Glycemic Management Committees: A Team Approach to Optimizing Care and Preparing for CMS Measures

Read our recent blog, Three Heads Are Better Than One: The Effect of New CMS Measures on Nurses, Dietitians, and Certified Diabetes Care and Education Specialists

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EPISODE TRANSCRIPT

Jodi Lavin-Tompkins:

Hello and welcome to ADCES's podcast, The Huddle: Conversations with the Diabetes Care Team. In each episode, we speak with guests across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm your host, Jody Lavin-Tompkins, a board certified nurse in advanced diabetes management and the director of accreditation and content development at the Association of Diabetes Care and Education Specialists. Our guest today is Hannah Day, a nurse practitioner and certified diabetes care and education specialist, who is also board certified in advanced diabetes management and is the director of clinical practice at Glytec. She's here to talk about what a glycemic management committee is and how creating a multidisciplinary team across the health system, both inpatient and outpatient, is an effective strategy to optimize glycemic management, improve patient safety, and help your hospital prepare for the new CMS measures. This episode is sponsored by Glytec. Glytec's eGlycemic management system centers on Glucomander, the only cloud-based FDA-cleared for patients with and without diabetes. Hannah, welcome to The Huddle.

Hannah Day:

Thank you for having me.

Jodi Lavin-Tompkins:

I would first like you to tell our listeners a little bit about your background and how you found yourself in the world of inpatient glycemic management.

Hannah Day:

Well, my healthcare career has focused on diabetes management for the past 15 years, first as an RN diabetes educator, then a CDCES, and then a nurse practitioner. Prior to joining Glytec, I served in multiple clinical and leadership roles at Northeast Georgia Health System, one as a diabetes program manager for the inpatient and outpatient program, and as administrative director for hospital medicine. In these roles, I led initiatives including implementation of Glucomander, building an Epic quality dashboard, and developing an inpatient glycemic management team. I also served as the project owner for the health system's multi-year quality and safety initiative to improve diabetes care across the continuum. As the project owner, I led and facilitated a glycemic management committee which oversaw multiple quality improvement initiatives around diabetes in both the inpatient and outpatient setting. But improving diabetes care has been a mission of mine for many years. My mother has type 1 diabetes and one of my long-term drivers is ensuring she would receive good care if ever in the hospital.

Jodi Lavin-Tompkins:

So this is somewhat personal to you then because you have this in your family. And so I'm sure there are some common challenges with inpatient glycemic management that you're helping all of your partners through in your role as the director of clinical practice at Glytec. So I'm wondering if you could share what some of these challenges are.

Hannah Day:

We do see common challenges across healthcare systems. One is a knowledge gap in inpatient glycemic management and diabetes management in general, especially understanding insulin therapy. Another challenge is establishing and adhering to the best practices when it comes to managing insulin in the hospital. Insulin therapy, as we all know, is recommended for managing hyperglycemia in the inpatient setting. So safely initiating insulin therapy and then safely transitioning the patient to an appropriate home regimen requires a good understanding of these best practices. Even though patients are in the hospital for a limited number of days, hopefully, this is a time when they're most vulnerable and at high risk for harm. And insulin's a high risk medication. There are many variables that must be taken into account when it comes to safely prescribing and administering insulin. And finally, coordination of care when there are multiple people involved can present challenges. Nurses, diabetes care and education specialists, physician residents, attendings, case managers, dietitians, and most importantly the patient, are all working to coordinate care during hospitalization while also planning the transition back to the outpatient setting. So we have to foster collaboration and ensure clinicians across the continuum have access to the information they need when it's needed. So as the Director of Clinical Practice at Glitech, I work with our partners to address and try to overcome these challenges. We focus on three main categories and that's people, process, and technology. Leveraging the people and teams they have to establish processes and use technology like eGlycemic management systems to hardwire best practices and standardize the transitions of care.

Jodi Lavin-Tompkins:

Okay, so it sounds like it comes down to people, processes, and technology, and how you put all of that together. I believe you've done that, Hannah, through your glycemic management committees you've served on. So can you give a high-level overview of the concept of a glycemic management committee, starting with what it is?

Hannah Day:

Absolutely. So at a high level, a glycemic management committee is a multidisciplinary team of subject matter experts and leadership roles who are both directing and leading quality improvement around diabetes management. Two key functions or characteristics of the committee that I want to highlight are the partnership among the clinical experts and the leaders on the committee and the quality improvement framework. The committee should follow a quality improvement framework, which includes assessing the current state and the current data available, then identifying gaps in care and the root causes of those gaps, and creating processes to address them, and then ongoing monitoring of process and outcome metrics.

