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Keeping paediatric diabetes on the radar: Delivering virtual peer reviews and quality improvement during COVID-19

Heather Clark, Matt Oultram, Nhung Vu, Andrea Srur
National Diabetes Quality Programme team members discuss how they are continuing to deliver the programme, taking a virtual approach to improve care and outcomes

The Royal College of Paediatrics and Child Health National Diabetes Quality Programme (NDQP) aims to improve care, outcomes and quality of life for children and young people (CYP) with diabetes and their families. The programme consists of two elements: a quality improvement collaborative and a quality assurance workstream that includes an annual self-assessment and peer review visit to paediatric diabetes units in England and Wales. Following the COVID-19 outbreak, face-to-face activities were postponed. To maintain programme delivery and ethos, the NDQP team has developed a new virtual approach that continues to be refined in response to stakeholder feedback.

Background to the NDQP
Building on international evidence, the RCPCH NDQP commenced in 2018 in collaboration with the National CYP Diabetes Network. The aims of the programme are to progress diabetes outcomes by improving multidisciplinary care within paediatric diabetes units (PDUs), to reduce unwarranted variation, and to involve families in service design and improvement.

The programme consists of two elements:

  • A quality assurance workstream that includes an annual self-assessment and peer review visit to PDUs, the latter of which is discussed here
  • A Quality Improvement (QI) Collaborative, which offers multidisciplinary teams the support and tools to identify, design and analyse their own interventions specific to the needs of the patients and families they care for.

To date, 156 PDUs from England and Wales have joined the programme, representing 90% of units across both nations. Traditionally the programme has consisted of face-to-face peer review visits and PDU teams coming together at a venue for 4 days to formulate and share QI projects.

A move to virtual delivery
Since June 2020, as a result of the COVID-19 outbreak the programme has delivered all of its activities virtually. Adaptions and innovations have been made to the quality assurance and QI workstreams to continue delivering the NDQP and improve outcomes for CYP and their families.

Quality assurance
To inform planning, it was essential that – regardless of the delivery mechanism – peer reviews maintained the programme’s principles of identifying good practices and facilitating constructive challenge in a supportive environment to enable services to raise issues and facilitate support. In addition, it was important that PDUs received a virtual review that was consistent with those visited face-to-face.

The virtual platform agreed upon was Microsoft Teams, in view of its security standards. PDUs’ use of Microsoft Teams or similar applications within their own service delivery has resulted in increased familiarity with the software over time.

The NDQP staff team has been on a steep learning journey, becoming proficient with the skills needed to manage a virtual meeting with multiple attendees to ensure all participants and reviewers are able to contribute within time constraints. It has been necessary to more closely define areas of discussion ahead of each session. In a few instances, participants highlighted that they felt discussion was less free flowing; however, the majority indicated that they were satisfied with the format and most participants agreed that they felt heard by the peer reviewers and able to share their experiences. It is acknowledged that there is lots to explore within a limited time and this feedback is in line with face-to-face responses.

The format of virtual peer reviews is now well established. There is always room for improvement and the team continues to refine the process, but overall feedback from those involved has been extremely positive. Service providers reflected that they attained the aims of peer review:

  • Highlighting achievements
  • Raising areas of challenge
  • Seeking support beyond the multidisciplinary team to action where appropriate
  • Increasing the profile of paediatric diabetes to facilitate continued improvement.

In addition, many teams commented that they have benefitted from a peer review at this time, with progress achieved on long-standing issues and service providers using the opportunity to reflect on their service. It is reassuring that most people were put at ease and felt able to be open with the peer review team once the review commenced. Meanwhile, peer reviewers expressed pride at delivering a high-quality review that was useful for service providers. They also commented on being able to take what they had learned back to their own services, sharing good practice and new approaches to challenges, as well as virtually linking with services further afield.

Less positive feedback has typically related to the constraints of the internet and the current COVID-19 context. For example, on some occasions the flow of discussions may be impeded by a weak internet signal, and it may be difficult to fully appreciate body language on screen and facial expressions when someone is wearing a mask. Other less positive feedback has been consistent with face-to-face experiences and predominantly relates to the preparation required and feelings of apprehension. For some reviews, the uncertainties of the period meant shorter notice was given.

Quality improvement
Before the pandemic, the QI Collaborative was delivered as a regional 4-day training programme, with each training day being approximately 3 months apart. Participating teams came together at a local venue to learn about QI, be coached, share improvement ideas and develop their own QI projects. These sessions enabled whole staff teams to spend time away from their workplace to focus on areas they wanted to improve and to plan their next steps while developing their QI knowledge. The pandemic has presented a number of challenges to the collaborative model. Physical meeting spaces have closed down and participating PDUs continue to be under increased pressure, with less time and fewer resources available for work on QI projects.

The QI Collaborative will be taking place remotely for the foreseeable future, which has meant a number of adaptations and changes. QI sessions are now delivered remotely via an online meeting space. This continues to provide a space for teams to work together, share improvement ideas and learn from others. New ways have been developed to facilitate popular exercises and activities, such as the World Café, where teams share their ongoing QI work with others. Remote meetings have resulted in team presentations being recorded, meaning that they can be shared with other teams within the QI Collaborative. QI training is now delivered through video tutorials and exercises on numerous aspects of QI, such as measurement for improvement, QI tools, complex systems and ensuring reliability. Video recordings are used to communicate programme developments with teams as well as any preparation they need to make between sessions. These are quickly accessible via a website link.

The virtual QI Collaborative is being adapted in response to feedback received. As the programme is now delivered online, it may require more self-management by participating teams than the face-to-face version. All teams are encouraged to see this journey as part of their service delivery plan, as they would have during the face-to-face sessions.

The podcast series, Figure 1, includes recorded conversations with teams reflecting on their experience of taking part in the QI Collaborative and their advice for others. It continues to be developed as a supplementary resource and will cover a number of extended discussions focussed on QI in paediatric diabetes services. The programme has also run three webinars aimed at providing listeners with discussions on current issues within PDUs, notably how services are delivering care amid the pandemic, but more recently in how services are supporting the mental health of patients and staff.

The virtual QI Collaborative has become a QI project itself. The approach is refined by analysing feedback and making small changes to each session. Plan, Do, Study, Act (PDSA) cycles are run following every online session to develop the approach in order to continually facilitate services to make improvements within this complex and constantly changing environment.

The NDQP team has rapidly made a number of innovative adaptions to keep paediatric diabetes on the Trust or Health Board radar despite the ongoing context. While maintaining the underlying ethos of the programme, the team will continue to utilise feedback to consider ways to facilitate preparations and ensure all stakeholders get the most out of virtual peer reviews and the QI Collaborative. The NDQP team would like to extend its gratitude to all stakeholders who have participated in peer reviews and the QI Collaborative so professionally and enthusiastically, and who have shared their genuine desire to drive service improvement for the benefit of CYP and their families.

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