LOOP Blog

Monday mornings are supposed to be difficult. There’s no such thing as a “Case of the Thursdays.”  Dragging out of bed Monday morning is supposed to be hard. Some weeks it is. Just this March there was a week where it just wasn't. I’m not entirely certain I even hit the snooze button (gasp!). I had just spent my weekend, the American worker’s time for decompressing, in meetings. Lots of them. But these were not just your average meetings – they were the ImproveCareNow Learning Session meetings.

Following them, I arrived back in Cincinnati with renewed enthusiasm - a renewed enthusiasm that invariably comes from attending these sessions. See, I’m a data guy. We’re typically pretty black and white - no grey. We come to the table with preconceived notions of what’s going to work and what’s not. Clinical data managers are not usually innovators. They’re not expected to be. In many cases, they’re not allowed to be. I can tell you that they’re missing out. Fate or karma or luck or whatever steered me away from the world of highly regulated (read: robotic, monotonous, widget-producing) clinical trials work, toward ImproveCareNow where I find myself encouraged to not only be rigorous, but also innovative in my approach to nearly everything.

As ImproveCareNow’s data manager, I've seen things I never would have imagined. We've abandoned the old query-and-response method of data cleaning and replaced it with a Quality Improvement (QI) based method of data quality improvement. When I tell my old colleagues about this process, I get a range of responses from a polite you-know-better-than-that tap on the head with a smile and nod, to downright indignation. Many of my peers have expressed reservations and have been kind enough to tell me that my approach won’t work. This is how I know what we’re doing IS working.

Any time those that “know” tell me that I’m crazy, it’s time to push on. Why?  Because it works. In 3 years, we’ve been able to improve the quality of ImproveCareNow’s registry (database) in terms of completeness, accuracy and timeliness not by adding a mountain of burdensome queries and rework to the care centers’ already full plates, but by doing what we teach in this network. Becoming partners in data quality with the ImproveCareNow teams working hard at each center, by applying QI science to work and processes of our central data management team, and by applying the same QI methodologies that have enabled ImproveCareNow to raise remission rates to places we didn’t even think possible. We’re taking the quality of the data, and by extension the quality of the data-driven tools and improvement that are developed and implemented by care centers, to places we were told we couldn’t go.

I’m not naïve enough to think that anything we try is going to be a success. Quite the opposite. Part of the journey is stumbling, falling, getting back up and applying what we’ve learned. And that’s what makes it easy to drag myself out of bed on those Monday mornings and get right back to it.

Dan Jeffers, MS, CCDM is a certified clinical data manager working at Cincinnati Children’s Hospital. When he’s not coming up with innovative ways to make the data in ICN2 even better, he’s chasing his kids and chickens around his Cincinnati farm.

Second QI Fundamentals webinar, done (and the next one is tomorrow).

We have all asked ourselves "what do I want to improve?" and our answers became the foundations of our ALOs. The next step was to formulate SMART (specific, measurable, attainable, realistic and time-bound) aim statements. I shared my aim statements with you in my last post. But I'll post them just below too. There are actually two aims in there. Do you think they're SMART?

My ALO as posted in the QI Fundamentals forum on the ICN Exchange. The Exchange is an internal knowledge-sharing platform, which ImproveCareNow uses to enable our participants to 'all teach and all learn', so we can improve care now.

The answer is yes. I've focused my project on a very specific target area (this blog) and I have measurable goals (add 4 new contributors, and increase weekly posting to 100%). I chose LOOP because I am the managing editor (so completing this project is well within my ability, or attainable and realistic), and it was easy to make it time-bound because the end date is September 4, 2014. That's the date of our Fall Learning Session, where my QI Fundamentals comrades and I will present the results of our ALOs.

Now it's time to set up run charts and see how I'm doing (and have something to show on September 4th). A run chart is a basic charting tool that displays variation over time. They are often used by professionals in quality improvement because they track the impact of changes on measures. A run chart can help someone like me (who is definitely no statistician) present my data in a way that tells the whole story. Maintaining a run chart is a good practice because it keeps me in touch with my data and ensures I am reviewing it in real-time so I can understand objectively if the changes I make (to my recruiting process) lead to an improvement (new LOOP contributors!). So instead of just observations or gut-feelings, I can rely on my data to support decisions about whether to adopt, adapt or abandon a certain change or intervention.

