1. Successful Models of Implementation 1

2. The 4 Spheres of a Quality Inpatient Glucose Management Program 2

3. 1 Recognition as a hospital priority Administrative supportAdministrative support Physician, nursing, pharmacy, dietary championsPhysician, nursing, pharmacy, dietary champions Appointment of a multidisciplinary hyperglycemia committeeAppointment of a multidisciplinary hyperglycemia committee 3

4. Arguments to Encourage Prioritization by Hospitals Emphasis on qualityEmphasis on quality Emphasis on patient safetyEmphasis on patient safety Patient/family satisfactionPatient/family satisfaction Competitive advantageCompetitive advantage Cost savingsCost savings The Joint Commission certificationThe Joint Commission certification Long-term educational benefits for traineesLong-term educational benefits for trainees 4

5. The 4 Spheres of a Quality Inpatient Glucose Management Program Institution-wide training efforts Physicians (attendings, residents)Physicians (attendings, residents) Nursing staffNursing staff PharmacistsPharmacists Medical assistantsMedical assistants DieticiansDieticians Patients and familiesPatients and families 2 5

6. The 4 Spheres of a Quality Inpatient Glucose Management Program Patient care protocols Patient identification strategy Patient identification strategy Formularies Formularies Policies and procedures Policies and procedures Blood glucose monitoring/A1C testing Blood glucose monitoring/A1C testing Glucose targets Glucose targets IV insulin infusions (with transitions) IV insulin infusions (with transitions) SC insulin order sets SC insulin order sets Hypoglycemia protocol Hypoglycemia protocol Insulin pump policy Insulin pump policy 3 6

7. The 4 Spheres of a Quality Inpatient Glucose Management Program Patient care protocols (cont’d) Inpatient diabetes management team Inpatient diabetes management team Discharge planning and transitions to outpatient care Discharge planning and transitions to outpatient care 3 7

8. The 4 Spheres of a Quality Inpatient Glucose Management Program Glucometrics Systematic acquisition, compilation, organization, reporting, and review of hospital blood glucose data and glycemia- related outcomes Systematic acquisition, compilation, organization, reporting, and review of hospital blood glucose data and glycemia- related outcomes 4 8

9. Obstetrics Patients with hyperglycemia are located throughout the hospital Cardiac CareDialysisEmergencyMed-Surg UnitRehabHome HealthPediatrics 9

10. ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468. Hyperglycemia in the Hospital A quality of care issueA quality of care issue A patient safety issueA patient safety issue A length of stay issue and a cost issueA length of stay issue and a cost issue There is an increased awareness among multiple stakeholders and a desire to change the current practiceThere is an increased awareness among multiple stakeholders and a desire to change the current practice There remain multiple challenges and barriers to practice changeThere remain multiple challenges and barriers to practice change 10

11. Perceived Barriers to Management of Inpatient Hyperglycemia Not knowing best options to treat hyperglycemiaNot knowing best options to treat hyperglycemia Not knowing what insulin type or regimen works bestNot knowing what insulin type or regimen works best Not knowing how or when to start insulinNot knowing how or when to start insulin Not knowing how to adjust insulinNot knowing how to adjust insulin Risk of hypoglycemiaRisk of hypoglycemia Unpredictable timing of patient proceduresUnpredictable timing of patient procedures Unpredictable changes in patient diet and mealtimesUnpredictable changes in patient diet and mealtimes Glucose management not adequately addressed on rounds Patient not in hospital long enough to control glucose adequately Lack of guidelines on how to treat hyperglycemia Preferring to defer management to outpatient care or to another specialty 11

12. AACE/ADA Major Recommendations for Optimal Glycemic Management in Hospitalized Patients Identify elevated blood glucose in all hospitalized patientsIdentify elevated blood glucose in all hospitalized patients Establish a multidisciplinary team approach to diabetes management in all hospitalsEstablish a multidisciplinary team approach to diabetes management in all hospitals Implement structured protocols for aggressive control of blood glucose in ICUs and other hospital settingsImplement structured protocols for aggressive control of blood glucose in ICUs and other hospital settings Create educational programs for all hospital personnel caring for people with diabetesCreate educational programs for all hospital personnel caring for people with diabetes Plan for a smooth transition to outpatient care with appropriate diabetes managementPlan for a smooth transition to outpatient care with appropriate diabetes management Moghissi ES, et al. Endocrine Pract. 2009;15:353-369. 12

