QI Blog: February 2021

I am extremely fortunate to work with a large team of remarkably dedicated individuals, with a variety of skills and expertise that is not defined by their job title. We are jointly responsible for the care of 250 patients with diabetes. As a group we took up the opportunity for QI training in 2017 and found it has permanently shaped our approach and therefore success in service development, even when we have been unable to maintain pace due to other barriers. In fact, the practice of QI is something we have been able to fall back on during the significant difficulties of the pandemic in 2020, and beyond.

My top tips for embedding QI into your service:

1. Develop a mission statement that is broad enough to cover the ethos and aims of your practice but specific and smart in its objectives.
2. Divide your service into the key areas and root causes that contribute to the success and failure of achieving this overall aim (fishbone analysis). This takes considerable time and good communication to do effectively, and helps educate the whole team in areas of the service that they are less familiar with.
3. With your mission statement in mind, and use of fishbone analysis, find a method to decide on one or two areas of improvement, involving the entire team in the decision making and conclusion. In order to do this well, understand the personalities in your team, how they function within a group setting, and how that might differ when having a private conversation. Consider the period and space required for everyone to be brave enough to discuss or declare their views. You may need to allow time away from a meeting to gather opinions, or may be able to gain consensus immediately, with a voting system, depending on the complexity or implications of what is at stake. Even if confident to use an immediate decision steering method such as visual voting, you can still allow people space to do this freely and without coercion or influence. In our present and future virtual environment, team decision making will need even more careful thought.
4. Make sure that QI remains on the agenda of team meetings, even if it is not realistic to pursue or discuss on a weekly basis. Dates for progress on projects should be owned and set by the individuals responsible for actions, rather than imposed. If the right environment is created, these deadline dates should also serve as trigger points for an individual to comfortably discuss difficulties in completion, and whether it is simply more time that is needed, or assistance of another kind.
5. Be prepared to test things out on a very small scale, and steer away from the mindset of huge amounts of data being required to prove benefit. This is a culture shift away from our upbringing of evidence-based medicine and academic research holding ultimate validity. QI is a much more pragmatic approach to trying out an educated hunch. A survey of patient feedback or data collected over a couple of clinics is enough backing to know whether your improvement is worth pursuing, needs adjusting, or perhaps binning entirely, even if that small amount of data proves nothing statistically or of a permanent nature.
6. Be brave and open-minded enough to both try something new and fail fast. An idea may have been tried in the past and shown to be of no benefit, but put bias aside and consider whether the result may be different in a new climate or environment, or with a different approach.
7. Revisit past achievements of the team periodically and celebrate them, reminding each other of every modest success when a boost is needed. If we don’t have a positive outlook, lots of small gains can be forgotten and outweighed in the midst of one moderate perceived failure. We have jointly seen the value of this approach in the pandemic (clap for the carers), and individually we do it subconsciously to keep us going through difficult times (what am I grateful for today?).

Our mission statement is “to improve outcomes for the children and young people in Southern Derbyshire, as measured by a cohort median HbA1c of 58mmol/mol or less by April 2021, by enhancing self-management skills to encourage patients to be proactive experts in their own care using all available technology, in order to live well with diabetes”.

By 2020, although we had exceeded the measurable and numerical part of our aim, in the context of the pandemic, our statement has not changed for the time being, as the emphasis now will be on the support of self-management skills.

Our initial QI project in 2017-18 was to enable all patients to download, and share their blood glucose data remotely with the MDT, by a platform called Diasend, and to facilitate this in schools for those with no means of IT access at home or via extended family. We had already been encouraging families to use this software for some time, but with limited success for many patients. The QI analysis and planning that we jointly undertook as a team crystallised that we should try a more proactive approach.

Paediatric Diabetes Specialist Nurse time was prioritised over other activity and invested and protected within the clinic environment solely for setting up accounts as a one-stop shop. This approach proved so successful that the development of a new remote nurse led Diasend clinic rapidly followed, to support self-management in between quarterly appointments. This started on a small scale, then expanded to patient demand into a 2 hour provision, 6 days a week.

When we abruptly moved to telephone appointments in Lockdown 1.0, the sharing of information between patients and healthcare team, and remote analysis of data to steer insulin adjustment, was already embedded in our routine practice. The quality improvement work had been through a number of ‘plan, do, study, act’ (PDSA) cycles, to create proformas to record doses and insulin adjustments in a consistent manner for all practitioners and families alike, minimising potential errors in communication by telephone or email.

Another QI project had been to use a personalised diabetes team smartphone app for patients, their families and other carers (extended family and school) and to populate this with information about care, resources on diabetes management, emergency top tips, and signposting to other services. Once again, we found this provision needed active promotion in 2020, to encourage its use widely for greatest benefit. It has served as an immediate vehicle to inform families of changes to services in Lockdown 2.0 and 3.0, and to answer frequently asked questions on shielding, self-isolation, and risks of COVID-19 with diabetes. Our section on emotional well-being may turn out to be one of the most important.

Quality Improvement may be popular terminology, but it is nothing new for us as individuals and for the organisations we work in. However, taking some time to learn formal techniques as a team, devising an approach and setting aside the time to do it, provides a structure for efficiency and accomplishment, and one which encourages wider participation and engagement.

Thank you to Derbyshire Children’s Paediatric Diabetes Team for working passionately to common purpose, and sharing a vision.

Dr Dita Aswani, Consultant Paediatrician and Lead for Paediatric Diabetes at Derbyshire Children’s Hospital

Read Dr Aswani’s article about QI and her team’s journey in the Spring 2021 edition of RCPCH Milestones here.