad Forid Alom explains. “That creates a data quality problem because if you can’t see the data you don’t know whether it is being input properly. If you can’t use it, there’s no incentive to make sure it’s right. Our strategy recognises that you won’t have the right data quality from the get-go, but by making it apparent and accessible, we can drive that data quality over time.”
Amar Shah adds, “We want to help people have faith in the data. We don’t want people to be questioning the data; we want to help people to be questioning how to use the data so they can improve.”
The power behind Power BI: Microsoft Azure
Because the use of Power BI depends so much on the quality of the data, the Trust also has another big project underway to rebuild the underlying data infrastructure. It will bring together information from tens of systems, including five Electronic Health Record systems, to create an integrated, modern data architecture.
Mohammad Forid Alom explains, “We moved to Power BI before we started our data architecture work because the visual part is what frontline staff can relate to. We have been able to achieve good things even with our original clunky architecture.”
Nevertheless, it was clear a new data architecture was necessary, as Aravinth Pandian, Head of Business Intelligence (Data Warehouse) at ELFT, explains, “We’re a diverse Trust, delivering a variety of services: mental health, community health, primary care. We have diverse systems in place and they don’t talk to each other. This makes Trust-wide reporting very difficult. We knew that, to create the right information platform for improvement, we needed a system-independent data model. A data model that is built around patients and patient flow not a particular system.”
To achieve this, the Trust turned to Microsoft again and, specifically, Microsoft Azure Data Lake. “We wanted to build a very modern data warehouse,” explains Aravinth Pandian. “Choosing Azure enables us to access everything in the Azure cloud, including Azure Data Factory and Azure Synapse Analytics.”
Amar Shah confirms, “Microsoft is helping us to ensure we have best-in-class architecture for our data that is resilient and secure.”
Getting the data architecture right will free the time of the analytics experts
The new data architecture will be a massive change for the Trust.
“There are many practical benefits to having an integrated data model,” explains Thomas Nicholas, Associate Director for Business Intelligence at ELFT. “First, frontline staff don’t have to ask the patient same question across the different systems. But, also, they can access the richness of data wherever it has been recorded. Even basic data will be improved: everyone will have the most up-to-date contact details, for example.”
As well as enabling staff to engage with analytics they’ve not had before, it will also bring huge change to the Trusts teams of analytics specialists. Each of the systems used around the Trust had its own team of analytics specialists running reports.“Our analytics teams spent a lot of time on how to code and develop to pull out the information. Only about 10 percent of their time was spent on analytics,” explains Mohammad Forid Alom. “We’re shifting now to focus more on what the data is telling us and visualising it in a meaningful way to our staff.”
“The new, modern data architecture is really exciting,” agrees Thomas Nicholas. “Our whole group of analysts can get the right data at a touch of a button. It enables the analysts to actually start doing the job they really want to do. Rather than tapping someone on the shoulder and saying which table do I find this in and why is it called this, we can start to look at the statistics, do the trend analysis and feed the stories back to our clinical colleagues.”
Improving the way the IT and analytics teams operate
The Power BI work has aided the analytics and technical teams, says Adnan Khan, Head of Business Intelligence (Visual Analytics): “We get a lot of requests from different departments for data. Through Power BI we have reduced that request log, because people can get the data from Power BI.”
The work with Microsoft Azure offers additional benefits. “The huge benefit of moving into the Azure cloud is the ability it gives us to spin up environments,” confirms Thomas Nicholas. “It enhances the way we work as a team, whether we are in development, testing or production phase.”
“Our choice of Microsoft Azure supports our move to a DevOps way of working,” agrees Adnan Khan. “As well as benefitting from Microsoft Azure’s scalability and availability, we can deliver work faster, have more flexibility, better resource utilisation, automate routine tasks, and gain visibility of work across projects.”
These streamlined development workflows will be important for the Trust to deliver on its big data strategy ambitions.
“Eventually, every service will have an app,” states Mohammad Forid Alom. “Before we build any analytics, we undertake a whole stakeholder engagement to understand what measures are important. It’s really shifted to what analytics means to the Trust’s strategy, teams and frontline workers. It’s no longer just analytics centred on commissioner’s requirements.”
The team has already delivered an Early Warning System for the inpatient mental health teams. This onepage matrix underpinned by 50 charts enables service managers to see where the service is experiencing pressure. Now, says Mohammad Forid Alom, “staff can quickly see where they need to focus attention”.
Another innovative solution is an app to look at data over time using Statistical Process Control (SPC). This app is now available for other Trusts and NHS organisations to use via the Microsoft Store. “With EasySPC, other Trusts can bypass some of the challenges we faced when starting our journey,” says Mohammad Forid Alom.
Amar Shah adds, “It’s just one example of how we’ve been able to develop solutions using Microsoft products that will hopefully add value to the whole healthcare community.”