As you can see in my run chart (above) I have added one new contributor since beginning the test (NOTE: I had to adjust my baseline because my starting number of contributors was 16, instead of 17) . Sarah Myers is the Executive Quality Director for ImproveCareNow. Looking back at my aim, you'll probably recall that I said I was going to add a clinician, research/improvement coordinator, dietitian and nurse contributor to the roster. How am I using the run chart to also track contributor roles to see if I'm achieving the qualitative part of my aim? Data labels. To add a data label in Excel: click on the data point you want to label (making sure no other points in the series are highlighted), right-click, then select "Add a Data Label".

So, I have a question for you: What constitutes a contributor to LOOP? This is my thinking: a person who has accepted an invitation from LOOP to create or use an existing WordPress account and be assigned a user level of Contributor or higher; once the Contributor invitation is successfully accepted, the user must contribute at least one post.

One post. Is that enough? If not, how many?

If I want to add more contributors to LOOP, what changes should I test? I'm thinking of putting an ad in the ImproveCareNow Digest - an eNewsletter sent to all our participants - asking for volunteers. Do you think this will yield anything? Do you think I have to get more personal and approach people 1:1, especially if I want to meet my diversity goal?

If I asked you to contribute to LOOP, what would you need from me to help you make your decision? I'd be interested to hear your thoughts.

 

In the decade I have lived with Crohn’s Disease, I have steadfastly steered clear of support groups. It always seemed as though I were resigned to a couple of options in talking about my Crohn’s: 1) stick with my private medical appointment with only my parents and doctor, or 2) cautiously venture into the mysterious world of support groups. I exclusively favored the first option, and carefully built my community of friends with IBD a la patient advocacy and volunteering. And while that strategy worked for me, I only recently realized there’s another way.When Sami and I were invited to participate in the Children’s Hospital of The King’s Daughters (“CHKD”) team’s demonstration of the group medical appointment (better known in the medical community as Drop-In Group Medical Appointments, “DIGMA”) at the ImproveCareNow Spring Learning Session, we were happy to help. We were admittedly unaware of how a DIGMA session worked; and arguably incredibly naïve about the feasibility and sustainability of a model that – at first glance – seemed to be the very kind of ooey-gooey-woe-is-me support group we had intentionally evaded.

Championed by the passionate team at CHKD in Norfolk, Virginia, the DIGMA model has enjoyed strong support from clinicians and families alike. Dr. Marc Tsou was introduced to the idea in the late 90’s when a parent gave him an article about the group model structure, about which he says, “It seemed to make so much sense. I thought of how many times in the day I’d say the same medical information to several families. Say that information six times, how inefficient, then think about how much that group appointment concept makes sense.” Dr. Tsou saw an opportunity to meaningfully build on the clinic’s collaborative culture; “Elements were there, the right type of people and group. The doctors were the ones who said we’ve got to do this, we’ve got to do this, the time was right, it was almost fate.” Fueled by his fearless nurse, Terri, Dr. Tsou and the CHKD team set about bringing the DIGMA model to their IBD families.

The first step was reaching out to a variety of clinicians – such as dieticians and social workers – to ensure that the group visits did not just include patients & families, but also a group of diversified care providers. After sending out an email to potential clinician participants, positive responses began to rush in. “For the most part all responded and had someone to come and participate,” Terri says. “Everybody was super receptive to it, they’ve showed up at every one since.”

Annette Kulzer, a mom of three boys including 16-year-old Kolin who lives with IBD, has been instrumental in running the group model appointments. “As a parent,” she says. “It opens doors to meet people we would have not met. If we were in another setting, we wouldn’t hear those stories.” An early adopter and believer in the DIGMA model, Annette has regularly provided a parent’s perspective into how the group appointments run. For example, after a group appointment with female and male patients, Annette suggested having separate groups for each gender and for different ages ranges to encourage comfort and participation. Annette and Kolin emphasize the sincerity of Dr. Tsou’s malleability in running the group sessions, and they always appreciate the weight their feedback holds.

In addition to the accessibility to a variety of clinicians and retaining certain elements of the traditional solo medical appointment (e.g., a one-on-one physical exam), the DIGMA model had a surprising but welcome impact; it provided novel insight for patients, parents, and clinicians alike through storytelling. Annette remembers a teenage patient who recounted having great difficulty taking the bus to sporting events with her teammates, since she was worried she might urgently need to use the bathroom. The story challenged Annette to reconsider Kolin’s hesitation to ride with his teammates to a game, as she came to understand that her son – who rarely complained – shared a similar fear that had gone unspoken.

