LOOP Blog

I had always been a sick child. I can remember constantly calling my parents from the nurse’s office. While sitting in the nurse’s office I found myself wondering what was wrong with me, and why everyone in the school office knew me by my first name. I was that kid.

Perianal disease is an important complication of Crohn’s disease in children. In May at Digestive Diseases Week 2015, a meeting of nearly 15,000 gastroenterologists from around the world, Dr. Jeremy Adler (@jeremyadlermd) presented research investigating instances of perianal disease (perianal fistulas, fissures and other perianal lesions) in pediatric Crohn’s disease, using data from the ImproveCareNow pediatric IBD registry (known as “ICN2”).

Using data from ICN2, Adler’s research team identified racial and regional differences in the development of perianal disease across multiple centers in the ImproveCareNow Network. Their research has shed light on when perianal disease most commonly occurs (early in pediatric Crohn’s disease) and suggests that early therapy should be aimed at fistula prevention. They concluded that the ICN2 registry is a valuable tool for population-based studies (like this one, which included data from many patients with IBD, across many different geographic areas), and suggest that more studies like this one be conducted to identify and evaluate preventative therapies for complications of Inflammatory Bowel Disease (like perianal disease).

This novel pediatric IBD research highlights the power of data, carefully collected and curated over time, to answer questions about complex conditions such as Crohn’s disease and ulcerative colitis and to shine light on ways we can work to improve the care and the health of patients in the near term.

ICN2 is the largest and fastest growing pediatric IBD registry in the world, with data from over 19,000 patients with IBD and 115,000 visits as of May 2015. The ImproveCareNow Network currently includes 75 participating pediatric IBD centers in 34 states and the District of Columbia and two in England, with nearly 45% of Crohn’s disease and ulcerative colitis patients cared for by US pediatric gastroenterologists. The purpose of ImproveCareNow is to transform the health, care and costs for all children and adolescents with Crohn’s disease and ulcerative colitis by building a sustainable collaborative chronic care network, enabling patients, families, clinicians and researchers to work together in a learning health care system to accelerate innovation, discovery and the application of new knowledge. Data in the ImproveCareNow registry is used for improvement, research and innovation.

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Editor's note: The ImproveCareNow registry (ICN2) has grown dramatically over the past several years, and now, from the research standpoint, we are beginning to see the fruits of that labor. Jeremy Adler and colleagues have used the registry to carefully describe a specific phenotype of pediatric Crohn's disease across the network. We are only beginning to scratch the surface in utilizing not only the registry, but also the rich community network upon which ImproveCareNow is built. More and different types of research efforts are coming, and hopefully, the number of studies will continue to grow as quickly as the number of centers and patients have grown within the network.

Outgoing Patient Advisory Council (PAC) Co-Chairs - Jennie David and Sami Kennedy, who co-wrote "What We Wish Our Parents Knew" - have announced their successors! Alex Jofriet, who is committed to turning his Crohn's diagnosis into a light for others to follow and Bianca Siedlaczek, who is excited to continue her patient advocacy career with ImproveCareNow. Keep reading for personal introductions from the new PAC co-chairs!

Meet Alex Jofriet!

Hi, my name is Alex. I was diagnosed with Crohn’s Disease at age nine. It took many years, about eight after diagnosis, for me to find remission. At diagnosis, I was one of those shy, studious kids who sat in the classroom, mostly invisible to my peers and I liked that. My diagnosis of Crohn’s Disease threatened that invisibility and it took me about five years to accept my disease and open up about what I was going through.

Now, looking back, that seems like long forgotten history as I have gone from wanting to be invisible to being involved in many advocacy endeavors. My involvement in advocacy led me to ImproveCareNow (ICN), which I have been involved in for the past 4 years. What has kept me involved with ICN is their focus on the whole IBD patient. As co-chair, I hope to add to this "whole patient" focus by increasing the amount of peer support for patients in the network through a universal mentoring system. I am appreciative of all ICN has done and continues to do and am super excited to get started!

Meet Bianca Siedlaczek!

Hi, my name is Bianca! I was diagnosed with Crohn's Disease about 7 years ago, when I was 9 years old. In the past 7 years, I have been through many hospitalizations, many flares, one surgery, one year of remission, and much more. Every one of my experiences with Crohn’s Disease, through the years, has facilitated the growth of my passion for being a patient advocate. Over the past year and a half, ImproveCareNow has given me the chance to fulfill my passion for being an advocate. From the beginning, when I came to my first Learning Session with my center in Michigan, I  loved what ICN was doing to improve patient care and how the network went about doing so.

