Assessment of a Day Hospital Management Program for Children With Type 1 Diabetes.

Importance: A shift in the setting of care delivery for children with a new diagnosis of type 1 diabetes led to a reorganization of treatment.

Objective: To determine whether a new diagnosis of pediatric diabetes can be successfully managed in a day hospital model.

Design, Setting, And Participants: This quality improvement study used retrospectively collected data on pediatric patients with a new diagnosis of diabetes who completed an inpatient program for education and insulin titration prospectively compared with patients completing a diabetes day hospital program.

Primary Care Quality Improvement Metrics and National Committee on Quality Assurance Medical Home Recognition for Children With Medical Complexity.

Unlabelled: The Complex Care Center at Cincinnati Children's Hospital Medical Center developed and implemented a set of evidence-based clinical process measures of immunization delivery, preventive and chronic condition laboratory screening, and behavioral health medication surveillance for use in the primary care setting.

Methods: Improvement activities focused on 4 measures across 4 domains mandated by the National Committee on Quality Assurance for patient-centered medical home recognition. Interventions were implemented in phases from January 2017 to October 2018.

Systemwide Implementation of Patient-Reported Outcomes in Routine Clinical Care at a Children's Hospital.

Background: Despite a growing literature on patient-reported outcomes (PROs), little has been written to guide development of a standardized, systemwide PRO program across multiple clinics and conditions. A PRO implementation program, which was created at Cincinnati Children's Hospital Medical Center, a large children's hospital, can serve as a standardized approach for the use of PROs in a clinical setting.

Methods: Recommended standardized PRO implementation components include identification of a committed clinical leader and team, selection of an instrument that addresses the identified outcome of interest, specifying threshold scores that indicate when an intervention is needed, identification of clinical interventions to be triggered by threshold scores, provision of training for providers and staff involved in the PRO implementation process, and the measurement and monitoring of PRO use.

Using a network organisational architecture to support the development of Learning Healthcare Systems.

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision.

Using Lean methodologies to streamline processing of requests for durable medical equipment and supplies for children with complex conditions.

Background: An improvement team from the Complex Care Center at our large pediatric medical center participated in a 60-day initiative to use Lean methodologies to standardize their processes, eliminate waste and improve the timely and reliable provision of durable medical equipment and supplies.

Methods: The team used value stream mapping to identify processes needing improvement. Improvement activities addressed the initial processing of a request, provider signature on the form, returning the form to the sender, and uploading the completed documents to the electronic medical record.

Walk-in Model for Ill Care in an Urban Academic Pediatric Clinic.

Objectives: Since the Institute of Medicine's 2001 charge to reform health care, there has been a focus on the role of the medical home. Access to care in the proper setting and at the proper time is central to health care reform. We aimed to increase the volume of patients receiving care for acute illnesses within the medical home rather than the emergency department or urgent care center from 41% to 60%.

Association of an Asthma Improvement Collaborative With Health Care Utilization in Medicaid-Insured Pediatric Patients in an Urban Community.

Importance: Asthma is the most common chronic condition of childhood. Hospitalizations and emergency department (ED) visits for asthma are more frequently experienced by minority children and adolescents and those with low socioeconomic status.

Objective: To reduce asthma-related hospitalizations and ED visits for Medicaid-insured pediatric patients residing in Hamilton County, Ohio.

Quality Improvement Strategies for Population Management of Children With Medical Complexity.

Background And Objectives: Children with medical complexity require the expertise of specialists and hospitals but may lack primary care to provide preventive, acute, and chronic care management. The Complex Care Center (CCC) at Cincinnati Children's Hospital Medical Center employed quality improvement methodologies in 3 initiatives to improve care for this fragile population.

Methods: Improvement activities focused on 3 main areas: population identification and stratification for care support, reliable delivery of preventive and chronic care, and planned care to identify and coordinate needed services.

Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices.

Background: Randomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow.

Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center.

Background: Cincinnati Children's Hospital Medical Center launched the Condition Outcomes Improvement Initiative in 2012 to help disease-based teams use the principles of improvement science to implement components of the Chronic Care Model and improve outpatient care delivery for populations of children with chronic and complex conditions. The goal was to improve outcomes by 20% from baseline.

Methods: Initiative activities included review of the evidence to choose and measure outcomes, development of condition-specific patient registries and tools for data collection, patient stratification, planning and coordinating care before and after visits, and self-management support.

Measuring Harm in Health Care: Optimizing Adverse Event Review.

Objective: The objective of this study was to identify modifiable factors that improve the reliability of ratings of severity of health care-associated harm in clinical practice improvement and research.

Methods: A diverse group of clinicians rated 8 types of adverse events: blood product, device or medical/surgical supply, fall, health care-associated infection, medication, perinatal, pressure ulcer, surgery. We used a generalizability theory framework to estimate the impact of number of raters, rater experience, and rater provider type on reliability.

Risk Factors for Unanticipated Readmissions During the Interstage: A Report From the National Pediatric Cardiology Quality Improvement Collaborative.

This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured.

Health-system-based interventions to improve care in pediatric and adolescent type 1 diabetes.