In recognition of this potential, the Trust’s Informatics team recently won the Royal Statistical Society’s Florence Nightingale Excellence in Analytics 2022 award for its work with Power BI. “The award is a great motivator to the team that we are moving in right direction,” says Aravinth Pandian.
Partnering with Cloud2, a BCN Group Company
Choosing to commit to the Microsoft ecosystem has had some unexpected benefits for the team. As well as the ease with which the team can share their innovations with other healthcare organisations, this has especially been felt in the ease of finding accredited partners with which to work.
“At the backend, we’ve really benefitted from Microsoft’s support and infrastructure,” says Amar Shah. “At the frontend, to make data accessible and usable in real time, we’ve also benefitted from Microsoft’s solutions and expertise. For both, we’ve benefited from their Partner ecosystem.”
The Trust has worked closely with Microsoft Gold Partner Cloud2, A BCN Group Company, to deliver much of its data strategy work, including the development of the EasySPC app. “Cloud2 has been critical: we wouldn’t have been able to do this without them,” says Amar Shah. “Because of the scale of the challenge, we knew we needed some external support. We looked for a partner that would bring technical expertise but would also be committed to knowledge transfer. And we’ve been delighted with the working relationship with Cloud2. As a Gold Partner, they are people with genuine expertise. But they have also helped us to develop our own internal team so we can do more of the work ourselves over time. They’ve helped us to develop some innovative new products that we’ve now made available to other Microsoft customers.”
How can a healthcare organisation address the technology skills gap?
Another unexpected benefit stemming from the team’s choice of Microsoft solutions has been felt in the recruitment and development of talent.
For Amar Shah, one of the key learnings for other Trusts thinking about embarking on this kind of data strategy is “the need to focus on building internal expertise and to create a development pathway internally with really clear roles.”
“Microsoft provides opportunities to utilise their training. We helped our internal team to become cloud architects by taking advantage of Microsoft’s Enterprise Skills Initiative programme,” reports Aravinth Pandian. “Our solutions architects are now Microsoft certified.”
“Microsoft has some wonderful programmes to help us,” agrees Amar Shah. “We are ensuring all our staff are Microsoft accredited and have a clear development pathway.”
“Choosing Microsoft makes sense from a resourcing point of view,” adds Aravinth Pandian. “With other solutions, it is hard for us to recruit the necessary technical expertise. In NHS, we can’t compete on price. But, as well as developing skills internally, we can find more good quality resources to recruit with a Microsoft skillset.”
Insight-driven curiosity can continue to transform the patient journey for the better
The breadth of information available in the new, integrated data model will support the Trust’s work to ensure equitable outcomes and experience across the region.
“One element of our improvement project looks at the use of restraint on BAME patients,” says Mohammad Forid Alom. “That data used to be collected manually from different systems. The integrated record will make that much easier. It will also make it easier to respond to FOIs.”
Amar Shah says, “As we progress on our journey, it has created a hunger for more data.” “It’s brilliant to hear that our work is really starting to have an impact on patient care – that’s where we really want to be,” agrees Aravinth Pandian. “Our feedback mechanisms are helping us to identify other
areas we want to develop.”
“Our gold value vision is to show the patient journey across the trust in all the different avenues and pathways and then get that vision across to our frontline services so they can start managing the patient journey proactively,” adds Thomas Nicholas. “When we can see the holistic picture, we can start thinking collectively about analysing those journeys.”
The future of the Trust’s data ambitions
“Understanding what best practice is this field isn’t always easy in terms of data architecture or data analysis in healthcare,” admits Amar Shah. “Microsoft has been really great in terms of helping us understand what best practice looks like and helping us find and work with our partners.”
“Having a partner has helped us think and learn along the way,” he continues, “I’d certainly recommend Microsoft to other Trusts. It’s also important to think about that transition in who we serve as a customer. Healthcare has a history of business intelligence serving our commissioners, rather than our own internal stakeholders.”
“Eventually, we will be able to use data to predict operational demands to proactively plan the delivery of patient care,” says Aravinth Pandian. “And we’ll add greater richness to the content we deliver by bringing in HR and finance data to provide a complete view of the service.”
“We’re already working on projects around risk assessment and staffing that users want us to investigate,” confirms Adnan Khan. “We want to move to Azure Machine Learning to do predictive analytics and diagnostic analytics. People in our teams have already done some work on this and are leveraging Microsoft resources to learn the technologies so we can move in that direction.”
“We still have a lot to do. We want to create an inhouse team with enough expertise to be able to guide our data journey,” concludes Amar Shah. “We’re now looking at integrating additional data sources from outside the organisation. A lot of our teams need to see ambulance data or social care data. That’s the future for us.”
“We want our clinicians to be curious. The data gives us clues. They can use that to ask the questions and to guide their exploration about what they can be doing differently in their service to really make a difference for patients.”