Successful Models of ImplementationSuccessful Models of ImplementationSuccessful Models of ImplementationSuccessful Models of Implementation

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Obstetrics

Patients with hyperglycemia

are locatedthroughout the

hospital

Patients with hyperglycemia

are locatedthroughout the

hospital

Cardiac Care

Dialysis

Emergency

Med-Surg Unit

Rehab

Home Health

Pediatrics

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ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468.

Hyperglycemia in the HospitalHyperglycemia 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 There is an increased awareness among

multiple stakeholders and a desire to change the multiple stakeholders and a desire to change the current practicecurrent practice

• There remain multiple challenges and barriers to There remain multiple challenges and barriers to practice changepractice change

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Perceived Barriers to ManagementPerceived Barriers to Managementof Inpatient Hyperglycemiaof Inpatient Hyperglycemia

• Not knowing best options to Not knowing best options to treat hyperglycemiatreat hyperglycemia

• Not knowing what insulin type Not knowing what insulin type or regimen works bestor regimen works best

• Not knowing how or when to Not knowing how or when to start insulinstart insulin

• Not knowing how to adjust Not knowing how to adjust insulininsulin

• Risk of hypoglycemiaRisk of hypoglycemia• Unpredictable timing of patient Unpredictable timing of patient

proceduresprocedures• Unpredictable changes in Unpredictable changes in

patient diet and mealtimespatient diet and mealtimes

• Glucose management notGlucose management notadequately addressed on adequately addressed on roundsrounds

• Patient not in hospital long Patient not in hospital long enough to control glucose enough to control glucose adequatelyadequately

• Lack of guidelines on how toLack of guidelines on how totreat hyperglycemiatreat hyperglycemia

• Preferring to defer Preferring to defer management to outpatient management to outpatient care or to another specialtycare or to another specialty

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AACE/ADA Major Recommendations AACE/ADA Major Recommendations for Optimal Glycemic Management for Optimal Glycemic Management

in Hospitalized Patientsin Hospitalized Patients

• Identify elevated blood glucose in all hospitalized Identify elevated blood glucose in all hospitalized patientspatients

• Establish a multidisciplinary team approach toEstablish a multidisciplinary team approach todiabetes management in all hospitalsdiabetes management in all hospitals

• Implement structured protocols for aggressive Implement structured protocols for aggressive control of blood glucose in ICUs and other hospital control of blood glucose in ICUs and other hospital settingssettings

• Create educational programs for all hospital Create educational programs for all hospital personnel caring for people with diabetespersonnel caring for people with diabetes

• Plan for a smooth transition to outpatient care with Plan for a smooth transition to outpatient care with appropriate diabetes managementappropriate diabetes management

Moghissi ES, et al. Endocrine Pract. 2009;15:353-369. 5

Successful Strategies for Implementation Successful Strategies for Implementation

• Champion(s) Champion(s) • Administrative supportAdministrative support• Multidisciplinary steering committee to drive the Multidisciplinary steering committee to drive the

development of initiativesdevelopment of initiatives– Medical staff, nursing and case management, Medical staff, nursing and case management,

pharmacy, nutrition services, dietary, laboratory, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, quality improvement, information systems, administrationadministration

• Assessment of current processes, quality of Assessment of current processes, quality of care, and barriers to practice changecare, and barriers to practice change

American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10:77-82. 6

Development and ImplementationDevelopment and Implementation

• Standardized order setsStandardized order sets– BG measurementBG measurement– Treatment of hyperglycemia AND hypoglycemiaTreatment of hyperglycemia AND hypoglycemia

• Protocols, algorithms Protocols, algorithms • PoliciesPolicies• Educational programs (physicians and nurses)Educational programs (physicians and nurses)• Glycemic management clinical team Glycemic management clinical team • Metrics for evaluation Metrics for evaluation

American College of Endocrinology Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10:77-82. 7

Standardize Insulin TherapyStandardize 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 SCIV to SC– Back to ambulatory regimenBack to ambulatory regimen

• Guidelines for special situationsGuidelines for special situations– Enteral nutritionEnteral nutrition– Parenteral nutritionParenteral nutrition