13. Successful Strategies for Implementation Champion(s)Champion(s) Administrative supportAdministrative support Multidisciplinary steering committee to drive the development of initiativesMultidisciplinary steering committee to drive the development of initiatives –Medical staff, nursing and case management, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, administration Assessment of current processes, quality of care, and barriers to practice changeAssessment of current processes, quality of care, and barriers to practice change American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10:77-82. 13

14. Development and Implementation Standardized order setsStandardized order sets –BG measurement –Treatment of hyperglycemia AND hypoglycemia Protocols, algorithmsProtocols, algorithms PoliciesPolicies Educational programs (physicians and nurses)Educational programs (physicians and nurses) Glycemic management clinical teamGlycemic management clinical team Metrics for evaluationMetrics for evaluation American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10:77-82. 14

15. Standardize Insulin Therapy Single insulin infusion concentrationSingle insulin infusion concentration Single insulin infusion protocolSingle insulin infusion protocol SC insulin order setSC insulin order set Hypoglycemia protocolHypoglycemia protocol Guidelines for transitionsGuidelines for transitions –IV to SC –Back to ambulatory regimen Guidelines for special situationsGuidelines for special situations –Enteral nutrition –Parenteral nutrition Moghissi ES, et al. Endocrine Pract. 2009;15:353-369. 15

16. Metrics for Evaluation A system to track hospital glucose data on an ongoing basis can be used to:A system to track hospital glucose data on an ongoing basis can be used to: –Assess the quality of care delivered –Allow for continuous improvement of processes and protocols –Provide momentum ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-68. 16

17. SUCCESSFUL MODELS Consultant Model 17

18. Endocrinologist as a Consultant Endocrinologist is called in to consult on patients identified with diabetes or hyperglycemiaEndocrinologist is called in to consult on patients identified with diabetes or hyperglycemia Writes orders and communicates the plan to othersWrites orders and communicates the plan to others Follows patients throughout hospital stay, makes therapeutic adjustmentsFollows patients throughout hospital stay, makes therapeutic adjustments Coordinates discharge and follow-up visitsCoordinates discharge and follow-up visits 18

19. Advantages of the Consultant Model Positions endocrinologists as leading experts in inpatient glycemic control practicePositions endocrinologists as leading experts in inpatient glycemic control practice Can bill for servicesCan bill for services 19

20. Disadvantages of the Consultant Model If nearly 40% of hospital inpatients have hyperglycemia, endocrinologist consultant cannot care for all of themIf nearly 40% of hospital inpatients have hyperglycemia, endocrinologist consultant cannot care for all of them Must wait for a consulting requestMust wait for a consulting request –May not be called each time it is appropriate Knowledge and skills are limited to few personnelKnowledge and skills are limited to few personnel 20

21. Keys to Success With the Consultant Model Hospital-wide understanding of the importance of calling for an endocrinologist consultHospital-wide understanding of the importance of calling for an endocrinologist consult Ability to tap in to other resources to manage large volumes of patientsAbility to tap in to other resources to manage large volumes of patients 21

22. SUCCESSFUL MODELS Diabetes Team Model 22

23. Newton CA, et al. Endocr Pract. 2006;12(suppl 3):43-48. Diabetes Team Model Endocrinologist Acts as medical director Leads a multidisciplinary team to manage patient care on an ongoing basis Nurse Practitioner or Advanced Practice Nurse Acts as case manager Interacts daily with residents, attending physicians, and nursing staff to improve glycemic management Conducts patient screenings to identify those with elevated glucose levels Uncovers opportunities for improvement in glycemic management and makes recommendations to the medical team 23