Jill, CHKD’s social worker agrees that sharing stories can be incredibly eye-opening, and says, “It’s very, very different when you can look into the face of another mom or another dad or another kid, and say I understand this. Okay here’s somebody like me, they’re doing alright.” Dr. Tsou adds, “There was one mom who broke down into tears, she got very emotional, you think gee these sessions no one will share very much, but really they’re sharing their souls and baring their deepest fears. People might be skeptical but it really happens, but that’s super gratifying, a bit surprising, and confirmed to us that we’re on to something and something that deserves the attention and energy to keep it going.” When asked about group session attendees who were unsure at first, Annette says, “We’ve had many patients and parents who come in resistant, but within 15 minutes they’ve had the Kool-Aid.”

The group session can also be liberating for patients, who perhaps fear that IBD will be an “albatross around their neck for the rest of their lives.” Kolin enthusiastically agrees, adding, “Telling people what you’re going through helps a lot.” Positive and on target support grows organically from the patient-driven and clinician-facilitated model, and Kolin says, “You’re going to get so much out of it.”

While the organizational burden was heavy at the beginning, the team has happily tackled logistical issues to provide this innovative practice to their patients. Dr. Tsou explains, “The group appointment allows for so much more sharing of feelings, fears, and that’s really what so many families want and need and it allows it in the framework of still providing care. We’ve all had to learn a little different way of doing it.” Terri adds, “No harm in trying something, and I would guarantee that if others tried this model, they wouldn’t go back, it really does impact patients and families.”

But the potential of the DIGMA model doesn’t stop there: the team sees practical applications to rural communities (i.e., being able to run a group session in a rural community to maximize patients who can be seen), and across medical specialties. Dr. Tsou says, “I think it’s going to be more mainstreamed. It is the way medicine will be practiced in the future, we’re at the leading edge of it, which is cool.” Kolin adds, “I really want it to spread. I was really skeptical of it at first, but I really do enjoy the DIGMA model.”

A group medical appointment is, at its core, a treasure chest for patients, families, and clinicians; the ability to offer a holistic, patient-centered, and team-approach to pediatric care is innovative and vital to the collaborative and transparent culture championed by ImproveCareNow. The passion, integrity, and dedication the CHKD team has for optimizing chronic illness care is not only evident, but most importantly completely contagious. “We’re all passionate about our patients,” says Terri. “We were born to do this, it’s been really wonderful. Everyone had the spirit, it was right for us.”

 Jennie

In 2014, a question came to the ImproveCareNow Registered Dietitian (RD) group about how to choose foods that can promote healthy weight loss and control hunger without causing a flare of gastrointestinal (GI) symptoms. By answering questions from our community, the RD group aims to provide valuable tools and information for patients and families to better understand the role of nutrition in managing Inflammatory Bowel Disease (IBD). The RD group encourages partnerships between patients and their care teams, including dietitians, so together they can design a dietary plan to avoid food-related complications from IBD and promote healthy weight maintenance.

[Editor’s Note: This article was originally published in CIRCLE January 2012]

Kids with Crohn's disease and ulcerative colitis often have low levels of vitamin D. How does that happen? When you are not feeling well, you don't eat as well. If you don't eat foods supplemented with vitamin D, it could lead to a vitamin D deficiency. You put sun screen on to prevent skin cancer (a good thing to do), but sun screen also blocks the ultraviolet rays that stimulate your body to make vitamin D. Some patients with Crohn's disease have inflammation in the part of the intestine that absorbs vitamin D into the body, so some of the vitamin D eaten goes right through without being absorbed.

Vitamin D is important for bone growth, bone density and bone strength, and for growth itself. So getting enough vitamin D is especially important for growing kids.   Vitamin D also appears to have other health benefits.

How much is enough vitamin D? Recently recommendations have changed-more vitamin D is recommended now than before: 600 units a day (instead of 400) for kids 1 to 18 years old. For patients with Crohn's disease or ulcerative colitis, sometimes more may be necessary, such as 800 or 1,000 or more units per day. (Caution: excessive intake of vitamin D can be harmful.) Ask your clinician or dietician what the right amount is for you.

How do you get enough vitamin D? A daily multivitamin supplement usually has 400 units per tablet so that's a good place to start. Vitamin D tablets are also available. Milk and yogurt are fortified with vitamin D, usually about 100 units per serving. Some orange juice is fortified with vitamin D.

