Improving Population Health for Children with Diabetes

糖尿病是发达国家儿童最常见的慢性疾病之一。Texas Children’s Hospital in Houston is the nation’s largest pediatric hospital and ranked as one of the top four Best Children’s Hospitals byU.S. News & World Report. Hospital leaders wanted to take a more data-driven approach to population health management for patients with diabetes. They started by pursuing outcomes improvements related to diabetic ketoacidosis (DKA) since data from the EDW revealed that 64 percent of diabetes patients discharged had this life-threatening condition and there was measurable variation in costs and care for patients with DKA.

为了减少变异，他们组成了一个糖尿病护理过程小组(CPT)。在CPT实现了改善DKA患者住院治疗的最初目标后，他们开始实施更大的改善，使所有糖尿病患者受益。

By empowering CPT members, leveraging data to drive decisions, and implementing new interventions effectively, the Diabetes CPT members have improved population health for patients with diabetes across all settings of care.

THE CHRONIC ILLNESS THREATENING AMERICA’S NEXT GENERATION

In 2012, 29.1 million Americans, or 9.3 percent of the population had diabetes. What’s even more troubling is that more than 200,000 of these Americans are under the age of 20.¹Diabetes is the most common life-threatening, chronic illness for children living in developed countries.²Texas Children’s Hospital is a leader in the research and treatment of children with diabetes. The organization evaluates more than 2,500 cases annually with the goal of helping children, adolescents, and young adults to manage their illness effectively—and live long, healthy, and active lives.

CHILDREN WITH DIABETES: REDUCING VARIATION IN COSTS AND CARE

Leaders at Texas Children’s wanted to take a data-driven approach to improving care for diabetes patients. However, they quickly recognized that EHR data alone would not be enough to inform their efforts. To access more clinical, financial, and operational data in real-time, Texas Children’s implemented the Health Catalyst Analytics Platform built using the Late-Binding™ Data Warehouse architecture (EDW). With this robust data now at their fingertips, the team used the Key Process Analysis application to determine that there was a measurable degree of unnecessary variability in care and costs associated with these patients, including increased length of stay (LOS) and readmissions.

LEVERAGING TEAMS, TECHNOLOGY, AND DATA TO IMPROVE CARE

Leaders at Texas Children’s wanted to take action to improve outcomes for patients with DKA, as well as the broader population of patients with diabetes. The improvement strategy encompassed four key initiatives:

• 建立糖尿病CPT。
• 授权团队持续推动改进。
• Taking a balanced scorecard approach to setting and achieving goals.
• Ensuring adoption of data-driven interventions.

Establishing the Diabetes CPT

德州儿童基金会的领导人们决定成立一个糖尿病CPT。cpt通常是为有大量患者、高程度的护理差异、一致性和质量上可测量的差距，以及重要的是，组织准备采取改进措施的护理过程而建立的。然而，组建团队只是第一步。糖尿病CPT仍然需要有经验的领导，在使用技术和临床标准促进数据驱动的过程改进方面有可靠的跟踪记录。儿科、儿科内分泌与代谢学助理教授Rona Sonabend博士和德州儿童学院助理主任Rhonda Wolfe RN、BSN、MBA是领导该团队的最强候选人。

Dr. Sonabend and Rhonda Wolfe, agreed to co-lead the diabetes CPTs, and understood that their teams would first solve the initial problems identified, and would then need to take on other challenges, continuing to improve care for patients with diabetes. The DKA improvement was a natural starting place but the teams wanted to ensure that the Diabetes CPT could expand their improvement efforts for the entire population of patients with diabetes, not just those admitted to the hospital for DKA. Understanding that the team desired to continue to grow and improve, the Diabetes CPT began its work—and within 1.5 years, opened a new Diabetic Care Unit for inpatients with DKA. Ultimately, the Diabetes CPT achieved every goal that had been identified—successfully decreasing length of stay, reducing variability, improving hospital throughput, and decreasing the readmission rate, all while improving patient satisfaction. The team’s early success in its DKA initiative served as the model for future improvements in care delivery for all diabetes patients.

To continue the forward momentum from the work on DKA, the Diabetes CPT identified core areas of focus to improve the care and outcomes for the diabetic patient population. In turn, this culminated in a comprehensive strategy for improvement, and five new CPTs designed to be co-led by a medical lead and an operational lead (see Figure 1) which report up through the Diabetes CPT.

• High Risk Care Process Team
• Education Care Process Team
• Inpatient Care Process Team
• Clinic Care Process Team
• Community Care Process Team

The new teams were designed to improve population health, reaching the entire population of patients with diabetes, including care providers in all settings. The interdisciplinary teams include everyone involved in patient care from parents and patients to those inside the hospital like physicians, nurses, and ancillary staff, and to those supporting patients outside of the hospital like school nurses and community based providers.

Empowering teams to consistently drive improvement

To be successful, the additional CPTs need to have strong leaders whose professional and personal passions are tightly aligned with the teams’ goals. That larger sense of purpose helps physicians and operational leaders to navigate the challenges of achieving and sustaining improvements. CPT leaders receive ongoing, in-depth training and development to ensure that they have the knowledge and skills to effectively implement quality improvement activities. Physicians who are new to quality improvement are also mentored by more experienced physicians.

