ââåchampions of Change the Impact of the Arts on Learningã¢ââ

NT Conway^*

University of Dundee and NHS Tayside, Dundee, Great britain and Aridhia Information science Ltd, Glasgow, UK

R Al Wotayan
Ministry of Wellness, Kuwait

A Alkuzam, FF Al-Refaei, D Badawi and R Barake
Dasman Diabetes Institute, State of kuwait

A Bell and G Boyle
Aridhia Informatics Ltd, Glasgow, UK

Southward Chisholm
NHS Tayside, Dundee, UK

J Connell
Academy of Dundee and NHS Tayside, Dundee, Uk

A Emslie-Smith
NHS Tayside, Dundee, UK

CA Goddard and SA Greene

University of Dundee, Great britain

Due north Halawa
Dasman Diabetes Found, Kuwait

A Judson and C Kelly
Aridhia Informatics Ltd, Glasgow, Britain

J Ker
University of Dundee, UK

M Scott
University of Dundee and NHS Tayside, Dundee, Great britain

A Shaltout and F Sukkar
Dasman Diabetes Institute, Kuwait

D Wake and A Morris
University of Dundee, Dundee, UK, NHS Tayside, Dundee, UK and Aridhia Informatics Ltd, Glasgow, Uk

D Sibbald
Aridhia Information science Ltd, Glasgow, Uk

Grand Behbehani
Dasman Diabetes Plant, Kuwait

Corresponding Author:

Nicky Conway
Kid Health, MACHS Building
Ninewells Hospital, Dundee, DD1 9SY
Tel:+44 (0)138 266 0111
Fax: +44 (0)138 238 3040
Email: [email protected] dundee.ac.united kingdom

Received date: 14 August 2013; Accustomed date: 7 October 2013

Background The ascension prevalence of obesity and diabetes in Kuwait represents a significant challenge for the state's healthcare arrangement. Diabetes intendance in Scotland has improved past adopting a system of managed clinical networks supported past a nationalinformatics platform. In 2010, a Kuwait–Dundee collaboration was established with a view to transforming diabetes intendance in State of kuwait. This newspaper describes the significant progress that has been made to date. Methods The State of kuwait–Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, manufacture and authorities. KSeHIN aims to deliver a package of clinical service development, didactics (including a formal postgraduate programme and standing professional person development) and research underpinned by a comprehensivem information science system. Results The computer science arrangement includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational information. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The developed registry (KHN), implemented in iv primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-begetting postgraduate educational plan provides module-based teaching and workplace-based projects. In addition, a new clinical skills eye provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. Conclusion KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, organization performance and professional development to provide a sustainable transformationin the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

Keywords

diabetes mellitus, education and training, general practice, health system reform, primary care, quality improvement

Introduction

The Kuwait adult population has the sixth highest prevalence of diabetes in the world, affecting approximately 24% of the population.[ane] A number of potential causes for the rising trends in diabetes have been identified, including genetic predisposition, westernised diet, lack of concrete activity and limited recreational facilities. Kuwait also has ane of the highest levels of obesity in the globe. Information technology is estimated that threequarters of the adult population are overweight or obese with the latter accounting for between xxx and 50% of the population.[2,3] These problems are not restricted to the adult population. The prevalence of diabetes in children and young adults is rising, estimated to be effectually 33 per 100 000.[4] Kuwait besides has a high prevalence of overweight and obesity in children and adolescents.[v–7] As the number of cases of diabetes and obesity continues to rise these patients place an e'er increasing burden on the healthcare system.