I look forward to transitioning from being a patient scholar to becoming one of the Patient Advisory Council’s Co-chairs. I am beyond excited to take this next step in my “advocacy career.” I cannot wait to continue working alongside the many centers involved with ICN and ICN’s staff. To say the least I am very excited to get started!

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The Patient Advisory Council (PAC) brings together patient advocates in ImproveCareNow as partners to create a network for pediatric IBD patient engagement. They create, co-create, and advise the creation of innovations to facilitate improvement in pediatric IBD care and quality of life for children and young adults living with IBD. The PAC welcomes passionate young adult patients (14 years and older) to join. To learn more or join please email [email protected]

There is an articulate and thoughtful patient engagement leader from the UK who I follow on twitter named David Gilbert. Like me, you may enjoy reading some of his reflections on the key role of patient leaders in improving care and health systems and think about the lessons for your own work in integrating patient and parent partners into your improvement teams. In ImproveCareNow, we share a lot of writing and reflections from those working as IBD advocates and improvers, but I personally learn a lot from the perspective of those working on very different issues (though it’s amazing how much improving care for IBD actually does have in common with improving care for other chronic conditions like mental illness and even patient safety issues!). David shared a quote that made me think about the recent growth of patient partnership we’ve seen right here on this side of the pond in ImproveCareNow:

“Knowing trees, I understand the meaning of patience. Knowing grass, I can appreciate persistence.”  (Hal Borland)

I recently wrote about early lessons learned in the ImproveCareNow Engagement and Leadership Campaign. We were feeling our way, helping a small group of centers figure out what it meant to grow their teams by including more parent and patient partners in planning, carrying out, and evaluating the impact of improvement and awareness activities. While only three months have passed, so much has happened. The ImproveCareNow Community met in March at our Community Conference and we enjoyed watching clinicians, parents, patients, and others work together to share and improve upon ideas for helping more kids with IBD get into remission and stay there.

But the other thing that has happened in this short time is that watching engagement and partnership grow in ICN has become a bit less like patiently watching trees and a bit more like marveling at the persistence of grass. I sat down last week to review ImproveCareNow centers’ monthly narrative reports (in which they share their activities, barriers, and lessons learned), as well as recent activity on social media. I was thrilled to see concrete steps toward partnership taking place at a number of centers that had not yet begun this journey just a few months ago. Here are just a few snippets of what we are seeing emerge:

From ICN Centers’ narrative reports:

“We have sought and received very positive feedback from our parent who attended the meeting and will begin working with her to plan how we can involve her more actively and engage other families.”

“We are meeting with a hospital rep on Friday to work on formalizing a parent group!”

“We had our first meeting with our parent partner!” 

“We had a meeting in April with our parent and will conduct monthly meetings with her.”

On our ICN Exchange

On Twitter

There is indeed still so much work to do. There are more than 70 care centers in ImproveCareNow and many are still contemplating how best to launch and navigate these new types of partnerships with patients and families. But what I find encouraging is that the stories of progress that are emerging are not concentrated in one type of ImproveCareNow center or in one Learning Lab or in the centers that are known for being quicker to adapt to change. And they are not all stories of one type of engagement…building a mentoring program with patients or inviting a parent to join a QI meeting or having parents complete a survey about areas for improvement. Centers, with their patients, are trying to identify their own specific needs and assets and craft partnership opportunities that build upon them. They realize that not every partner—and not every clinician for that matter—is ready to engage at the same level (be it awareness, participation, contribution, or ownership as described by some of my colleagues in JAMA last year.) And they realize that that’s OK.

Partnering in these new ways can be hard. To extend the “persistence of grass” analogy, sometimes things grow too quickly and we even see weeds emerge. It takes work to get through those patches and get back to things growing the way they should. Patient partners may not feel heard right away—may not feel like full partners. Clinicians may feel worried about sharing their clinic’s opportunities for improvement and may even feel that their expertise—their ideas—carry less weight. As someone who helps the different stakeholders in this system work together, I am the first to admit that it is not always easy and can indeed be scary: We step on toes. We use the wrong words. We don’t always give everyone equal “airtime.”  But it’s particularly encouraging to see members of this community openly discussing these concerns and barriers and helping each other come up with ideas for surmounting them.

Three months from now I fully expect we will have more progress to share and will continue to see the fruits of our patience over the years as we have watched this community grow.  I am eager to see community members share their stories on this blog and help us learn from and with them.