Moghissi ES, et al. Endocrine Pract. 2009;15:353-369. 8

Metrics for EvaluationMetrics for Evaluation

• A system to track hospital glucose data on an A system to track hospital glucose data on an ongoing basis can be used to:ongoing basis can be used to:– Assess the quality of care deliveredAssess the quality of care delivered– Allow for continuous improvement of processes and Allow for continuous improvement of processes and

protocolsprotocols– Provide momentumProvide momentum

ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-68. 9

SUCCESSFUL MODELSSUCCESSFUL MODELSConsultant ModelConsultant Model

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Endocrinologist as a ConsultantEndocrinologist as a Consultant

• Endocrinologist is called in to consult on patients Endocrinologist is called in to consult on patients identified with diabetes or hyperglycemiaidentified with diabetes or hyperglycemia

• Writes orders and communicates the plan to Writes orders and communicates the plan to othersothers

• Follows patients throughout hospital stay, makes Follows patients throughout hospital stay, makes therapeutic adjustmentstherapeutic adjustments

• Coordinates discharge and follow-up visitsCoordinates discharge and follow-up visits

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Advantages of the Consultant ModelAdvantages of the Consultant Model

• Positions endocrinologists as leading experts in Positions endocrinologists as leading experts in inpatient glycemic control practiceinpatient glycemic control practice

• Can bill for servicesCan bill for services

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Disadvantages of the Consultant ModelDisadvantages of the Consultant Model

• If nearly 40% of hospital inpatients have If nearly 40% of hospital inpatients have hyperglycemia, endocrinologist consultant hyperglycemia, endocrinologist consultant cannot care for all of themcannot care for all of them

• Must wait for a consulting requestMust wait for a consulting request– May not be called each time it is appropriateMay not be called each time it is appropriate

• Knowledge and skills are limited to few Knowledge and skills are limited to few personnelpersonnel

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Keys to Success With theKeys to Success With theConsultant ModelConsultant Model

• Hospital-wide understanding of the importance Hospital-wide understanding of the importance of calling for an endocrinologist consultof calling for an endocrinologist consult

• Ability to tap in to other resources to manage Ability to tap in to other resources to manage large volumes of patientslarge volumes of patients

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SUCCESSFUL MODELSSUCCESSFUL MODELSDiabetes Team ModelDiabetes Team Model

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Newton CA, et al. Endocr Pract. 2006;12(suppl 3):43-48.

Diabetes Team ModelDiabetes Team Model

EndocrinologistEndocrinologist

• Acts as medical directorActs as medical director• Leads a multidisciplinary team Leads a multidisciplinary team

to manage patient care on an to manage patient care on an ongoing basisongoing basis

Nurse Practitioner or Nurse Practitioner or

Advanced Practice NurseAdvanced Practice Nurse

• Acts as case managerActs as case manager• Interacts daily with residents, Interacts daily with residents,

attending physicians, and attending physicians, and nursing staff to improve nursing staff to improve glycemic managementglycemic management

• Conducts patient screenings to Conducts patient screenings to identify those with elevated identify those with elevated glucose levelsglucose levels

• Uncovers opportunities for Uncovers opportunities for improvement in glycemic improvement in glycemic management and makes management and makes recommendations to the recommendations to the medical teammedical team

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Advantages of the Team ModelAdvantages of the Team Model

• Strengthens multidisciplinary approach to careStrengthens multidisciplinary approach to careof patients with diabetes or hyperglycemiaof patients with diabetes or hyperglycemia

• Allows each professional to share different areas Allows each professional to share different areas of expertise while standardizing systemsof expertise while standardizing systems

• Clinical staff can become more specialized in Clinical staff can become more specialized in effective diabetes managementeffective diabetes management– Enhanced opportunities for higher level trainingEnhanced opportunities for higher level training

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Disadvantages of the Team ModelDisadvantages of the Team Model

• Administrative and medical staff leadership must Administrative and medical staff leadership must see this as a priority and devote resourcessee this as a priority and devote resources

• Does not change culture to become more Does not change culture to become more focused on diabetes hospital-widefocused on diabetes hospital-wide