Kuwait is situated in the Arabian Gulf and has a population of approximately 3.9million people.[8] Whilst Kuwait territory covers approximately 17 000 kmⁱⁱ, the metropolitan area is full-bodied inside 200 km², and contains approximately 97% of the total population. [nine] The population is served by the Kuwaiti healthcare system, which is free at the point of delivery and comprises most 100 primary health centres in addition to six secondary care hospitals and a further 10 hospitals offering tertiary level intendance. Health policy makers face a number of challenges in meeting the public's expectations for loftier-quality services that are easily accessible. Infrastructure and resources are largely full-bodied on treating established disease in an episodic fashion with limited connectivity between primary and secondary care systems. Investment in curative rather than preventive services has resulted in a range of secondary services provided in primary care settings. The upshot is that patients act equally consumers, often bypassing primary care in an attempt to seek a diagnosis or treatment that meets their expectations.nine In 2006, the Dasman Diabetes Institute (DDI) was established. This tertiary level centre aims to forestall and care for diabetes and other related conditions via a combination of research, training, treatment, pedagogy and health promotion.[ten] However, it is also best-selling that a transformational change in the health service is required, particularly in relation to the management and prevention of diabetes and the provision of long-term continuity of care.

Diabetes care in Scotland relies on a serial of managed clinical networks supported past a national informatics platform.[eleven] The prevalence of diabetes in Scotland has increased over the past decade.[12] Despite this, in that location has been a sequential comeback in quality performance indicators and the incidences of diabetes-related complications accept decreased.[12–14] The prevention of non-catching affliction is at present securely embeddedwithinNHS principal intendance systems.[15,xvi] By offering a package of informatics, research, instruction and clinical governance, the Kuwait–Dundee collaboration aims to learn from the Scottish experience to provide a sustainable approach to tackling the diabetes epidemic in State of kuwait.

The Kuwait–Scotland eHealth Innovation Network

The Kuwait–Scotland eHealth Innovation Network (KSeHIN) is a partnership between the Kuwait Ministry of Health (MoH), the DDI, NHS Tayside (NHST), the Academy of Dundee (UoD) and Aridhia Computer science Ltd. This international collaboration was established in October 2010 with the signing of a memorandum of understanding (MOU) outlining the scope of the project. The aims of KSeHIN are to address the enormous challenge of diabetes and its complications in Kuwait by delivering an integrated packet of clinical service evolution, education and research, all underpinned by land-of-the-fine art technology. Specifically, KSeHIN aims to enable the effective and safe treatment of patients at reduced cost through real-time integration of clinical and administrative services for disease direction, inspect and governance; to create knowledge through capacity edifice and staff development, and to achieve scientific advance through date with the international research community. In the three years post-obit the MOU, pregnant advances have been made in achieving the stated aims of KSeHIN – the collaboration was shortlisted for a 2012 Times Higher Education Laurels in recognition of this progress.[17] This paper provides an overview of KSeHIN's achievements to date, and how this international collaboration between authorities, wellness, education and manufacture has the potential to further improve healthcare delivery and outcomes.

Computer science: the Kuwait Health Network and the Childhood Onset Diabetes Electronic Registry

An integral part of the overall KSeHIN programme has been to establish an information science platform for healthcare improvement and quality balls. It was envisaged that past doing and so, the availability of real-fourth dimension patient case management data from beyond the healthcare domain would not only lead to improved health outcomes, only would also deed equally a catalyst for educational and research activities. The State of kuwait Health Network (KHN) was developed by Aridhia Informatics Ltd in collaboration with senior clinicians across master, secondary and tertiary healthcare in Kuwait to provide an computer science solution that supports integrated intendance of diabetes and its complications. The system includes a illness registry for adults with diabetes containing clinical information based on a defined dataset of coded clinical terms. The chronic disease management solution is designed to be fully integrated with existing primary and secondary intendance information technology (IT) systems and provides a unified patient view across healthcare domains.

