Summary

From 2018 to 2021, Birmingham Children’s Hospital (BCH) was a negative outlier in the National Paediatric Diabetes Audit’s (NPDA) seven key care processes. To address this, BCH adopted a Quality Improvement (QI) initiative using Plan-Do-Study-Act (PDSA) cycles in 2022. The team initially focused on enhancing the annual review clinic, resulting in improved care delivery. By 2023, all clinics were included, integrating data-driven insights and accountability, leading to novel approaches. This data-driven methodology significantly improved the completion of care processes, making BCH an above-average performer by 2023 and anticipated positive outlier in 2024.

Innovation

The BCH diabetes team’s application of PDSA cycles from 2021 to 2023 serves as an exemplary model for leveraging systematic feedback and key performance indicators (KPIs) to enhance healthcare quality. This approach was initiated after the team was identified as a regional negative outlier in paediatric diabetes care process completions, recording less than 35% annually from 2018 to 2021. The objective was to evolve from a negative outlier to a benchmark of excellence within three years. The core strategy embraced the principle, ‘what gets measured, gets managed’, focusing on making every patient interaction and data collection opportunity count and driving enhancements in care processes, encompassing HbA1c levels, BMI assessments, blood pressure and other evaluations. In 2021/2022, BCH’s attempts to centralise data collection during an annual review clinic fell short. Despite creating patient information leaflets and protocols for data entry, the results were poor due to the absence of regularly measured KPIs and comprehensive attendance, as only 75% of patients attended the annual clinic. The team introduced monthly reporting of KPIs at operational meetings in 2022. This new system clarified the processes each clinician was responsible for and fostered accountability through an accountability board that tracked individual compliance. From 1 April onwards, each clinic became a data collection point, with administrators playing a crucial role in auditing which care processes were completed and by whom. This brought significant improvements, with care process completions rising above the national average. In 2022/2023, BCH developed concise scripts for the team to effectively communicate the importance of blood tests, ensuring better compliance and knowledge among patients and families. Furthermore, phlebotomy was facilitated. Administrative lapses in transferring blood results were rectified. Throughout 2023/2024, the application of monthly KPIs, strategic feedback at operational meetings and accountability leaderboards improved patient care and positioned BCH as a likely positive outlier in the 2024 national rankings for completion of the paediatric diabetes care process.

Equality, Diversity and Variation

The NPDA shows that children and young people from black and Asian ethnic backgrounds have HbA1c levels higher than their white counterparts. The disparities extend across socioeconomic lines. THE BCH cohort consists of more than 60% of this demographic. As a benchmark of excellence in diabetes care, BCH directly addresses these disparities. Regular and thorough screening processes ensure that all children receive consistent, high quality care, regardless of background. This standardised approach minimises variations in treatment that often correlate with ethnic and socioeconomic differences. BCH’s focus on data-driven and tailored patient education further enhances equity. BCH effectively communicates the importance of regular screenings and management strategies by understanding and integrating patients’ cultural and socioeconomic contexts into care plans. This tailored approach, using interpreters and patient leaflets, overcomes barriers to health literacy. Moreover, BCH’s technology and data use ensure no child is left behind, with clinicians aware of, and accountable for, each child’s care.

Results

In 2022, the care processes required for paediatric diabetes management were revised nationally, reducing from seven to six. This prompted more focus on the remaining care processes, including HbA1c levels, BMI assessments, blood pressure measurements, thyroid function tests, urinary microalbumin levels and foot examinations. The annual review clinic alone was insufficient, with only 60% of the six key processes completed. By identifying specific KPIs in 2022/23 and establishing a continuous cycle of accountability and reporting, the team saw that ‘what gets measured, gets managed’. The compliance leaderboards were particularly effective in driving accountability and behaviour change. Completion of the six processes increased to 79%, making BCH an above-average performer. By 2023, a full year of prior data pinpointed specific periods and processes where compliance waned. Targeted initiatives were launched to address these gaps, such as auditing the transfer of blood test results from the ICE system to Twinkle. Educational initiatives underscored the clinical importance of each care process; these were not merely bureaucratic requirements but crucial for early detection of potential complications and timely intervention. Compliance with these essential processes rose to 85% for 2023/24, which should mean a positive outlier status. Furthermore, 2023/24 had the highest completion rate on every metric except foot check, which was slightly below the previous year’s score. The care process performance will join BCH’s positive outlier status for mean adjusted HbA1c since 2021.

User Feedback

In 2022, BCH’s diabetes team learned from the fact that it had not consulted the administration team or patients on using the annual review clinic for completing care processes in 2021/22 and shifted to a more inclusive and collaborative approach. The consensus was to transform every clinic visit into an opportunity to complete these processes, beginning each year on 1 April. This gave most patients three or four opportunities to complete the care processes within a year. Furthermore, the team emphasised the need for a clear dashboard outlining the specific data collected at each clinic. They also highlighted the motivational impact of knowing their efforts were being monitored. A crucial pivot was placing the administrator at the centre of this process. Tasked with creating clinic dashboards and auditing compliance, she became a pivotal figure and her real-time insights into compliance patterns and proactive suggestions were invaluable. Her feedback was consistently integrated into operational team meetings to refine processes further. This bottom-up approach revolutionised the project, demonstrating that respecting and integrating feedback from all team members and patients is essential for success. The next goal is to reach 90% compliance. This project exemplifies the power of simplicity in achieving significant improvements in healthcare delivery.