Jodi Lavin-Tompkins:

Well, you mentioned partnership among the clinical experts and leadership. So in this type of quality improvement framework, then what specific roles would normally be included in a glycemic management committee?

Hannah Day:

The committee should include your subject matter experts in diabetes management that would include representation from pharmacy, dietary and nutrition, nursing, physicians. Also represented should be quality improvement experts in your organization, along with clinical leadership from nursing, pharmacy and physicians. It should include IT representation along with your informaticists and the lab too, your point of care coordinators should definitely be represented on the committee. But I do wanna point out both inpatient and outpatient clinical roles are ideally represented as the goals of the committee can be related to measures across both of these settings, as well as the transitions in between, ensuring that you're taking a population health approach.

Jodi Lavin-Tompkins:

Well, that's an important point that even though the committee is based in the inpatient setting, you said that outpatient representation is important. So to expand on that, can you tell our listeners where a committee like this fits into a hospital's organizational structure?

Hannah Day:

Well, leadership support and visibility into the work is essential and therefore how the committee fits into the organizational structure, as you mentioned, is key. Ideally, the committee is structured to report up to a larger safety or quality committee. And it's also important that the goals of the committee align with the organization's larger strategic goals, whether those be safety related or quality related. And that's key to ensure leadership support of the goals and the efforts of the glycemic management committee.

Jodi Lavin-Tompkins:

Yeah, and I can imagine that alignment with larger goals of the organization would really be key. So why do you think it's essential for a hospital to have a glycemic management committee?

Hannah Day:

Well, it's essential for all hospitals to have quality improvement as a priority. Also, more than a third of hospitalized patients have diabetes or glycemic management issues. Even though diabetes may not be the principal reason that a patient is hospitalized, we know the importance of optimally managing diabetes or hyperglycemia in the hospital to ensure safety and to reduce mortality. At Northeast Georgia Health System, we looked at our data and we found that, just like many other hospitals across the United States, about a third of our patients have a diagnosis of diabetes or hyperglycemia. And the impact of diabetes is seen across all departments, not just a few. We also noted that 45% of our 30-day readmissions had a diabetes diagnosis and that's almost half of readmissions. So with such a large portion of the inpatient population affected by diabetes, having a cross-functional, multidisciplinary group of people who are focused on quality of care and patient safety around glycemic management is necessary to drive change, to sustain and hardwire standard processes that you're working to put in place and ultimately to improve outcomes.

Jodi Lavin-Tompkins:

I like that you said that because it stands to reason that when you improve outcomes, you're really more likely to meet quality measures. But I would guess that available resources such as budget and roles and bandwidth can all vary drastically from hospital to hospital. So Hannah, what do you think are the absolute must haves or minimum elements to get a glycemic management committee started?

Hannah Day:

First, identify your champion or your champions, which as we know is oftentimes a diabetes care and education specialist, who can then partner with a physician or provider leader for a really powerful dyad, and then grow the team from there, identifying other members across disciplines who also have a passion for diabetes care and quality improvement.

Then second, access to data and a team that can analyze and really dive into the data to provide actionable information is key. This is one of the many ways we partner with our customers at Glytec. Data is key to not only identifying areas of opportunity and areas to work on, but also important in measuring ongoing success. And then third, As I've mentioned before, having a quality improvement framework to follow is important. This is not only key in how you approach improvement work, but it's also helpful in obtaining buy-in from other clinicians and leaders when you're working to spread a standard process across the system. It helps to clearly communicate why the work is important and how you as a health system are addressing it. So to summarize, the top three are identifying your champions, analyzing your data, and following that quality improvement framework.

Jodi Lavin-Tompkins:

So I think at this point of the conversation, Hannah, it might be useful if you could give our listeners an example of how you use the QI framework at your hospital.

Hannah Day:

Yes, so one example, we reviewed our hypoglycemia and hyperglycemia rates for patients in the ICU who were being treated with IV insulin infusions. After a deeper review and multiple chart audits, we learned that the current IV insulin infusion protocols were not always followed, likely due to complexity, and many patients experienced rebound hyperglycemia and in some cases recurrent DKA after that infusion was stopped. So this led us to updating our insulin infusion protocols and a major education initiative around those protocols. But ultimately, as we continue to monitor the data and the impact of our improvement efforts, this led us to ultimately implementing Glucomander as our eGlycemic management system to improve overall safety with insulin infusions.

Jodi Lavin-Tompkins:

So when it comes to safety, I think the Center for Medicare and Medicaid Services, or CMS, has introduced glycemic management measures that will affect the way hospitals track and report rates of severe hyper and hypoglycemia. And I just want to give a brief overview of those measures. So the first rule measures prolonged untreated hyperglycemia rates in hospitals, while the second is intended to measure preventable severe hypoglycemia due to adverse drug effects. And if you want more information, you can find full details on these measures in the links in the resources below. So Hannah, what role would a glycemic management committee have in helping their hospital prepare for these new measures?