KHN is an outcome-focused analytical application that provides healthcare professionals (HCPs) with instantly accessible information regarding current provisions of intendance. In addition,KHNprovides a secure network for the commitment of loftier-quality clinical information, data and documents. Within the secure network, patient data can flow with operational data, ensuring that healthcare professionals accept access to the most accurate confidential picture of patient health condition and the operational context in which they are beingness treated. KHN facilitates data collection, tailored for the multidisciplinary team (see Appendix i), and provides team members with a unified overview of clinical, laboratory-based and operational data. A user-attainable analytics module allows healthcare professionals to instantly view their organisation'southward achievement of key operation indicators, diabetes quality outcome measures and to stratify patients according to gamble of complications (run across Appendix 2).

Prior to implementation, connectivity was established on a national scale betwixt primary, secondary and 3rd care settings using a healthcare domain model.[18] National master care clinical data was also linked with information from four laboratory information systems at an individual patient level, providing provisional data on disease prevalence in improver to enabling information seeding of KHN.19 KHN v. ane.0 was implemented every bit a airplane pilot in the capital region of Kuwait in February 2013. There are approximately 4000 people with diabetes registered on the organization, which is currently live and being used in iv primary healthcare centres. The scalability of the system's architecture ways that national deployment is eventually possible, assuming that the pilot meets with approval from all stakeholders. In addition to providing clinical and organisational support, KHN also serves as a platform for the educational and research work streams.

A mixed methods programme of evaluation is currently underway to place facilitators and barriers to the wider adoption of the arrangement, whilst seeking feedback on the usability and usefulness of the system. Early on usage data would suggest a mixed response from the 28 HCPs involved in the airplane pilot, with local champions accessing the organization on a daily ground, in dissimilarity with minimal utilize by some others. Usability was assessed via a 46-particular questionnaire which incorporated Brooke'due south 10-item Organisation Usability Scale (SUS).[20] Responses were obtained from xx of 35 users (57%) with representation from all members of the multidisciplinary team in each of the four clinics. The mean SUS score was 64.1 (95% confidence interval [CI] 55.six–72.five) out of a possible 100. It has been suggested that developers should aim for an SUS score > 70. Scores under l are accounted unacceptable, whilst a score of 50–70 would suggest scope for improvement. [21] In addition to the questionnaire, feedback was obtained during field testing and implementation back up. Users found the organization to be useful merely the chief barrier to widespread adoption was a lack of integration with existing principal care IT systems, resulting in duplicate data entry. This was due to a disruption in the information feed which hopefully will exist reinstated, as KHN is designed to be fully integrated with such systems. Farther feedback from clinicians included the wish to formally view an assessment of their quality performance indicators (QPIs) in the format of an offline report (as well every bit being able to view QPIs interactively on KHN). This is now provided via a fully automated report generator that utilises a combination of analytical and document grooming freeware which instantly collates domain-specific results. This allows clinic leads to easily publish and disseminate a near existent-time summary of QPIs in a print/tablet-friendly format.

The Babyhood Onset Diabetes Electronic Registry (CODeR) was also developed as a collaborative project within KSeHIN. CODeR evolved from a pre-existing childhood diabetes registry which has been gathering information since 1992, as part of the WHO Multinational Collaborative Diabetes Mondiale (DiaMond) Projection.[22] Instance ascertainment procedures have been described previously.[23,24] Briefly, cases are identified past authorised individuals who undertake regular review of case records obtained from both main and secondary intendance. Data captured includes demographics, clinical presentation and family unit history. This dataset has been used to demonstrate a rising incidence of blazon 1 diabetes within the childhood population of Kuwait, resulting in one of the highest prevalences within the Gulf region.[23–25] CODeR converted the existing registry into a web-based awarding providing authorised users with instant access to population-level information for the purposes of clinical follow-upwardly of individuals, affliction surveillance, healthcare planning and the identification of population sub-groups of involvement. CODeR has collected data from each of the five health regions inside Kuwait since January 2011. In that yr, 313 new cases of diabetes in children aged up to 19 years were identified, with type 1 diabetes accounting for 88% of the cases. The overall incidence rate of blazon one diabetes was 37.1 per 100 000 per year (95% CI 32.two– 42.0) for children aged 0–fourteen years. This represents a 1.seven-fold increment in incidence in the same historic period group since 1992–97 (xx.9 per 100 000 [95% CI 18.8– 23.0] ).[24] A further 234 patients were added to the registry in 2012. Validation of the information for these patients is currently being undertaken.

