Glycemic Management Committees: Empowering Healthcare Excellence Through Collaborative Care

An in-depth overview of the role and importance of Glycemic Management Committees, where we'll explore their role in healthcare excellence, discuss their impact on patient outcomes, and provide guidance on how to establish one at your own institution. Below the video you can download the slides and a quick-start guide.

Betsy Kubacka: Hello, and welcome to this session on Glycemic Management Committees, Empowering Healthcare Excellence Through Collaborative Care. My name is Beata Kubaka, most know me as Betsy, and I will be the presenter for this session. So, I currently serve as the VP of Clinical Partner Solutions with Glytec, as well as continue to work clinically as an endocrine nurse practitioner at Hartford HealthCare.

My relationship with Glytec started in 2015 when I was the clinical project lead for implementing Glucommander across the country. My time in inpatient glycemic management is greater than 10 years, and I'm very passionate about improving inpatient glycemic management for our patients. So you, as you may imagine, implementing a project like Glucommander was made much easier by having a committee to work with.

So today we will be talking about how to start these committees. Our objectives today are to look at the why, why do we want to improve glycemic management? And so that'll be a review of the national landscape and then the what and the how. So what are those committees? What do they do? How can they help?

And how do we get started? And finally, we will have, we will hear from two of our experts who will share their experience in leading glycemic management committees. So we know that health care costs continue to rise and diabetes is a big contributor to that rising cost. In fact, one in four healthcare dollars is spent on diabetes management, and this is largely due to hospitalization.

And we know that insufficient glycemic control can lead to rehospitalization or readmissions, longer lengths of stay as well as those poor glucose control will lead to poor outcomes and increased morbidity mortality. So it is important that we do have a focus on glycemic management, and as we move to value based medicine.

Purchasing, and Capital Payment Structures, it may provide the impetus for our institutions to also put greater focus on improving glycemic management. We have seen CMS use readmissions as a marker of quality when it comes to other chronic disease states. And you heard yesterday that CMS has now turned to looking at glycemic management.

We've had since 2008 hospital acquired DKA, HHS, and hypoglycemic coma be identified as never events by CMS. But now we have two quality measures that CMS has introduced and is now collecting data on. And that is the severe hypoglycemia, BGs below 40 during a hospitalization after we have provided a medication to lower our glucose, and also severe hyperglycemia of greater than 300 after the first 24 hours.

Essentially CMS is stating that these can be highly preventable, thus they are going to be considering these as patient harm events. And so this again is coupled with the need to improve our patient care, this provides us with another impetus to improve that care. So, overall, we know glycemic care management, or glycemic care matters.

There are many publications, many studies that really highlight the importance of glycemic control in the hospital setting. And just to reiterate, these studies and publications show improved patient outcomes, decreased mortality, decreased length of stay, readmissions, and overall cost. So, in order to achieve good glycemic management, we can turn to guidelines.

We have ‘the how’ to improve glycemic management by looking to our experts. The ADA publishes standards of care on an annual basis. There is a full chapter on inpatient glycemic care, and this can be used as a guide. We also have additional sources from the Endocrine Society, as well as SHM, that could really help guide and inform our practice so that we strive to achieve those best, um, best care standards.

So, if we know we have a problem, and we have guidelines to help address it. Why is it so hard? Some may say status quo is easy, sliding scale is easy, and so that's what they do. But if we dig a little deeper and look at what that implementation gap may be, there may be a true unawareness, a lack of staff awareness of the importance.

There may be a lack of champions, or lack of standardization, and certainly a lack of measures or metrics. We don't know what we don't know. If we're not measuring, we don't know how we're performing. So how can we improve glycemic care? How do we make this step into improving in our organizations? This is where we'll begin talking about glycemic, the importance of a glycemic care committee.

So step number one is to build the infrastructure to support your patients and support your staff. This will require a leader and preferably administrative support. So we can either start through administration or through a grassroots effort through a leader. A leader can be a single person, it can be a small team, and these can come from a variety of disciplines.