Hannah Day:

We as diabetes care and education specialists have been recognizing this as an issue for many years and have been wanting to drive improvement. Now we have CMS and likely other metrics coming down, which makes this the time to take action and look at the next steps to create improvement. Once again, data is key. Glucose data analytics, reporting, dashboards, visualizations are all needed to highlight opportunities and challenges, also drive change and quality improvement work and highlight wins along the way. We know the majority of US hospitals don't have automated capability to extract and analyze glucose data. At Glytec, our partners are able to leverage glucometrics, which is our analytics platform to aid in this. But a glycemic management committee should have oversight if a hospital chooses to report on these metrics. The committee can facilitate system-wide processes needed to standardize glycemic management and improve those hyper and hypoglycemia rates.

Jodi Lavin-Tompkins:

So in addition to preparing for the measures then, can you give our listeners an example of how a glycemic management committee can impact the measures?

Hannah Day:

Absolutely. So one example affecting really all hospitals is the process needed to ensure that coordination of the meal delivery, the glucose check, and insulin administration. Hyper and hypoglycemia rates are often traced back to poor coordination of this meal triad. And oftentimes there is no standard process for insulin delivery in coordination with meals. The glycemic management committee could oversee the effort in coordinating the teams, piloting and creating a meal triad process, and leveraging the technology to standardize and hardwire it across the health system. Now with the CMS measures, it's an ideal time to be fostering these glycemic management committees to ensure you have the right structure in place to standardize best practices.

Jodi Lavin-Tompkins:

Okay, it sounds like forming or using a glycemic management committee in this environment, where hospitals are being pushed now to meet new measures, could be an advantage. So whether someone has a successful glycemic management committee or is just looking at starting one, what are the three key action items they could start doing now to set themselves up for success in the future?

Hannah Day:

To start now, first, create awareness of the importance of glycemic management. This may be through highlighting patient stories or variances in patient care or through educational campaigns, but it's important to ensure your frontline clinicians and leaders have visibility into what's happening at your facility around glycemic management. Second, as I've mentioned multiple times, assess the data you currently have. And if you don't have reports yet, you can start with chart audits. Highlighting specific glycemic data for your organization will help create that further awareness of the importance of glycemic management and allow you to get a sense of what your current state looks like with glycemic management. And finally, start identifying your champions. Do you have physician champions, nurse champions, or pharmacy champions who are passionate about glycemic management? And form that partnership with them to get started.

Jodi Lavin-Tompkins:

Well, Hannah, this has been a great conversation, and I'm just wondering if you have any closing thoughts for our listeners.

Hannah Day:

Well, first, I want to reiterate that although, as you mentioned at the beginning, we often think of glycemic management committees being inpatient focused. It's also important to have outpatient representation on the committee. This can ensure that those transitions of care from inpatient to outpatient are considered among improvement initiatives that the committee may prioritize. You may even have subcommittees. One focused on inpatient initiatives, one that's focused on outpatient initiatives, and one that's focused on the transitions of care in between. I'd also like to point out that a hospitalization is a time in a person's life when coordination of care among multiple clinicians, again, both inpatient and outpatient, is crucial. Glycemic management committees are key in driving and facilitating processes that will enhance that coordination of care. And a main win in forming a glycemic management committee is that it brings to light the importance of glycemic management in the hospital and beyond. This increased awareness will go further than anything else. And while you can't necessarily tie a specific data point to that, we as diabetes care and education specialists know that can have an immeasurable impact on patient care. Also, if you want to learn more, please don't hesitate to contact us. We're very lucky at Glytec to have more than 40 clinicians on our staff who have a wealth of experience and knowledge around glycemic management. We're happy to talk more and answer any questions you may have.

Jodi Lavin-Tompkins:

Well, Hannah, thank you for taking the time to join us for this episode of The Huddle and for sharing your knowledge and experience with our audience. For me, as a diabetes care and education specialist, I know how useful this information is for practice. So I'm sure our listeners really appreciate hearing your first-hand experience.

Hannah Day:

Thank you so much for having me.

Jodi Lavin-Tompkins:

Thank you for listening to this week's episode of The Huddle. I also want to thank Glytec again for sponsoring this episode. To access the notes and resources from today's episode, head over to diabeteseducator.org/podcast. And remember, ADCES membership gets you free access to resources, education, and networking that improve your practice and optimize outcomes for your clients. Learn more about what ADCES can do for you at diabeteseducator.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable to your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.

This article originally appeared on The Huddle.