Education: postgraduate courses and the State of kuwait Clinical Skills Centre

From the outset, KSeHIN has sought to establish a programme of educational activity that equips healthcare practitioners working across the entire health sector in diabetes care to make changes in the mode they exercise and evangelize intendance. This involves members of the primary care and specialist care teams. The programme is structured to enable learning to be relevant and is tailored to the cultural context in which it is being delivered. The postgraduate grade teaching is coordinated via a virtual learning environment hosted by DDI servers – the KHN Learning Zone – access to which is via users' KHN login details.

Students can enrol in a postgraduate certificate, diploma or masters in diabetes care and educational activity. The modular structure offers a rest between students' professional person development needs and the need to ensure they develop the knowledge of clinical, educational, leadership and organisational theories relevant to a multidisciplinary team approach to the management of chronic diseases within a healthcare system. By designing the assessments around workplace-based projects, students have been able to brand significant improvements in healthcare delivery in Kuwait from the outset. Qualifications from credit-bearing courses (postgraduate certificate, postgraduate diploma and MSc) are awarded by UoD, in accordance with the Scottish Credit and Qualifications Framework. The wider healthcare customs also has the opportunity to participate in boosted continuing professional evolution by registering for standalone individual modules, symposia and workshops.

Teaching is provided within the DDI education suite and the newly established Kuwait clinical skills centre. The latter, based on a similar facility in Dundee, allows students to learn new skills and explore new working practices to meliorate patient care in a safe environment with the aid of simulators. This is the first clinical skills suite of this type in the Gulf area. An inaugural clinical skills conference was hosted by the centre in 2012,[26] and it is acting as a catalyst for the development of faculty, grooming and skills in this educational discipline inside the Middle Due east. This sustainability is cardinal to ensuring the ongoing development of the utilize of simulation and enhancing reliable standards of practice in technical and non-technical skills.

Over 150 MSc students are currently enrolled and are completing modules in a range of topics including: diabetes, cardiovascular direction, eHealth, chronic disease management, facilitation and leadership, and reflective professional practise. The bulk of students work in primary care, whilst others are based in secondary care, industry and academia. To engagement, students have completed over 400 piece of work-based projects, involving: clinical audit, clinical guideline development, education skills, and leadership and change direction projects. These projects provide immediate impact in terms of improving clinical intendance – examples include: the establishment of diabetes patient instruction programmes, technology support for diabetes intendance, development of retinal screening services, and developing materials for the multicultural/multilanguage population. There is a widespread geographical distribution of students' workplaces within Kuwait which serves to demonstrate the reach of the programme in terms of the dissemination of good clinical practise (run into Figure 1). Students are encouraged to publish results, and are given the opportunity to present their piece of work at a national level via the annual 'Dasman–Dundee DiscoveryCourse' – aCPDaccredited national conference aimed at HCPs currently working in Kuwait.[27]

Effigy 1: Geographical distribution of students' workplaces in State of kuwait metropolitan area. Markers represent workplaces. Marker size is proportional to the number of students working there

Students accept been asked to reverberate on grade content, their learning and practice via questionnaires and other novel methods designed to overcome cultural barriers.[28–30] On the whole, this feedback has been positive and has direct contributed to development of course content (see Box 1).

Box ane: Free-text comments from students

Clinical governance: national standards

KSeHIN established a clinical standards committee, comprising members from primary and secondary care (MoH), college education (Kuwait University) and tertiary services (DDI), with additional input from the international clinical diabetes community. The committee developed 15 evidence-based Clinical Standards for Diabetes Intendance in Kuwait which provides clinicians, patients and researchers with clearly divers standards for optimal diabetes care.[31] The demand for multidisciplinary teamworking and effective referral procedures between primary and secondary care service providers is emphasised throughout. The standards are regularly reviewed and revised to make certain they remain relevant and up to engagement. The standards too form the basis of the key performance indicators and diabetes quality outcome measures accessible to KHN users via the analytics module. They were adopted nationally in 2011 and accept received government endorsement (encounter Box ii).