Did you catch the article in HuffPost Health News about a large-scale comparison between the efficacy of Mindfulness Based Cognitive Therapy (MBCT) and anti-depressants?

This area, MBCT, is a growing interest of mine and I’m hoping to attend some trainings on it. I have informal training on mindfulness and use it myself, to great benefit! Here’s what I would say to someone else…

As a graduate student in a business school, I strive to apply what I’ve learned about management science to address problems of importance to society. So needless to say, working on research projects in partnership with the C3N Project and ImproveCareNow (ICN) has been educational and enlightening. Growth of the ImproveCareNow Network has brought both exciting opportunities and new practical challenges, as Sarah Myers discussed in her recent LOOP post. In the spirit of continuous improvement, ICN leaders wanted an enhanced, evidence-based understanding of Learning Labs and other models for collaboration at different levels of scale. And I was thrilled for the opportunity to support this effort.

Many of you will recall a survey distributed last summer by ImproveCareNow. The survey presented a series of questions with two scenarios for network-based group learning, asking respondents to choose the scenario which seemed most conducive to learning and improvement. Those paired scenarios appeared to be very similar; a few respondents even wrote to tell us that the survey was defective, presenting the same question over and over again! But, in fact we were using an advanced and efficient method, the discrete choice experiment (DCE), to collect feedback on strategies for continuous learning from within the network itself. Discrete choice methods – common in marketing research as well as health economics and policy studies – use experimental design to assess the relative importance that customers/end-users place on attributes of a given product, service, or scenario. For example, a DCE for the design of new laptop computers might examine factors such as weight, battery life, memory, and price. Comparison of patient treatment options with DCE might explore tradeoffs between efficacy, cost, and invasiveness.

Our DCE for ImproveCareNow evaluated three group learning techniques: micro-communities called “Learning Labs”, quality improvement curricula, and team-to-team mentoring. As a research team, we are extremely appreciative of the 149 survey respondents representing 63 ICN care centers. We had a response rate of 65%, increasing confidence that our results accurately represented network preferences.

Overall, we observed that ImproveCareNow participants preferred mixed Learning Labs (including both novice and experienced care teams) over cohorts of teams with similar levels of experience, sequential curriculum (introduction of topics in a structured succession) rather than a simultaneous overview of QI tools and interventions, and ad hoc mentoring based on focal topics rather than an assigned, permanent mentor team. We also observed interesting variation in preferences across subgroups based on individuals’ time in the network, professional roles, and characteristics of care centers such as patient population size. I am excited to share these results in greater detail – and most importantly, to discuss what we’ve learned with the ICN community – at the upcoming network-wide webinar on Tuesday May 12 (11 ET). Please join us to weigh in!

As improvement networks scale up, it is not enough to do more of the same in a bigger way… Understanding how to adapt structures for continuous learning as networks grow and change is necessary for development of learning health care systems. Engaging network participants to share their collective wisdom is essential for improving what ImproveCareNow does, and also for targeted improvements in costs, care, and outcomes.

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published by ImproveCareNow on behalf of Shannon Provost

Shannon M. Provost, MBA, is pursuing a PhD in Information, Risk, and Operations Management in the McCombs School of Business at the University of Texas at Austin and building a program of research around innovation ecosystems, social networks, and the science of improvement. She is also an Assistant Instructor of undergraduate business statistics. Shannon is grateful for learning opportunities which have emerged through her work as a visiting researcher at the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s Hospital Medical Center and as a member of the Institute for Healthcare Improvement faculty. Personal interests include travel, fashion, literature, beagles, and attempting to play golf.

Parker is an energetic, blonde haired, little boy. Just like many boys his age in Vermont, Parker enjoys skiing, bike rides, grass-stained jeans, and his new puppy Bailey. During the summer of 2014 this perfectly healthy heart-throb of a boy was crippled with abdominal pain, fatigue, and weight loss. By the end of summer all of these horrible symptoms culminated in a diagnosis of Crohn’s disease at the blissfully innocent age of 7. As his family was coming to grips with life with a chronic incurable illness, Parker’s symptoms got worse. He was quickly admitted to the University of Vermont Medical Center and received his first dose of infusion medications to fight Crohn’s.