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Keys to Success With the Team ModelKeys to Success With the Team Model

• Must have streamlined, effective communication Must have streamlined, effective communication between team membersbetween team members

• Systems must effectively identify hyperglycemic Systems must effectively identify hyperglycemic patients early in the stay to allow the team to patients early in the stay to allow the team to manage the caremanage the care

• Continuous education must be provided Continuous education must be provided systematically throughout the institutionsystematically throughout the institution– Can be a combination of didactics, online learning, Can be a combination of didactics, online learning,

bedside rounds, etcbedside rounds, etc

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SUCCESSFUL MODELSSUCCESSFUL MODELSSystem-Wide ModelSystem-Wide Model

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Olson L, et al. Endocr Pract. 2006;12(suppl 3):35-42.

System-Wide ModelSystem-Wide Model

• Endocrinologist oversees hospital-wide program, Endocrinologist oversees hospital-wide program, which trains all clinical staff to identify and assist in which trains all clinical staff to identify and assist in managing patients with diabetesmanaging patients with diabetes

• Systematic hospital-wide program with allSystematic hospital-wide program with allmembers of the clinical team enhancing diabetesmembers of the clinical team enhancing diabetesknowledge and skillsknowledge and skills

• Endocrinologist serves as “champion” and oversees Endocrinologist serves as “champion” and oversees development and implementation of protocolsdevelopment and implementation of protocols– Available as resource for complex casesAvailable as resource for complex cases

• All clinical staff undergo training on diabetes and All clinical staff undergo training on diabetes and hyperglycemiahyperglycemia– Diabetes nurses serve as resources to house staffDiabetes nurses serve as resources to house staff– Floor nurses manage routine care based on protocolsFloor nurses manage routine care based on protocols

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Advantages of theAdvantages of theSystem-Wide ModelSystem-Wide Model

• Achieve hospital-wide culture change when all Achieve hospital-wide culture change when all clinical employees work toward a common goalclinical employees work toward a common goal

• Effective resource utilization by disseminating skills Effective resource utilization by disseminating skills and knowledge throughout the hospitaland knowledge throughout the hospital

• Facilitates standardization while respecting unit Facilitates standardization while respecting unit cultureculture

• Offers opportunities for systematic program rolloutOffers opportunities for systematic program rollout– Evidence-based training can be offered hospital-wide or Evidence-based training can be offered hospital-wide or

rolled out gradually by coordinating between units “linked” rolled out gradually by coordinating between units “linked” by routine flow of patients for consistency of careby routine flow of patients for consistency of care

– Surgery Surgery ►► Intensive Care Intensive Care ►► Med Surg Med Surg

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Disadvantages of theDisadvantages of theSystem-Wide ModelSystem-Wide Model

• Units may “backslide” if no ongoing monitoring/ Units may “backslide” if no ongoing monitoring/ accountabilityaccountability

• More difficult to control day-to-day adherence to More difficult to control day-to-day adherence to glycemic control practiceglycemic control practice

• Staff turnover creates need for ongoing training/ Staff turnover creates need for ongoing training/ awarenessawareness

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Keys to Success With theKeys to Success With theSystem-Wide ModelSystem-Wide Model

• Commitment from top levels of clinical and Commitment from top levels of clinical and administrative teamsadministrative teams

• Ongoing results monitoring of clinical and financial Ongoing results monitoring of clinical and financial improvementimprovement– Sharing results system-wideSharing results system-wide

• Active involvement of all key departmentsActive involvement of all key departments– Nursing, lab, information services, billing, dietary, Nursing, lab, information services, billing, dietary,

education, and so oneducation, and so on

• Communication and maintenance of a high level of Communication and maintenance of a high level of awareness among staff and physicians throughoutawareness among staff and physicians throughoutthe systemthe system

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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

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

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JOINT COMMISSION’S JOINT COMMISSION’S DISEASE-SPECIFIC DISEASE-SPECIFIC CERTIFICATIONCERTIFICATION

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The Joint Commission. http://www.jointcommission.org/certification/certification_main.aspx

Joint Commission’sJoint Commission’sDisease-Specific Care CertificationDisease-Specific Care Certification