To absorb vitamin D into your body, it has to be bound to some fat. So when you take your vitamin D supplement (including skim milk or non-fat yogurt) be sure to eat food with fat at the same time, for example, at least 2 or 3 teaspoons of peanut butter, or margarine or oil.

No bones about it! Get your daily vitamin D. For more information click here.

Richard Colletti, MD
Network Director, ImproveCareNow

Recently, the ICN Exchange needed to undergo maintenance unexpectedly for two days. Some people in the ImproveCareNow Network probably noticed it more than others. I know that as someone who has come to rely on it to keep up with what centers are working on and looking at, I was keenly aware of its absence.  So you can imagine how thrilling it was when it came back online!

Now that the Exchange is back up and running (and better than ever - with plans and resources in place to prevent such outages in the future!) it occurs to me that even a quick glance at the Exchange clearly shows the richness, diversity, vibrancy—and the multifaceted dynamics of our community.

When I glanced at the Exchange today this is what I saw:

ImproveCareNow centers, like Children's Hospital of The King's Daughters, jumping in and collaborating with parents, patients, and other centers to make sure that we are all learning together!

Opportunities that highlight how much we really, really want and need to learn from each other so we can collaborate even better!

Multidisciplinary partners, like the RD group, are staying connected with each other and getting organized so they can take on projects that will build their visibility and leadership in ImproveCareNow.

ImproveCareNow QI teams are becoming even more accountable and transparent in their day-to-day QI work.

Parent Partners are setting their 90 day goals, tracking their progress and keeping the Network informed!

And finally, amazing patients around the country are teaching us more and more every day.

And that is just a quick glance! So thank you to everyone who has been a part of helping us build this vibrant community. I, for one, can’t wait to see where the community goes next!

The ICN Exchange is an internal knowledge-sharing platform that the ImproveCareNow Network uses to communicate, collaborate and innovate across the miles. Clinicians, Researchers, Patients, Families and Improvers are able to log into the ICN Exchange and share seamlessly and steal shamelessly!  The ICN Exchange has enabled ImproveCareNow to extend our “all teach, all learn” collaborative approach to medicine far beyond our monthly webinars and twice-annual Learning Session. It allows us to identify ideas and best practices in pediatric IBD care and introduce them into the care delivery process much faster—improving care for our patients now.

https://twitter.com/Sarituno/status/448862983939436544

I have been working with ImproveCareNow - a Network that uses Quality Improvement (QI) techniques to bring about improvements in the care and health of children and adolescents with Crohn's disease and ulcerative colitis -  for nearly 3.5 years. And, yet I have not had any formal QI training. That ends now, because I'm taking the Spring 2014 QI Fundamentals series.

QI Fundamentals is a series of seven, hour-long webinars lead by one of the Network's QI coaches and a project called an Applied Learning Opportunity (ALO). The curriculum has been designed for teams who have just joined the ImproveCareNow Network and new members of established teams. By the end of our six months together, a QI  Fundamentals class graduates with knowledge and understanding of basic QI skills and tools that ImproveCareNow uses to drive measurable improvements.

New teams are encouraged to focus their ALO on registration and data collection, which means many will choose a project that helps them identify IBD patients in a much broader patient population. This basic ability is so foundational to the QI work that each team will be doing in the future. Remission rate for IBD patients at each center, for instance, is calculated based on the total population of IBD patients - so dialing in a process for knowing all patients with IBD is critical so a team can accurately see how they are doing in terms of getting more patients into remission and keeping them there.

You're probably thinking to yourself, the number of patients with IBD (which we call a "denominator") must change over time as new patients are diagnosed and as others transition out of pediatric care. And you'd be right. But don't worry, the ICN data management team has got that covered. They request quarterly updates from all participating ImproveCareNow centers. So, I'd say it's pretty fundamental to know how to identify patients with IBD at your care center.

This begs another question. Since I'm not part of a team at a care center (read: I don't see patients), what will my ALO be? Well, I'm glad you asked. The answer is: you're looking at it. Yup, I'm focusing my ALO on LOOP. In fact, here is my aim:

So, I'm walking the walk - reading up on QI, planning and carrying out my own ALO, complete with aims and run charts and data oh my, and probably even presenting my results at the Fall 2014 ImproveCareNow Learning Session (which is September 4-6, if you're wondering).

Look for my next post after the second Fundamentals webinar on April 9th.