“I don't want this for him, there must be a mistake, Parker is my rock” his Mom, Keri remembers thinking. “As a parent you go through the motions and the emotions of a diagnosis. I think the hardest moment for me as a mom, was being strong in front of him, for him, and the family, and then breaking down when I was alone. I remember one moment, late at night in the hospital walking down the hallway of the children's floor, and I stopped. I could barely walk any further. I had to keep telling myself, one step at a time, whatever it takes to move, feeling so isolated and alone, and from that moment on, that has been my motto. One moment at a time, one day at a time, and one step at a time, to just keep moving forward.”

After three long days as an inpatient at the UVM Children’s Hospital, Parker was discharged. He almost literally rode his scooter right out of the hospital. With a huge smile painted on his face, you could almost see the shackles of illness begin to release their grip. The energetic little boy that they knew was coming back to the surface with every giggle that squeaked out of him, and they kept moving forward – one step at a time.

As the ICN Improvement Coordinator here in Vermont, I first met Parker just a few weeks after his diagnosis. He was getting an infusion and I had come to talk with his family about ImproveCareNow. Whenever I approach patients and families about ImproveCareNow, my wish is that they will see this Network as a glimmer of hope in what is most likely a very dark place, and ultimately that they will want to get more involved.

Through the icy grip of winter, Keri and Parker continued coming to the Children’s Hospital every 8 weeks for infusions. During one of these otherwise uneventful visits, Keri asked about becoming more involved with Parker’s care. Although this question is short in length and easily rolls off the tongue, I feel it is one of the most powerful questions a family can ask. That uneventful visit ultimately lead to one of the most engaging and empowering conversations and relationships that either of us had experienced in a long time. Personally, I don’t think either of us could have ever imagined what was waiting just around the corner. It wasn’t what we were expecting but was exactly what we were hoping for, and certainly something we weren’t going to say no too. This project with Keri has evolved over time and has been a huge learning experience for everyone, but we’re going to keep moving forward – together – one step at a time.

I look forward to sharing more with you as our relationship, and indeed our adventure, unfolds.

Recently I shared several characteristics of communities that I believe are a key part of what makes ImproveCareNow more than an improvement Network, but a real community. One of the characteristics is that communities are made up of smaller communities.

In ImproveCareNow there is no shortage of smaller communities. The wonderful thing about some of these is that they have developed organically. For example, if you are a physician, nurse, parent, dietitian, improvement coordinator, or social worker, you are now part of a small but vibrant community that includes others in that same role. Members of these groups help on-board and mentor each other, take on small projects that help the whole Network focus on issues related to IBD care that might be overlooked by other roles, and provide a social support system that helps make each individual’s ImproveCareNow journey just a little bit more inclusive and fun.

Many of these small communities emerged from the interest, motivation, ideas, and leadership of their members. They are now largely self-driven and are even beginning to branch out in inter-community collaborations as a result of a “project pitch” session at our Spring Community Conference. There are also groups of like-minded people who have common interests and want to take on a project together, small committees that form to address a specific issue, and groups of people working together to plan aspects of our webinars and Community Conferences.

Some of our other smaller communities have been developed by design. In ImproveCareNow we talk a lot about our “Learning Labs”, which are small groups of ICN care centers with similar characteristics like size or organizational structure. Learning Labs enable centers to work more closely together to catalyze improvement and—perhaps more importantly—maintain that “small town” feeling that is such an important ingredient in our Network.

Why did we decide it was important to create Learning Labs? Back in 2008, there were eight ICN care centers. Everyone knew one another, all were aware of the projects that other centers were working on, the volume of messages on our listerv was not overwhelming, and our monthly webinars were full of lively, uninhibited conversation. Sharing was easy and the conversations were manageable; I like to say that we didn’t need the “mute” button on our webinars.

But as we grew these conversations became harder to manage; the background noise from many clinical settings was more distracting, the volume of e-mails in which centers shared updates and ideas was becoming frustrating to our participants, and there were more faces and names to remember. As a result, ICN leadership found ourselves doing more talking and the ICN care center teams doing more listening and less teaching and responding. Literally and figuratively, the Network was getting noisy and quiet at the same time. The most concerning side-effect was that big ideas that needed to be shared were getting drowned out by the noise—from a nurse who didn’t want to speak up on a large conference call to a parent partner who had a great idea but was concerned about putting it out there for the whole Network to see. It became challenging to maintain our ability to collaborate and share seamlessly. So we decided to try breaking out into smaller groups – much like we do during our Community Conferences – to increase our capacity for active and meaningful participation.

And so the ImproveCareNow Learning Labs were born.