Despite significant advances in pharmacology and technology, glycemic targets are difficult to achieve for patients with type 1 diabetes (T1D) and management remains burdensome for patients and their families. Quality improvement (QI) science offers a methodology to identify an aim, evaluate complex contributors to the goal, and test potential interventions to achieve outcomes of interest. Day-to-day management of diabetes is often an iterative process but interventions exist at all care levels: individual patient and family, clinic, and larger population and health system.

Quality Metrics in Neonatal and Pediatric Critical Care Transport: A National Delphi Project.

Objectives: The transport of neonatal and pediatric patients to tertiary care facilities for specialized care demands monitoring the quality of care delivered during transport and its impact on patient outcomes. In 2011, pediatric transport teams in Ohio met to identify quality indicators permitting comparisons among programs. However, no set of national consensus quality metrics exists for benchmarking transport teams.

POSNA Quality, Safety, Value Initiative 3 Years Old and Growing Strong. POSNA Precourse 2014.

The purpose of this paper is to summarize the Pediatric Orthopaedic Society of North America (POSNA) quality, safety, and value initiative (QSVI). Specifically, it will outline the history of the program, describe typical quality improvement techniques, and how they differ from traditional research techniques, and, finally, describe some of the many projects completed, currently underway, or in planning for POSNA QSVI.

Using improvement science methods to increase accuracy of surgical consents.

The surgical consent serves as a key link in preventing breakdowns in communication that could lead to wrong-patient, wrong-site, or wrong-procedure events. We conducted a quality improvement initiative at a large, urban pediatric academic medical center to reliably increase the percentage of informed consents for surgical and medical procedures with accurate safety data information at the first point of perioperative contact. Improvement activities focused on awareness, education, standardization, real-time feedback and failure identification, and transparency.

Improving outcomes for underserved adolescents with asthma.

Background And Objective: Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting.

Using quality improvement to optimise paediatric discharge efficiency.

Background: Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%.

A comprehensive model to build improvement capability in a pediatric academic medical center.

Cincinnati Children's Hospital Medical Center developed a comprehensive model to build quality improvement (QI) capability to support its goal to transform its delivery system through a series of training courses. Two online modules orient staff to basic concepts and terminology and prepare them to participate more effectively in QI teams. The basic program (Rapid Cycle Improvement Collaborative, RCIC) is focused on developing the capability to use basic QI tools and complete a narrow-scoped project in approximately 120 days.

"On the scene": Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Cincinnati Children's Hospital Medical Center is transforming the way it cares for its patients by building a sophisticated model that focuses on accountable care across the continuum. As nurses from different parts of the organization, we act as change agents to develop an integrated structure built around the patient's needs, from prevention to self-management. We demonstrate how organizational structure, fluid staffing, professional practice, and healthy behaviors operationally catalyze the continuum of care, and how we utilize self-management, community-based programs, and care integration to change the outcome for our patients and families.

Republished: developing capable quality improvement leaders.

Background/objective: Cincinnati Children's Hospital Medical Center created the Intermediate Improvement Science Series (I(2)S(2)) training course to develop organisational leaders to do improvement, lead improvement and get results on specific projects.

Design Methods: Each multidisciplinary class consists of 25-30 participants and 12 in-class training days over 6 months. Instructional methods include lectures, case studies, interactive application exercises and dialogue, participant reports and assigned readings.

Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool.

Objectives: To evaluate and characterize the Global Trigger Tool's (GTT's) utility in a pediatric population; to measure the rate of harm at our institution and compare it with previously established trigger tools and benchmark rates; and to describe the distribution of harm of the detected events.

Methods: Per the GTT methodology, 240 random inpatient charts were retrospectively reviewed over a 12-month pilot period for the presence of 53 predefined safety triggers. When triggers were detected, the reviewers investigated the chart more thoroughly to decide whether an adverse event occurred.

Quality improvement initiative to reduce serious safety events and improve patient safety culture.

Background And Objective: Many thousands of patients die every year in the United States as a result of serious and largely preventable safety events or medical errors. Safety events are common in hospitalized children. We conducted a quality improvement initiative to implement cultural and system changes with the goal of reducing serious safety events (SSEs) by 80% within 4 years at our large, urban pediatric hospital.

Developing capable quality improvement leaders.

Background/objective: Cincinnati Children's Hospital Medical Center created the Intermediate Improvement Science Series (I(2)S(2)) training course to develop organisational leaders to do improvement, lead improvement and get results on specific projects.

Design Methods: Each multidisciplinary class consists of 25-30 participants and 12 in-class training days over 6 months. Instructional methods include lectures, case studies, interactive application exercises and dialogue, participant reports and assigned readings.

The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants.

Objective: Human milk has well-established health benefits for preterm infants. We conducted a multidisciplinary quality improvement effort aimed at providing at least 500 mL of human milk/kg in the first 14 days of life to very low birth weight (VLBW) (< 1,500 g) infants in the neonatal intensive care unit.

Subjects And Methods: Improvement activities included antenatal consults with at-risk mothers, staff and parent education, a breast pump loaner program for uninsured/underinsured mothers, pump logs, establishment of a donor milk program, and twice-daily physician evaluation of infants' ability to tolerate feedings.