It could be a physician, it could be an advanced practice provider, someone from the quality department, a pharmacist, a diabetes care and education specialist. Usually it's someone with a little bit of passion for diabetes that takes on this challenge of improving glycemic management. And we know hospital resources vary based on your hospital size, your patient case mix, and as well as financial support, this support may look different, and there is no one best model, and you can tailor this to meet your needs.

But when you have administrative support and a leader, we know that this may not be enough because glycemic control is needs are found throughout the hospital. We have 30 to 40 percent of our inpatient population requiring some type of glycemic control, whether that be due to a history of diabetes, stress hyperglycemia, or even medication induced hyperglycemia.

These patients can be found anywhere from your ED, ICU, ORs, so really anywhere in that hospital setting. And we also know that the patient care does have, does require many different disciplines in order to manage and care for that patient with diabetes. So those are the folks that you can look at in recruiting to your glycemic management committee.

So step number two is to recruit your team. Seek out representatives from various disciplines and roles. Those that are most affected by any coming changes may be best suited for implementing change. As we have champions within our departments, we tend to get more buy-in into any type of changes. And again, just to review, those interdisciplinary team members may be providers, and those providers may be an endocrinologist if you have one available, a hospitalist, intensivist, ED providers, again, advanced practice providers folks from surgery, surgeons, pharmacists, dieticians, nurses, quality experts, care coordinators, diabetes care and education specialists.

And as you work on projects, you likely will include other team members such as your IT or informatics team, laboratory, and even perhaps behavioral health. So there are various departments that you can look at when creating those teams. And creating a glycemic care committee is considered best practice.

So again, finding those like-minded individuals is important and chances are you'll find a lot of people who want to help with this since, again, diabetes is a growing epidemic and we know that many of us have diabetes or have loved ones with diabetes. So, thinking about what a glycemic management committee does may help you identify the good candidates for your team.

So, how often have you heard that we're doing a good job, but it's not as good as it could be? So, we would start by assessing our current state. How are we doing? Comparing our practices to those best practice guidelines, identifying risks and barriers, organizing and leading change. The Glycemic Management Committee is really tasked with facilitating acceptance, overcoming resistance and inertia, and then developing and implementing initiatives to improve care.

So looking at your policies, protocols, order sets, really striving to standardize care. To that end, your staff may need education. We may need tools for patient education. So determining whether those are needs of the organization and then really tracking that performance and then providing feedback to the organization on how this program and initiatives are working.

So, knowing how you may want to start and knowing what you need to do, a good start is creating a charter. A charter keeps the team on track and provides a framework to achieve those project goals. So, defining the vision, looking at your goals and objectives. Are those goals SMART, meaning specific, measurable, achievable, relevant, and time-based.

So what do you want to do? How are you going to do it? And when do you want it done by? And so once you have those goals and objectives, you can determine a problem statement, list the deliverables as part of that process, and create an implementation plan. What resources are you going to need? Do you need a budget?

And then again, call out those potential risks so that, you know, the barriers that you may face as you embark on this initiative. So many of your quality improvement projects may fall into one of these buckets. And so we often start with our policies and protocols. And then we look at our patient care as well as the coordination of insulin checking the blood glucose, delivering insulin, and the meal is often a source of challenge, so that's often a project for quality improvement.

Looking at your order sets, do they facilitate standardized practice amongst your providers? And again, looking at the staff education and the patient education needs. Do you need data platforms built? Do you have a way to extract your glucometrics? And then looking at that transition of care from inpatient to outpatient care to help prevent those readmissions.

So glycemic improvement projects may vary. And so from those broader areas, you will prioritize your efforts. And usually you will start with those low hanging fruit, something that can show success. Remember, this is a journey. It's not a sprint. We are here to create a process in order to improve glycemic care, and it all can't be done in one shot.