Today we have seven Learning Labs. Each lab is guided by an assigned quality improvement coach and meets via webinar every other month to share lessons learned from quality improvement projects, share and discuss their center-specific data and outcomes, and develop ideas for collaboration. The labs spend time working together and sharing their progress at our Community Conferences; and they review written summaries of the best quality improvement ideas and barriers taking place within their Learning Lab on a regular basis so they can identify ways to accelerate their progress as a group.

We apply quality improvement principles to everything we do in ImproveCareNow, including testing changes and observing the results to determine whether they result in an improvement. The same is true for our Learning Lab model. What have we observed about the Learning Labs so far? We have seen stronger relationships form in these groups and have seen centers that would not previously have collaborated share ideas and launch projects together. We have seen nurses, improvement coordinators, and patient and parent partners speak up and teach on Learning Lab calls in ways they were not previously comfortable doing. The Learning Labs have also helped our leadership team achieve some key community-building goals:

The Learning Labs have become a fun and meaningful part of the ImproveCareNow journey. But there is so much more to learn about their impact on our centers, our Network outcomes, and on the participant experience. And knowing this community, they will look very different two years from now than they do today!

I am hoping that readers from our ImproveCareNow centers will share their experience with being in Learning Labs in the comments section below. How have they enhanced your experience? How would you change them for the better?

I am writing this having just returned from several whirlwind days in Chicago at the first ever ImproveCareNow Community Conference. The ImproveCareNow Network has come together in person twice a year for seven years, but this was the first time this gathering was not called a Learning Session—the traditional Quality Improvement Collaborative term for in-person meetings. We changed the name for several reasons, the most important being that ImproveCareNow is now indeed a community. Here are some reasons why:

We have each of these things in ImproveCareNow and in future LOOP posts I will share examples of each. But one that I didn’t list,which became very clear to me at the conference, is that the best communities take risks together. I want to share a bit more about that here.

One of our conference goals was to brainstorm new interventions—in QI-speak, “changes to test,” - that will help us get even more kids with Crohn's disease and ulcerative colitis into remission. Prior to the conference, we developed a new list of key drivers—or focus areas—that we thought were most important to improvement. Now it was time to crowd-source the best ideas for interventions to tackle in each area. This tends to be the most fun part of the process!The ImproveCareNow Network has developed interventions together before. But this time, we wanted to make sure our incredible diversity and stakeholder engagement was really reflected in these new interventions. In the weeks leading up to the conference, each center interviewed patients and parents to get input on challenges and opportunities in each Key Driver area. In doing so, they opened themselves up to a variety of feedback; I know this felt risky to some centers.

But as a community we took the risk together. Prior to the conference, nearly all of our 254 participants chose the three Key Drivers that most interested them. Once we received their choices, we put together small groups (6-9 people) that were as diverse as possible-blending people from different centers and with most groups including at least one patient, one parent, and others from several clinical roles. Planning this felt risky even as it felt like the right thing to do. Would people want to spend almost two hours of valuable conference time in an informal exercise with people outside of their peer groups? Would lone parents and patient at the tables feel overwhelmed, ignored, or vulnerable? Would conversations stall with the minutes ticking by slowly?

It ended up being a risk well worth taking. Between 2:00 pm and 4:30 pm on Saturday the low, quiet, steady buzz of conversation eased all of my concerns about people diving in and learning with those very different from themselves. Many observers noted that as  groups tackled the provided questions, the first thing they did was turn to the parent or patient at the table—deferring to their expertise. When each of the three 40-minute discussion periods ended, we worked harder than expected to get each group to wrap up and move to their next tables. And the notes that were shared—and will guide our work in the months and years ahead—are full of some of the richest, most diverse insights I’ve seen in my quality improvement career.

We work hard to make sure all participants in this community have the quality improvement structure, skills, and tools to achieve their goals. Even more important is making sure the right centers and people connect so they can do more together than alone. We foster this online on our ICN Exchange knowledge commons, on monthly webinars, and at our Community Conferences. Admittedly, this gets a bit more challenging as we grow and we don’t always get it right. But what these collaboration sessions showed me is that community members desperately want to keep connecting across roles and centers and that they embrace the expertise of everyone at the table. They are building their own momentum and will continue to do so even as we get bigger and push our network infrastructure to keep up. So thank you to the ImproveCareNow community for taking risks together, leaving roles and titles aside, and creating a better today and tomorrow for and with kids with IBD.