CPT领导也为改进团队的工作做出贡献。团队领导不仅要主持会议和委派任务，还要参与数据验证等任务，同时仍要履行他们的临床和运营职责。团队内部没有等级制度。所有成员贡献他们的想法，分享他们的专业知识，并有平等的代表性，使他们充分参与和投资于改善结果。同样地，所有的团队成员都会定期提供反馈，要么赞赏他人的贡献，要么发现需要改进的地方。

The five Diabetes CPTs meet independently every two weeks. During these meetings, the teams develop and refine their outcomes goals, generate ideas for Plan-Do-Study-Act (PDSA) cycles, and evaluate the effectiveness of their work. Every six weeks, the co-leads of the Diabetes CPTs meet to present their work, clarify questions, and align on goals. These conversations are critical to finding linkages with other teams and gaining consensus on proposed improvement plans. Team leaders not only celebrate each other’s big wins but also provide corrective feedback when necessary. This regular cadence of cross-team meetings fosters relationships and collaboration, helps to prioritize resources, and maximizes team efforts to benefit patients.

Taking a balanced scorecard approach to setting and achieving goals

Texas Children’s uses a Modified Delphi process for the development of balanced score cards for each department that are aligned with the Institute of Medicine domains of healthcare quality (see Figure 2).

每个糖尿病CPT负责建立与平衡计分卡相一致的可测量的改进目标。每个团队都有一个具体的工作计划来支持这些目标和整体任务。团队使用来自EDW的数据来评估当前的表现并探索改进的机会。通过关注数据，并知道它是唯一的真相来源，团队能够将他们的讨论集中在数据告诉他们关于他们的表现的什么。在确定改进的机会之后，团队成员确定他们的优先级，并专注于可操作的活动。如果所提议的更改是必要的，但几个月都无法完成，团队成员就会将项目搁置，并选择一些他们现在可以继续进行的事情。

To facilitate data-driven outcomes improvement, each team develops improvement goals that include the specific outcome goal (aim), balance measures, and timeframe for when the goal is expected to be achieved. The teams review national performance benchmarks while establishing goals, allowing them to evaluate how Texas Children’s performance compares to children’s hospitals across the country. Often, the team members discover that the organization’s performance is already higher than the benchmark. However, they also understand that the benchmark performance may not be adequate and frequently set goals that exceed national benchmarks. The CPT has the advantage of having a diabetes specific analytics application which is built on the EDW and capable of integrating information from multiple data sources. By integrating improvement goals into the Pediatric Diabetes Application, teams can quickly visualize and monitor progress towards these goals at every meeting.

每个目标都必须有一个积极的PDSA改进计划和明确的干预措施。该团队致力于实现预期的改善，并重点关注将改善患者结果的活动。儿科糖尿病应用程序也对PDSA活动进行了跟踪，以便cpt可以评估其干预措施与目标之间的有效性(参见图3)。在一个应用程序中跟踪结果目标和相关的PDSA活动，有助于团队了解哪些干预措施是有效的，应该继续，以及哪些干预措施没有产生结果，因此应该停止。

Most importantly, team members know that their work doesn’t stop once they achieve an outcome goal. They continue to monitor performance in the application to ensure that improvements are sustained. If performance slips, the team investigates why and then develops corrective action plans.

Ensuring adoption of data-driven interventions

有效地实施变更并确保持续采用是成功的质量改进工作的关键组成部分。这就是为什么一旦数据表明所建议的干预措施是有效的并能改善患者的预后，CPT成员就会立即付诸实施。他们将计划中的变更与关键的涉众进行沟通，同时提供支持变更的数据，以及团队及时采用变更的期望。这种对数据驱动行动的承诺——识别和实施改进机会——提高了改进的速度和规模。

团队成员也明白，虽然每个人都想改善患者的结果，但改变可能是困难的。因此，寻找每一个机会来利用技术和自动化来减少终端用户的负担是至关重要的。他们设计工作流程是为了减少(如果不是全部消除)不遵循新建立的流程的可能性。将已证明的基于标准的护理、决策支持、自动警报和结构化的顺序集与现有的工作流程相结合，使临床医生更容易做正确的事情。作为持续改进过程的一部分，团队监测工具的使用情况以及干预措施的每个组成部分对结果的影响。如果工作流程中的一个步骤或一个工具没有带来改进，他们会重新评估选项，并可能停止使用该工具。

RESULTS

糖尿病cpt在多个护理地点的所有护理环境中改善了糖尿病患者的人口健康，并成功地维持了这些改善。下面是一些最重要的结果，并链接到每个单独的CPT案例研究以获得更详细的信息。2022年世界杯预赛分组

• 44 percent relative decrease in LOS for patients with DKA.
• 30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
• 34.4 percent relative improvement in the percentage of patients with diabetes who receive the influenza vaccine.
• More than 90 percent of patients receive the annual preventative screening recommended by the American Diabetes Association for thyroid stimulating hormone, lipids, and retinal exams, and more than 80 percent receive recommended microalbumin testing.
• Implementation of a standard diabetes education curriculum for patients and families.

“我们的病人已经得到了比五到十年前更好的治疗。我们也知道，五到十年后，医疗保健会有所不同，会更好。最重要的是，我们不再等待别人来为我们做这些改进工作。我们非常勤奋，专注于从组织内部改善患者护理。”

– Rona Sonabend, MD
Assistant Professor of Pediatrics
Pediatric Endocrinology & Metabolism
Baylor College of Medicine

WHAT’S NEXT

Dr. Sonabend and the Diabetes CPT members are confident that their data-driven quality improvement efforts have positively impacted outcomes for the entire population of diabetes patients. They are equally confident that outcomes will continue to improve because of their effective implementation of interventions and diligent monitoring of metrics on an ongoing basis. Having already achieved such impressive results, Dr. Sonabend and her teams have even bigger goals for the future, aspiring to transform the current model for care delivery and reimbursement system for chronic disease care. They believe that their demonstrated model for quality improvement should be used by others to enhance and improve care, and that these improvements should be financially-incentivized.

REFERENCES

1. 美国糖尿病协会。(2015)。Statistics about diabetes.
2. Kushner, J. (2015).Diabetes 101: Commonly asked questions. Texas Children’s Blog.

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