Look on Twitter, Facebook, LinkedIn, and many other social media outlets over the past few weeks, and ImproveCareNow is all over the place. Many quotes about “parents as partners,” “real patient engagement,” and “amazing collaboration.” It’s fantastic to see the buzz we are generating. It’s huge, and important, and feels like it will catalyze many others who are working on similar efforts to jump in and do the same. We have a lot to teach now, even as we learn. It’s helping us achieve health outcomes we did not think possible and will probably help others do the same.

But what does this mean at the micro level, in the day-to-day shuffle (and sometimes tornado!) of getting the real work of running this complicated Network done? I don’t pretend not to realize that the care teams out there across in our 65 centers are doing the hard work – planning visits in advance, getting to know our new automated reporting tools, and trying to fit this all into their already complex clinic workflows. They (with the families they serve) are real heroes in this Network. But a lot of work also goes on at the ImproveCareNow leadership and staff levels to make it all possible. And I consider myself very fortunate to be in the position, as part of this team, where I get to see how many of the pieces fit together, and witness the not so subtle shift in what it means to “work for ImproveCareNow.”

I’m going to use our recently completed Spring Learning Session as an example. Even just one year ago, planning the Learning Session meant that the core Quality Improvement (QI) project team and I looked at Network priorities and recent lessons learned, identified who would do a good job speaking about these things, and pieced together what usually turned out to be a good agenda for a good meeting. Parents and patients were starting to attend Learning Sessions, but were on the fringes and some would tell you they spent their weekend trying to figure out where they fit in. We felt good about including them, but we didn’t feel good about not understanding quite how we all fit together.

What a difference a year can make! In planning for the Spring 2014 Learning Session I found myself watching as unprecedented collaborations between clinicians and parents, data managers and parents, took place across the miles. In one instance, what began as an offhand comment about the potential for a parent panel at the Learning Session, which would address how centers can better engage families in QI work, became a series of many, many emails between a clinician, several parents, and ImproveCareNow staff. Over three months we worked together to co-design the objectives and draft a call-to-action that the panel could deliver to the Network. The result was one of the highlights of this Learning Session.

In another instance, a parent asked for permission to use Network remission data in his presentation—the kind of data that he knew could illustrate the ImproveCareNow story best. Again, I found myself watching an amazing email discussion unfold between the parent, our ImproveCareNow data manager and the centers that agreed to have their data displayed in a novel way by a parent. This kind of conversation about data (“send me that,” “no, let’s try it this way,” “yes, that will have the most impact”) happens all the time within ImproveCareNow. But until now, had been limited to QI, data management, communications, and IT staff.

I used to believe ImproveCareNow staff and leadership needed to work for the clinicians, parents, patients and others that make up this Network…they were partners, but also customers and we had to make it all work well for them. I now realize it’s all about working with them so they can help us get things right. So yes, I work with the many care teams who are providing more proactive and reliable medical, nursing, nutritional, social work, and psychological support to pediatric patients with IBD. But I also work with Justin, Jamie, Sami, JenJo, Jennie, Tania, Beth, David, and many, many others who have ideas and experiences that also need to be integrated into this learning health system.

Today these patient and parent partners email me just as any of my other coworkers would. They email me during the work day, but also at 11:00 PM and 4:00 AM, during their time. They do so despite having busy full-time jobs inside or outside of their homes and despite the extra time they already devote to caring for children with a chronic illness. They share their ideas, ask for my input, worry about pushing us too fast (I often hear: “we’re not going to get you all fired, are we?”), worry about not pushing us fast enough, and ask how my kids are doing. I push them to post things on our internal knowledge-sharing platform, the ICN Exchange, just like I push the care centers. They are creating 90-day goals to focus and guide their work just like the care centers.  Most of all, they are helping us walk together into a new model for running this Network, understanding we won’t get it right every time, caring about the impact on others who are new to this level of partnership too, and above all, making sure we all stay connected to what this work is really about:

One of the joys of working with the ImproveCareNow Network is seeing the results of co-production introduced more broadly to a learning community. At the same time, communicating what this is all about can be tricky – the idea that patients and clinicians can actually be partners (in health, care, improvement, and research) - is such a paradigm shift.  In fomenting this culture change, we have come to a deep appreciation of story-telling, art, and other creative expression as a powerful way of communicating beyond the hard data. That's why it's so breathtaking when we see this come along:

https://twitter.com/michaelseid11/status/448458248627027969

Justin, who made this video, is a parent in the ImproveCareNow network.  Collaborating with other parents and with some (minor) input from ImproveCareNow staff, he distills, in less than 90 seconds, this movement to its essence so much better than my feeble words could do.