• The Joint Commission’s Disease-Specific Care The Joint Commission’s Disease-Specific Care Certification Program evaluates disease Certification Program evaluates disease management and chronic care services provided by management and chronic care services provided by direct care providers such as hospitalsdirect care providers such as hospitals

• Certification is available for virtually any chronic Certification is available for virtually any chronic disease or conditiondisease or condition

• Certification decision is based on assessment ofCertification decision is based on assessment of– Compliance with consensus-based national standardsCompliance with consensus-based national standards– Effective use of evidence-based clinical practice guidelines Effective use of evidence-based clinical practice guidelines

to manage and optimize careto manage and optimize care– An organized approach to performance measurement and An organized approach to performance measurement and

improvement activitiesimprovement activities

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The Joint Commission. http://www.jointcommission.org/assets/1/18/Benefits_of_Certification.pdf

Benefits of Joint CommissionBenefits of Joint CommissionDisease-Specific Care CertificationDisease-Specific Care Certification

• Improves the quality of patient care by reducing variation Improves the quality of patient care by reducing variation in clinical processesin clinical processes

• Provides a framework for program structure and Provides a framework for program structure and managementmanagement

• 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 Strengthens community confidence in the quality and

safety of care, treatment, and servicessafety 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

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Scope of Joint CommissionScope of Joint CommissionInpatient Diabetes CertificationInpatient Diabetes Certification

ProcessADA Clinical Practice

Guidelines embedded in care processes

ProcessADA 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 Quality and safety of care safety of care for inpatients for inpatients with diabeteswith diabetes

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Joint Commission Standards forJoint Commission Standards forDisease-Specific Care Certification:Disease-Specific Care Certification:

OverviewOverview• 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

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Joint Commission Joint Commission Inpatient Diabetes Inpatient Diabetes Certification: Certification: Key RequirementsKey Requirements

• Designated multidisciplinary team and team Designated multidisciplinary team and team leaderleader

• Staff education in diabetes managementStaff education in diabetes management• Medical record identifies diabetes mellitus Medical record identifies diabetes mellitus

(existing or newly diagnosed)(existing or newly diagnosed)• Plan coordinating insulin administration and Plan coordinating insulin administration and

meal deliverymeal delivery• Nutritional assessments for patients not Nutritional assessments for patients not

consistently reaching glucose targetsconsistently reaching glucose targets

The Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 31

Joint Commission Joint Commission Inpatient Diabetes Inpatient Diabetes Certification: Certification: Key RequirementsKey Requirements

• Written protocols for the management of Written protocols for the management of patients on patients on IV insulin infusionsIV insulin infusions

• PI program evaluates episodes of hypoglycemia for PI program evaluates episodes of hypoglycemia for root causes and trendsroot causes and trends

• Blood glucose monitoring protocolsBlood glucose monitoring protocols• A1C results available for patients with known A1C results available for patients with known

diabetesdiabetes• Blood glucose monitoring results available for all Blood glucose monitoring results available for all

team membersteam members• Individualized plan for treatment of hypoglycemia Individualized plan for treatment of hypoglycemia

and hyperglycemiaand hyperglycemiaThe Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 32

Joint Commission Joint Commission Inpatient Diabetes Inpatient Diabetes Certification: Certification: Key RequirementsKey Requirements

• Patient comprehension of self-management Patient comprehension of self-management documented in medical recorddocumented in medical record

• Patient education componentsPatient education components– Use of personal glucose monitorUse of personal glucose monitor

– Meal plan managementMeal plan management

– Medication administration instructions (oral agents and Medication administration instructions (oral agents and injectable medications)injectable medications)

– Signs and symptoms of hyperglycemia and hypoglycemiaSigns and symptoms of hyperglycemia and hypoglycemia

– Treatment of hyperglycemia and hypoglycemiaTreatment of hyperglycemia and hypoglycemia

– Emergency contact informationEmergency contact information

– Additional education/resourcesAdditional education/resourcesThe Joint Commission. Inpatient Diabetes Care Certification Teleconference. December 9, 2009. http://www.jointcommission.org/certification/inpatient_diabetes.aspx. 33