So you will add different projects as you go along. And as I said earlier policies, protocols, order sets is usually a place to start ensuring that you have a treatment plan to prevent and treat hypo and hyperglycemia, making sure that your staff understands how to identify those emergencies, how to treat those emergencies, that meal triad, what is the process, do you have, you know, gaps between that glucose check and the insulin delivery.

Ensuring that everyone understands the role of nutrition with insulin. We often see insulin held when glucose is in target. So we want to make sure that staff has an understanding of those roles and provide that education. And so, you know, looking at that transition and other areas, is very important.

And finally, we want to celebrate our successes. Often this work is done through intrinsic motivation, so these folks are really intrinsically motivated to improve. And we know change is complex, and it's often met with resistance. So celebrating progress really can enhance a team's performance, satisfaction, and loyalty to the initiative.

And celebrating and acknowledging that hard work, it really fosters positive and supportive environments and that positive culture that we're looking to achieve. And once you, eventually, you may be seeking to validate all of this in achieving certification or, or our newest designation that has been introduced by LeapFrog.

So you want to showcase your work to the public. You want to be able to tell the public, we here at our institution provide excellent inpatient diabetes care. And so these are some ways that you can really put that message out. So, don't do it alone, you'll find your people, and people want to help across every discipline.

Some key takeaways are glycemic management committees are necessary. They're integral to improving the quality of glycemic care. Each organization is different and those committees will be different based on your resources, your needs. But the common shared core characteristics will be the same. With a strong foundation, excellence is possible.

So, I hope this gives you some ideas on how to create a glycemic management committee at your institution and some initiatives that you may think about when you embark on this mission. We will now turn our presentation to our esteemed colleagues who will share their experience and perspectives on glycemic management committees.

Welcome Tiffany and Sylvia. You both led glycemic management committees. And I would like to introduce Tiffany as a registered nurse and certified diabetes care and education specialist. She is currently at Glytec as a clinical project lead as well as clinical customer support manager, working with clients both during and after implementation of Glucommander.

Prior to joining Glytec, she was a diabetes leader in the Northeast Georgia Medical Center Glycemic Management Committee. Joining her is Sylvia. Sylvia is a registered nurse, certified professional in patient safety, and has a bachelor's in human factors psychology with Lean Six Sigma Yellow Belt.

Formerly a process improvement specialist at AdventHealth Daytona Beach, she facilitated their glycemic committee, and is now a Glytec clinical customer success manager working with hospitals across our country. Thank you both for joining me.

So Tiffany, could you please give our audience an example of a project or a win that stands out to you?

Tiffany Young: Thanks, Betsy. Yes, so my win and my project kind of go hand in hand, really improvement work that we did. Our biggest win that I think we have as our glycemic committee was the collaboration that we had between the endocrinology medical director that I worked with, our provider groups, the nursing groups, and myself.

We built a rapport that when they saw the endocrine director and I walking down the hall, providers and nurses both knew that we were coming to talk about something good, that something that was going to help improve their patient care. It also gave us the ability to answer any of their questions or get feedback to that glycemic committee for consultation.

For order set improvements, anything, of course, that would benefit their care of the patient. Some improvement work that we completed was using our glycemic data that we reported to the committee for education opportunities or optimizations of current order sets and policies. One improvement that sticks out in my mind, of course, we're all coming on the tail end of the pandemic, and we probably all saw a rise in our acute care hyperglycemic data, so we decided to do a root cause analysis on our patients admitted to a few of those acute care units, with COVID that were receiving steroids.

We, of course, saw that they were vulnerable. We also determined that they were not really using the 40/60, you know, basal bolus split formulation that we had talked about utilizing, before, when we first started seeing COVID patients. So, we reported this out to the committee. We gathered feedback from the providers that were on our committee.

And to be able to determine the best approach to educate the providers around the insulin dosing. There were a few modes of education that were recommended by those providers on the committee. So one of them was to send out a tip sheet or a pocket card to the hospitalist group. So we sent that out and then we decided as well that we needed to do some roving in person education around this.