Box 2: Kuwait Regime of National Clinical Standards

Long-term continuity of care is improved by establishing a civilisation of record keeping within a comprehensive electronic system that provides connectivity between healthcare domains. Students enrolled in the postgraduate courses are all currently working within the Kuwaiti health system across a number of domains. This ensures that newly acquired skills can exist immediately applied to the working surroundings. Thus the sustainability of the programme is ensured in terms of equipping those within the healthcare arrangement with the skills necessary to implement change.

In terms of improving patient outcomes, the national clinical standards described previously include the recommendation that glycated haemoglobin (HbA1c) is measured at least every six months, serum cholesterol and body mass index (BMI) are measured annually and blood pressure (BP) is measured at each dispensary visit. By April 2013, there were 4390 registered patients, 4305 (98.1%) of whom had type ii diabetes. At this early on phase of implementation, adherence to the national standards is generally low – a minority of patients take had their cholesterol or BMI checked within the last 15 months, whilst approximately twothirds had HbA1c and BP measured in the same flow. Of those who take been screened, most patients are failing to encounter clinical targets, placing them at increased risk of long-term morbidity and mortality (see Table i). Planned KHN software releases for the coming months include: boosted QPIs, disease stratification, clinical determination support tools and tailored

Table 1: Number of patients screened for complications of diabetes and the proportion coming together current guideline targets. Data from iv primary healthcare centres within the capital region of Kuwait within a 15-month period (February 2012 to April 2013)

In addition to providing immediate access to QPIs, the coded dataset at the centre of the KHN disease registry has established a phenotypic database for those living with diabetes in State of kuwait. The scalability of the infrastructure ways that KHN has the potential to collect this data on a national scale. In improver, time to come stratified medicine research is possible by linking this repository with any emergent genomic data.

Conclusion

The over-arching aim of KSeHIN is to co-ordinate a national programme which will embed value within daily clinical practise and to provide testify for improved patient care. The achievements of the KSeHIN collaboration are the upshot of a substantial investment of fourth dimension and effort past all stakeholders. These include partners in health, educational activity, manufacture and government working beyond geographical and institutional boundaries. Local clinicians' opinions have been a disquisitional component in the development of both the KHN system and the educational program. Identifying these specific users' needs from the beginning and responding to their feedback in an iterative fashion has ensured that KSeHIN continues to run into these needs whilst remaining relevant to the cultural context into which it is existence implemented. This collaborative approach lies at the centre of KSeHIN's achievements.

Successful quality improvement interventions lead to improve patient outcomes, enhanced organisation performance and improved professional development.[32] This paper demonstrates how KSeHIN has targeted all three aspects of quality comeback to enable modify to a healthcare system that is both sustainable and scalable. KSeHIN represents a truly transformational change in diabetes clinical care and positions Kuwait as an exemplar site for engineering science innovation, integrated chronic disease management and academic health science collaboration both within Gulf and the wider international healthcare community.

Funding

This work was supported by the Ministry building of Wellness, State of kuwait.

Upstanding Approval

All clinical data were anonymised and no approvals were required.

Peer Review

Not commissioned; externally Peer Reviewed.

Conflicts of Interest

NTC and DW receive sponsorship from Aridhia Computer science Ltd. AB, AJ, GB and CK are employed by Aridhia Informatics Ltd.AMis a managing director and DS is chairman and CEO of Aridhia Informatics Ltd.

Acknowledgements

The KSeHIN collaboration is grateful for the contribution and ongoing support of the Ministry of Health, State of kuwait.

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