Samantha Kennedy - outgoing Patient Advisory Council ("Pack") Co-Chair - is heading off to medical school in the Fall. In an inspirational message to Community Conference attendees - and indeed the whole ImproveCareNow Community - she thanks everyone for working within ImproveCareNow and for believing we can make a difference together. And she reminds us that our work (with patients specifically, and in general) may not be easy or quick or tidy, but 'it is the future, and we need to be the same sort of brave you ask patients to be as we pave that road.'

Sami's words are inspiration on-tap. Enjoy!

This is not a goodbye.

Yes, I will be a student at Cooper Medical School in the fall. Yes, Jennie and I are transitioning the Patient Advisory Council into the hands of wiser, brighter, and as it so happens, younger colleagues. Yet, this is not a goodbye. I have little doubt you will agree: once you are a part of ImproveCareNow, you are always part of ImproveCareNow. As I enter medical school, I question how I can best serve as both a patient advocate and a medical student. I know only this for certain: I cannot imagine practicing in a system without ImproveCareNow and similar networks I hope will be just as successful for other conditions. We are not only creating health for kids with inflammatory bowel diseases; this is making the whole system healthier.

By name, we are a curriculum. We are a learning health network, a network – learning – together. I think it is easy to forget what that means - that we’re all students. If I have been brought up through the education system correctly, as I hope I have as a soon-to-be-graduating senior, being a student is not about getting everything right every time. Students try. Students revise. Students experience. Students have open and engaged minds that recognize success not as a thing but as a method. We are students. We are a learning health network.

When I first started co-chairing the PAC, I really strongly believed we needed to build a model framework for the engagement of patients in a learning health network. Jennie and I took the PAC and restructured it into task forces. We are distributing leadership. We are increasing intra-PAC participation. We are concentrating our resources on developing sustainable task forces, on developing leaders. We are increasing our collaboration with your care centers throughout the network, finding ways we can help each other. We are trying to foster and amplify the voices of not only PAC members, but patients throughout the network. We are establishing a project management structure. We are clarifying guidelines for what active membership means. We are piloting a recruitment program. We are PDSA-ing what ideal patient engagement here at Community Conferences should resemble.

I do not like how those sentences begin. “We are” as a phrase signifies something that is ongoing, not something that is done. As students, researchers, and leaders, we like progress and conclusions. It can feel to me that some of the work we are engaging in is continuing indefinitely.

In our case, however, “we are” is a phrase of success. We are lasting. We are continuing. We are making changes, which lead to other changes, hence prompting more changes.
We are changing the paradigm. In 2013, the Patient Advisory Council was a Facebook group. Today, we are present on multiple network-wide communication platforms and building a presence within care centers. In 2013, we were trying to fit into interventions, to carve out corners and spaces and places we could fit. Today, we are co-creating our own innovations; you are allowing us to co-create yours because you see the value in that. We are challenging the paradigm of how patients and clinicians should interact. In 2013, patients and parents were a minority here. Today, we are here in force. We are fifteen patients. Fifty percent of the PAC is here this weekend. That has never happened before. In 2013, we were acquaintances, colleagues. Today, I call many of you friends and mentors - we talk about mentoring so often here just in the peer-to-peer patient sense, and that is a huge deal, but we are a community of mentors. I don’t know if we recognize that explicitly enough. We are learning in a network, we are learning not only from each other but with each other.

Very rarely will our work end with a hard stop, but that would be the wrong measure by which to judge ourselves and our success. A hard stop would only indicate failure, that we have stopped approaching barriers creatively and stopped challenging ourselves, so that we can go no further. To be a learning health network, I believe we are held to the same standards as all ideal students. We try and we do not give up, even when we want to, even when our work feels tedious, even when we feel as if we are is not enough, even when we feel as if we are achieving little. If we measure ourselves by growth and not an endpoint, we see ourselves as a community in a clearer light.

We are ImproveCareNow. I am ImproveCareNow, and I am really enthusiastically proud of that. I cannot wait to carry that to Cooper with me and beyond and see where it takes all of us. Thank you for working within ImproveCareNow, and for believing that we make a difference together. Please go home and believe in your own patients and believe they can help you go further. It may not be easy or quick or tidy - like some of us really like - but it is the future, and we need to be the same sort of brave you ask patients to be as we pave that road.

If we stop believing patients and families matter in care, our magic as a collaborative will be lost. We celebrate our successes not because failures do not happen, but because when we keep trying and trying and trying, we succeed. It may feel like magic, but it is we are just people – believing –together.