So of course we brought those tip sheets and pocket cards with us. And did some education to the providers one on one, gathered feedback, see if we needed to make any optimizations to the order sets. And then we also noted when we were rounding that one of the providers said this would be great to talk about in our morning huddles.

So they took that tip sheet, placed it on their morning huddle board, so that way they could have ongoing education. We of course know that hospitalists have different weeks of rotations, so we ensured we covered multiple weeks for this education to ensure we try to cover as many hospitalists as possible.

And then in the next coming months, we were able to report, you know, a decrease in our hyperglycemic rate based on that 40/60 basal bolus split for our patients. So, it really shows that, you know, like Betsy mentioned, that a small project, you start small or, or you, you get those little wins, because that can just really have a big impact right there in the moment, especially with everything we were going through with COVID.

So, again, little impact of work. But high outcome.

Betsy Kubacka: Wow. Absolutely. It's very important work. So, thank you for sharing that, that insight. And now we'll turn that same question to Sylvia. 

Sylvia Elledge: Yes, thanks. So, I just wanted to add, the data plays a huge role in the beginning of any project.

You, you can't have any wins but you also can't have any wins without the support and the collaboration from the right people. So a quick win that our glycemic committee accomplished was just a simple implementation of a door identifier. Just like you have a fall risk indicator, this would indicate that the patient in the room needed a BG...

They needed their blood glucose checked. So meal trays would be delivered at the nurse's station if the dietary restriction door indicator was on. But a dietary restriction can also indicate a strawberry allergy, very different from a patient that needs insulin. So that was something that you could call, you know, low hanging fruit, a quick win, something that was so simple and.

It opened the eyes of multiple teams, but the project that meant the most to me was an abbreviated Kaizen PI project around a handful of hospital acquired DKA events that we were starting to see a trend on. We gathered the right folks together and We helped learn, we, we learned ourselves, and then we helped others realize the impact of a series of events and decisions that were the root cause to hack DKAs.

And to go through that, it felt like the earth moved under our feet. Because many opportunities or fallouts revealed in the past sort of all collided together in this big event. And it really should not take a hack. It should not take a hospital acquired condition to get everyone's attention for change and to prove that there's a need for education.

It takes a lot of holes in the Swiss cheese to line up just right for harm to occur. And this project really helped our facility, our leaders, our end users, our frontline to really come together and create an awareness of when to hold and not to hold the right insulins. The impact of dehydration when someone's living with type 1 and type 2 diabetes.

And even overlooking diabetes as a diagnosis when a patient's urgently admitted for something that has nothing to do with it. This, among several other findings, is what we revealed during this event. And it really helped us roll out some resources, some tools, not just education. But a multidisciplinary awareness, because it can be so easy in a hectic hospital for a provider to, you know, think that it was something the nurse did, or the nurse to think it was something the pharmacist did, and, you know, going back to having a multidisciplinary team.

Everybody's eyes get open and they all realize how what they do impacts, not just someone else's role, but that care of the patient.

Betsy Kubacka: Oh, to that point, Sylvia, would you mind telling us a little bit about your glycemic team? Just briefly describe the structure of your team. 

Sylvia Elledge: Sure, I did not come into an established committee so as a process improvement RN, I oversaw most of our inpatient glycemic data.

So I started to find opportunities that needed to be addressed, and with the support of my manager and my director, everyone knew that it was time to create a committee. We reached out to our sister hospitals of the same size. Fortunately, that hospital is part of a very large hospital system. So, there's that benefit that you can collaborate together.

But I wanted to find someone of a similar size. So, I set out to do that and gather some information on how their structure was. And I also did a gap analysis on the Joint Commission Disease Specific Certification in Diabetes. I was sort of... I was sort of aiming for the stars, Betsy.

