ICN Fall 2013 LSDayton Children’s Hospital March 31, 2019
Agenda
Introduction: overview, clinical pathway, sites (5 min) Review and
refinement of KDD and overview of the candidate pathways (10 min)
Survey Results and discussion (25 min)
Overview of results (5 min) Ask attendees to explain their rational
for selection (10 min) Discussion / Questions (10 min)
Definitions and gathering of steps of pathway and measures (15 min)
Next steps (5 min)
Why Are We Doing This?
Experienced ICN centers should be offered a challenging project to
support their improvement Developing care pathways and the
following clinical standardization will enable ICN to support the
reduction in unintended variation, increase care center’s ability
to learn from their processes and ultimately improve outcomes
Global Aim: Increase the standardization of key processes across
ICN centers to improve outcomes
3
Project Overview Previously approached centers interested in
further standardizing care Clinical pathways provide a framework
Agreed to standardize 1 pathway first Our work will include:
Build consensus around a standard Deliberately choose quick wins
Integrate pathways into clinical workflow Effectively feed back
process and outcome data (especially variation) Ensure a thinking
mind is at the interface of the patient and pathway
Clinical Pathways
Framework to promote standardization (see invitation email for
resource links) “A complex set of related interventions for the
mutual decision-making and organization of care processes for a
well-defined population of patients, during a well-defined period.
Clinical pathways should be applicable for ~85% of the defined
population.” (aiming for 80%)
Clinical Pathways
ICN will provide support for this project By participating, we all
agree that there will need to be some compromise, and that to
standardize a not-quite-perfect pathway is better than to continue
in multiple different “perfect” pathways
Participatory approach in selecting the first pathway(s)
Participating Sites Arnold Palmer Hospital for Children Barbara
Bush Children's Hospital at Maine Medical Center Children's Mercy
Dayton Children's Hospital Monroe Carell Jr. Children's Hospital at
Vanderbilt NW Pediatric Gastroenterology - Randall Children's
Hospital Oklahoma University Medical Center Pediatric
Gastroenterology & Nutrition Associates Riley Hospital for
Children
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Arnold Palmer Hospital for Children Barbara Bush Children's
Hospital at Maine Medical Center Children's Mercy Monroe Carell Jr.
Children's Hospital at Vanderbilt NW Pediatric Gastroenterology -
Randall Children's Hospital Oklahoma University Medical
Center
ACHIEVING SUSTAINED REMISSION
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Global Aim
Standardized diagnostic pathway (IBD suspected 1 yr from
diagnosis)
Pre-visit Planning 2.0 / Health Maintenance Assessments
(6 months from diagnosis transfer of care to adult/other)
• Standardized needs assessments. • Communication expectation
mgmt/timeline. • Track and measure reliability of adherence to
pathway • Center and Provider level data
Improve outcomes through increased
centers
Remission centers by December 2022
AND
Achieving Sustained Remission centers by
December 2022.