24. Advantages of the Team Model Strengthens multidisciplinary approach to care of patients with diabetes or hyperglycemiaStrengthens multidisciplinary approach to care of patients with diabetes or hyperglycemia Allows each professional to share different areas of expertise while standardizing systemsAllows each professional to share different areas of expertise while standardizing systems Clinical staff can become more specialized in effective diabetes managementClinical staff can become more specialized in effective diabetes management –Enhanced opportunities for higher level training 24

25. Disadvantages of the Team Model Administrative and medical staff leadership must see this as a priority and devote resourcesAdministrative and medical staff leadership must see this as a priority and devote resources Does not change culture to become more focused on diabetes hospital-wideDoes not change culture to become more focused on diabetes hospital-wide 25

26. Keys to Success With the Team Model Must have streamlined, effective communication between team membersMust have streamlined, effective communication between team members Systems must effectively identify hyperglycemic patients early in the stay to allow the team to manage the careSystems must effectively identify hyperglycemic patients early in the stay to allow the team to manage the care Continuous education must be provided systematically throughout the institutionContinuous education must be provided systematically throughout the institution –Can be a combination of didactics, online learning, bedside rounds, etc 26

27. SUCCESSFUL MODELS System-Wide Model 27

28. Olson L, et al. Endocr Pract. 2006;12(suppl 3):35-42. System-Wide Model Endocrinologist oversees hospital-wide program, which trains all clinical staff to identify and assist in managing patients with diabetesEndocrinologist oversees hospital-wide program, which trains all clinical staff to identify and assist in managing patients with diabetes Systematic hospital-wide program with all members of the clinical team enhancing diabetes knowledge and skillsSystematic hospital-wide program with all members of the clinical team enhancing diabetes knowledge and skills Endocrinologist serves as “champion” and oversees development and implementation of protocolsEndocrinologist serves as “champion” and oversees development and implementation of protocols –Available as resource for complex cases All clinical staff undergo training on diabetes and hyperglycemiaAll clinical staff undergo training on diabetes and hyperglycemia –Diabetes nurses serve as resources to house staff –Floor nurses manage routine care based on protocols 28

29. Advantages of the System-Wide Model Achieve hospital-wide culture change when all clinical employees work toward a common goalAchieve hospital-wide culture change when all clinical employees work toward a common goal Effective resource utilization by disseminating skills and knowledge throughout the hospitalEffective resource utilization by disseminating skills and knowledge throughout the hospital Facilitates standardization while respecting unit cultureFacilitates standardization while respecting unit culture Offers opportunities for systematic program rolloutOffers opportunities for systematic program rollout –Evidence-based training can be offered hospital-wide or rolled out gradually by coordinating between units “linked” by routine flow of patients for consistency of care –Surgery ► Intensive Care ► Med Surg 29

30. Disadvantages of the System-Wide Model Units may “backslide” if no ongoing monitoring/ accountabilityUnits may “backslide” if no ongoing monitoring/ accountability More difficult to control day-to-day adherence to glycemic control practiceMore difficult to control day-to-day adherence to glycemic control practice Staff turnover creates need for ongoing training/ awarenessStaff turnover creates need for ongoing training/ awareness 30

31. Keys to Success With the System-Wide Model Commitment from top levels of clinical and administrative teamsCommitment from top levels of clinical and administrative teams Ongoing results monitoring of clinical and financial improvementOngoing results monitoring of clinical and financial improvement –Sharing results system-wide Active involvement of all key departmentsActive involvement of all key departments –Nursing, lab, information services, billing, dietary, education, and so on Communication and maintenance of a high level of awareness among staff and physicians throughout the systemCommunication and maintenance of a high level of awareness among staff and physicians throughout the system 31

32. The Choice Is Yours! Each hospital has different internal systems and resources available to implement an effective diabetes management program You can start by assessing your facility and its systems. You may choose to begin using a certain model, then change as the program develops 32