Betsy Kubacka: Of course you were! Knowing you now…

Sylvia Elledge: So I knew it had to be multidisciplinary. I knew we needed to draw up a charter. All those points that you mentioned already. But I didn't want to do those myself and then tell the committee this is what we're doing. Right. I wanted them to think it was their idea. So we had a lead hospitalist, a lead intensivist, the PI medical director, leaders from nursing and pharmacy, from the lab.

Most hospitals do have a point of care supervisor, clinical nutrition, even informatics, education, and a few others.

Betsy Kubacka: Oh, thank you. So, your committee was very diverse, multidisciplinary, and you were able to really implement a lot, you know, really make those changes and improve care for your patients.

Tiffany, was your, the structure of your glycemic committee similar to what Sylvia described, or can you tell us a little bit about your committee at your hospital?

Tiffany Young: Yes, so mine was a little bit different. When I became the diabetes program manager, our glycemic management committee had already been established a few years prior.

Diabetes was a pillar goal when the committee was established initially, and it was no longer a goal once I became the manager, but the facilities still felt like glycemic committees were important, and therefore we continued it. So, as a diabetes program manager, I was the chair of the committee, so I scheduled the meetings, gathered the glycemic data, reviewed the order sets and policies that needed renewal, and prepared the presentations.

Not long after I joined though, the organization also hired an endocrinology medical director, and she agreed that, you know, being the co-chair was probably the best thing for the committee and certainly wanted all the help that I could get. So, we decided to restructure the committee at that time to have a little bit more high-level oversight and then have the ad hoc members for when we needed their insight and their specialties.

So we had the Committee comprised of representatives from pharmacy. Each facility had their own physician leader representation, nursing leadership, medication safety, quality and regulatory, IT, POC, and lab coordinator, and we even had an outpatient pharmacist, again, for those transitions of care.

To kind of dive into what we had as far as structure every, every meeting, we always started the meeting with safety. So we always reported out on those safety variances, and discuss the next steps so that we can avoid that safety event from happening again. We also reviewed any of the outpatient diabetes committee data as well as key decisions that the committee was making that could impact inpatient care as well.

We reviewed any of those policies and procedures, like I mentioned, as part of my role. And then we dove into that glycemic data that Sylvia said it was so important to have. Luckily, we were a Glucommander client, so we had EPIC data and we had Glucommander data. Our EPIC data had your hypo and hyperglycemia rates along with some others around utilization.

We displayed the data in a chart format that included our goal. Our previous year's data, the previous month data, and then the current month data. And we separated that not only by facility, but acute care versus critical care as well. And then again, we got great data from Glytec, from my clinical customer success manager at the time with KPI reports.

And on these reports, they did a great job about reporting the hypo and hyperglycemia rates while on Glucommander utilization. And just like mentioned previously, in Dave's presentation, that blood glucose timeliness, man, that was a great report to get. So this data was separated by facility as well as critical care and acute care, just like Dave showed us in the demonstration as well.

And then at the end of the meeting we also discussed ways to improve that glycemic data, just like in the story I told about assigning those tasks and chart reviews so that we could determine what needed to be educated or changed within the organization. And then we always ended with opportunities from providers or nurses on how to optimize glycemic management.

So it gave the providers, nurses, a free floor to ask questions of their colleagues or what they were hearing about while they were working on the floor. And we were able to vet those and then of course take them to their approving bodies to make those changes within an order set policy or create that education.

Betsy Kubacka: Wow, that sounds great. You really were able to bring those folks from the pointy end, right? Those folks that are touching the patient into the committee in order to recognize and identify what are those areas for improvement. I mean, that's exactly what a glycemic committee should be doing.

It's what we should be getting together, understanding what our current state of care is, and then implementing those changes. Now, when you were doing these, did you run into any type of challenges, any barriers as you were trying to implement these types of, um, new processes within your organization?

Tiffany Young: I'll say our biggest challenge was initially, I know I mentioned that we restructured the organization, but in the beginning, we had a hard time getting all the providers to show up that we had on the, you know, on the committee, you'd get one or so, and they couldn't make a decision because we were a multifacility organization.