therapy levels)
Treatment plans (Decision to start a particular therapy treatment
change or transfer of care to
adult/other)
• Standardized intervals of clinic visits and monitoring within the
first year after diagnosis • Complete diagnostic and initial
evaluation (from MCG) • Correct classification of disease phenotype
& severity (Paris, PGA, sPCDAI, PUCAI) • Standardized initial
treatment pathways: induction and maintenance • Standardized
teaching intervals and content, including nursing, social, and
psychological
content/support
monitoring • Standardized de-escalation pathway back to treatment
plan or escalation to surgery
• Appropriate pre-screening (including labs, from MCG) •
Standardized education on risks/benefits • Standardized shared
decision making tools and application • Standardized flow from
decision to first dose of definitive treatment, including checks •
Standardized monitoring intervals
• Standardized process for PVP review, including PVP • Standardized
annual health maintenance assessment
Clinical Pathways
centers
New diagnosis Initial treatment plans TDM/ dose adjustment
Pre-visit planning
New Diagnosis IBD suspected 1 yr from diagnosis Complete diagnostic
and initial evaluation Correct classification of disease phenotype
& severity Standardized initial treatment pathways: induction
and maintenance Standardized teaching intervals and content,
including nursing and psychosocial content/support Standardized
intervals of clinic visits and monitoring within the first year
after diagnosis
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Decision to start a particular therapy treatment change or transfer
of care to adult/other) Appropriate pre-screening Standardized
education on risks/benefits Standardized shared decision making
tools and application Standardized flow from decision to first dose
of definitive treatment, including checks Standardized monitoring
intervals
12
15
calpro
Post-induction TDM
PVP/ Health Maintenance
6 months from diagnosis transfer of care to adult/other
Standardized process for PVP review Standardized interval for PVP
for each patient Standardized health maintenance assessment/visit
annually
17
18
NAME
MRN:
Health Maintenance
Annual visit
Vitamin D every 6 months
Special Considerations
Additional Recommendations:
6 pre-conference surveys completed
20
Which CP is most needed? Which CP would result in largest change in
your center’s remission
Maintenance therapy Maintenance therapy TDM/ Dose adjustments TDM/
Dose adjustments TDM/ Dose adjustments TDM/ Dose adjustments TDM/
Dose adjustments TDM/ Dose adjustments
New diagnosis New diagnosis Initial treatment plans Initial
treatment plans
Results of Pre-Work Site Surveys
21
Which CP is would results in largest change in your center’s
sustained remission?
Which CP would result in largest change in other center’s
remission/sustained remission?
Maintenance therapy Maintenance therapy TDM/ Dose adjustments TDM/
Dose adjustments TDM/ Dose adjustments New diagnosis TDM/ Dose
adjustments Initial treatment plans
New diagnosis New diagnosis TDM/ Dose adjustments TDM/ Dose
adjustments
Results of Pre-Work Site Surveys
22
New Diagnosis
Pre-Visit Planning
3 2 1 4 4 3 1 2 3 2 1 4 3 2 1 4 1 2 3 4 2 3 4
2.7 2.3 1.4 3.7
23
New Diagnosis
Pre-Visit Planning
3 2 1 4 4 3 1 2 3 2 1 4 3 2 1 4 1 2 3 4 2 3 4
2.7 2.3 1.4 3.7
Survey Discussion
24
25
calpro
Post-induction TDM
visit Surveillance
Post-Induction Levels 5 6 14 12 20 14 15 29 19 15 23 29 29 25
32
New Anti-TNF Initiations 9 20 26 30 25 21 18 32 25 18 26 31 37 27
35
0
10
20
30
40
50
60
70
80
90
100
Desired Direction
Table 1. Frequency of subtherapeutic post- induction anti-TNF
levels (2016-2017)
Results: Using QI methodology, we improved post-induction anti-TNF
TDM from a baseline of 43% in 2015 to > 80% by the end of 2017,
with sustained improvement. Infliximab post- induction TDM improved
from a baseline of 59% to 82% while adalimumab post-induction TDM
improved from baseline of 14% to 79%. In total, 36% of all anti-TNF
post-induction levels were less than 5 μg/mL, with nearly 60% of
post-induction infliximab levels being less than 5 μg/mL.
Unpublished data (under peer-review, JPGN)
Infliximab (n = 83)
Number of Annual Levels
Obtained 4 6 9 9 12 11 8 17 9 8 15
Number Due (at 15 months) 9 17 24 25 19 18 15 25 16 16 21
0
10
20
30
40
50
60
70
80
90
100
of All Anti-TNFs
Due for Collection (at 15 months)
Desired Direction
Let’s Get to Work!
Definitions Gathering of steps of pathway and measures What
measures are key to track
30
Education/discussion on clinical pathways Select 1-2 pathway(s)
First steps (defining, gathering info, measures) Site testing:
PDSAs of pathway(s)
Biweekly or monthly calls (as long as needed) Build consensus
Select metrics Build data collection/reporting plan
Fall 2019 Preliminary results Re-examine KDD/theory of
change?
Slide Number 1
Project Overview
Clinical Pathways
Clinical Pathways
Participating Sites
Participating Sites
Survey Discussion
Next Steps