33. JOINT COMMISSION’S DISEASE-SPECIFIC CERTIFICATION 33

34. The Joint Commission. http://www.jointcommission.org/certification/certification_main.aspx Joint Commission’s Disease-Specific Care Certification The Joint Commission’s Disease-Specific Care Certification Program evaluates disease management and chronic care services provided by direct care providers such as hospitalsThe Joint Commission’s Disease-Specific Care Certification Program evaluates disease management and chronic care services provided by direct care providers such as hospitals Certification is available for virtually any chronic disease or conditionCertification is available for virtually any chronic disease or condition Certification decision is based on assessment ofCertification decision is based on assessment of –Compliance with consensus-based national standards –Effective use of evidence-based clinical practice guidelines to manage and optimize care –An organized approach to performance measurement and improvement activities 34

35. The Joint Commission. http://www.jointcommission.org/assets/1/18/Benefits_of_Certification.pdf Benefits of Joint Commission Disease-Specific Care Certification Improves the quality of patient care by reducing variation in clinical processesImproves the quality of patient care by reducing variation in clinical processes Provides a framework for program structure and managementProvides a framework for program structure and management Provides an objective assessment of clinical excellenceProvides an objective assessment of clinical excellence Creates a loyal, cohesive clinical teamCreates a loyal, cohesive clinical team Promotes a culture of excellence across the organizationPromotes a culture of excellence across the organization Facilitates marketing, contracting, and reimbursementFacilitates marketing, contracting, and reimbursement Strengthens community confidence in the quality and safety of care, treatment, and servicesStrengthens community confidence in the quality and safety of care, treatment, and services Recognized by select insurers and other third partiesRecognized by select insurers and other third parties Can fulfill regulatory requirements in select statesCan fulfill regulatory requirements in select states 35

36. Scope of Joint Commission Inpatient Diabetes Certification Process ADA Clinical Practice Guidelines embedded in care processes Process ADA Clinical Practice Guidelines embedded in care processes Structure Compliance with 28 national consensus-based standards Structure Compliance with 28 national consensus-based standards Outcome Use of performance measurement data for performance improvement initiatives Outcome Use of performance measurement data for performance improvement initiatives The Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. Quality and safety of care for inpatients with diabetes 36

37. Joint Commission Standards for Disease-Specific Care Certification: Overview Program managementProgram management Clinical information managementClinical information management Delivering or facilitating clinical careDelivering or facilitating clinical care Supporting self-managementSupporting self-management Performance measurement and improvementPerformance measurement and improvement 37

38. Joint Commission Inpatient Diabetes Certification: Key Requirements Designated multidisciplinary team and team leaderDesignated multidisciplinary team and team leader Staff education in diabetes managementStaff education in diabetes management Medical record identifies diabetes mellitus (existing or newly diagnosed)Medical record identifies diabetes mellitus (existing or newly diagnosed) Plan coordinating insulin administration and meal deliveryPlan coordinating insulin administration and meal delivery Nutritional assessments for patients not consistently reaching glucose targetsNutritional assessments for patients not consistently reaching glucose targets The Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 38

39. Joint Commission Inpatient Diabetes Certification: Key Requirements Written protocols for the management of patients on IV insulin infusionsWritten protocols for the management of patients on IV insulin infusions PI program evaluates episodes of hypoglycemia for root causes and trendsPI program evaluates episodes of hypoglycemia for root causes and trends Blood glucose monitoring protocolsBlood glucose monitoring protocols A1C results available for patients with known diabetesA1C results available for patients with known diabetes Blood glucose monitoring results available for all team membersBlood glucose monitoring results available for all team members Individualized plan for treatment of hypoglycemia and hyperglycemiaIndividualized plan for treatment of hypoglycemia and hyperglycemia The Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 39

40. Joint Commission Inpatient Diabetes Certification: Key Requirements Patient comprehension of self-management documented in medical recordPatient comprehension of self-management documented in medical record Patient education componentsPatient education components –Use of personal glucose monitor –Meal plan management –Medication administration instructions (oral agents and injectable medications) –Signs and symptoms of hyperglycemia and hypoglycemia –Treatment of hyperglycemia and hypoglycemia –Emergency contact information –Additional education/resources The Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 40