Quality Improvement in Children's Diabetes Services

Our National Diabetes Quality Improvement Collaborative supports multidisciplinary teams over a nine-month training programme to use the tools to identify, design and analyse their own interventions specific to the needs of the children and young people and their families that they care for.

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This site has been produced for those who are working within services who are part of the National Diabetes Quality Programme. If you would like access, then please contact diabetes.quality@rcpch.ac.uk


Featured project – July 2021 – Chesterfield Paediatric Diabetes Team

Article available here.

Featured project –

Tools to Improve Pump Skills (TIPS) – Chesterfield Paediatric Diabetes Team

 Our team’s purpose is as follows –

‘To compassionately educate, support and empower patients to optimally manage their diabetes considering their emotional wellbeing enabling the young person to fulfil the life they want to lead’.

How we developed our project

This idea came about as we have around 50% of our patients on pumps, however our NPDA data showed that there was not really any difference at all in HBA1C comparing the pump and the PEN patients. This is despite robust education at start up on pump therapy and all the additional technology that is involved in being on a pump. We felt the need to address this and provide more ongoing education.

The initial idea was to provide some group sessions, but we’ve traditionally had problems with attendance in previous groups that we’ve run. Further to this, the pandemic came along, so we decided to some up with some micros education sessions to incorporate in clinic, where we had a captive audience.

We called our intervention ‘Tools to Improve Pumps Skills’ (TIPS).

Our Driver diagram (above). Our goal is to improve HBA1C for young people using insulin pumps, by using micro education.

We used process mapping to look at clinic flow and see how we could incorporate micro education within clinic with minimal impact on clinic time.

We also ran a fishbone analysis (diagram below) to identify what was needed, and to consider things from all angles. This made us think about what to cover in our micro-education topics, such as what equipment was needed, our processes (what would go on within the clinic), the roles of different staff members and very importantly our measurement.

We employed some survey software to establish the baseline levels of skills and needs in our patients. We thought about how we would get some instant feedback in clinic and used ‘Pringle boxes’ as a simple way of collecting feedback. For example – asking people to put a counter at the end of the clinic, as to whether their experience was positive or negative and whether they felt they had learned anything. In addition, we tracked the numbers of patients downloading monthly.

We developed a consolidation sheet as we went along to assess learning from the previous topic. That was something that wasn’t actually in our original fishbone analysis, but it came about as the process went. We are also measuring HbA1c at intervals aiming for 6 months, 12 months, 15 and 18 months.

Our journey so far

Inevitably, we hit some barriers and one of the main ones was patients initially were not all reading the tips sheet in the waiting room or completing the questions to bring into their clinic room.

Some of the solutions we came up with were as follows:

  • Firstly, reminding reception staff to prompt people to look at the Tips sheets
  • Secondly, we put a slip on top of the education TIPS leaflet to ask patients to fill in while they were waiting.
  • Thirdly, we asked the admin staff if they would email their tip sheet to that question before clinic where possible.

Our interventions and PDSA cycles

We developed 6 micro-education topics for our clinics. These each lasted a 3-month period and include

1) Downloading – which we have completed

2) Reviewing basil rates – in process

3) Temporary basil rates

4) Blood glucose patterns and carb ratio adjustments

5) Extended boluses and glycaemic index

The idea of a consolidation slip to review previous topics arose as we were doing the process and is the result of our Plan, Do, Study, Act (PDSA) cycles, which we completed in out fortnightly team meetings.

Another adjustment we made following another PDSA cycle was an adjustment to our Pringle Box feedback system. This had previously included asking all patients whether they felt they had learned anything in clinic, however we wished to focus this feedback more on the pump patients. This gave us more specific feedback.

A further idea from the PDSA process is that we realised that some pump patients cannot download at home, so we came up with the idea of providing a drop-in session for patients to come into the hospital and download. Although we have not managed to start this yet, we are keen to do so.

Bright spots

  • We feel we have a shared objective to improve patient experience and outcomes. Hopefully patients know we have their best interests at heart!
  • We have an increased amount of team time because we’ve had to make time for extra meetings and that’s been a positive aspect of this project
  • The clinic flow process seems slicker. It is felt that team members are bringing education into all appointments and this has not only been for the pump patients. The unexpected bonus is that the education delivered and over-spilt into our Pen patients, where there has been an increase in discussions about downloading their meters.

Feedback from patients and families

Our feedback was overwhelmingly positive, with some stating that it was helpful to review knowledge even of they were already familiar with the subject matter.

Our instant anonymous feedback from clinic showed the following –

– Pump patients – 95% response rate. 87% said they learned something in clinic. 13% did not (9 March – 11 May N=38)

– All patients (pen and pump) – 91% had a positive experience in clinic. 9% had a negative experience (12 Jan – 11 May 2021 N=160).

Outcomes so far

  • HBa1c data at 3 months – was 62 mmol/mol, now 59.5 mmol/mol.
  • Numbers of who can now download at home – was 51%, now 77%
  • Monthly downloading at home – was 28%, now 60%

Continuing our journey…

We are continuing to roll-out our 18-month programme and measuring our data. We will be implementing a downloading station drop-in for those who cannot download at home.

We would like to disseminate our micro-education pathway to our network and young adult clinic.

Overall, we aim to continue to improve the service we provide and to empower patients to optimally manage their diabetes. We are very grateful for the opportunity to engage in this process!


Monthly video – Maintaining motivation

Are we nearly there yet!…

This video is made for QI Champions and leaders and offers some useful advice on maintaining motivation for your improvement work during challenging times.

References

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