We wanted to ensure everybody was bought in. So once we restructured and had that high-level oversight we were able to make decisions a lot quicker and without having to take things back and bring them back. So it was a lot easier once we restructured to a more high-level committee.

Betsy Kubacka: So, uh, how about you, Sylvia? What challenges did you have when you were, um, actually leading your glycemic committee? I know it was brand new, so you might have had a few more challenges, especially initially. So why don't you share those with us?

Sylvia Elledge: So, year after year, believe it or not, hospitals have a turnover rate, right?

So, member retention for this committee, as a result of turnover, was the biggest challenge. Constantly having to re-pitch the importance of our committee's mission, our committee's purpose. Not just to executives or nurse managers, but facility-wide. Because I was determined to continue to have a multidisciplinary team.

But I also had a subcommittee of glycemic champions. And that was divided into critical and non critical care. Because like Tiffany, that's how we split our data. And the challenges for critical care areas were not the challenges of the non critical care areas. These teams with Nursing, but also the high level leaders constantly changed.

So I had to make sure that I kept everything organized and ready to re-pitch it every time I needed to. Keep it alive. And obviously, you know, sometimes a facility's priorities have to change. The priorities shuffle a bit. You know, we started in 2017 and we all know what happened in 2020. And so we just kept trucking along, but it was definitely our biggest challenge.

Betsy Kubacka: Yes, absolutely. I have some questions from the audience if you don't mind answering some. For Tiffany, can you share your hyper and hypoglycemia target range goals?

Tiffany Young: Unfortunately, it was so long ago. I want to say that we did, of course, report your severe and, you know, hypoglycemia. So, if we had severe hypoglycemia, of course, less than 54, and your hypoglycemia less than 70.

Betsy Kubacka: Okay. All right. Okay. Thank you.

Uh, one second. We're having a technical difficulty at the moment, I believe. Just one moment.

Tiffany Young: I can say that we were looking at your patient days, your data for patient days. We did have patient stays as well, so we had a couple different metrics around patient days and stays. So, but we of course made sure, like Jordan mentioned, that we were comparing apples to apples, so we didn't want to report you know, percentage of patient days and percentage of patient stays and compare those. 

We wanted to ensure we were always comparing apples to apples. And then also we took that, like I mentioned when I was talking about our structure, we took the Glucommander data separated from our EPIC glycemic data just to ensure that we were again comparing apples to apples and not apples to oranges.

Betsy Kubacka: Makes total sense. You will get very various results if you're not comparing the same. Yeah, that's a very good point to make within this. So, any final words of advice that you would offer to the folks in the audience who might be excited about the idea of starting a glycemic management committee within their organization?

Tiffany Young: I'll go first. I would just say really just get started. Like Betsy mentioned in her presentation, it doesn't take a lot of folks. It does take the right folks. But it doesn't take a lot of folks to get started. Just like I mentioned in my improvement work that we talked about, look at the data, develop a plan to improve the data, make rounds or determine an education plan.

We of course know that there's larger projects, just like Sylvia mentioned, but those can take quite a bit of time. So having that low hanging fruit or those things that really show that when. Right away, they can, you know, really have a large impact. And once people start seeing the success and the great work that you're doing, they're sure to follow.

Your group will grow. Everybody will start coming in. They'll want to be a part of it.

Betsy Kubacka: Oh, that's absolutely true. Now, Sylvia, do you have any, any words of wisdom for us?

Sylvia Elledge: I do. And I'm sorry, my voice has been so distracting for some, just like Tiffany said, just start. Just start. It does not have to be perfect.

When I mentioned that I did that gap analysis, the committee was already up and running. Those comparisons, that data gathering, that really just helped me fine tune what it could look like, what it should look like. The biggest thing, honestly, it has to be multidisciplinary. You have to be able to collaborate together, work as a team.

Your first meeting should be fun. Establish your purpose and goals together. Brainstorm together. Learn their workflows from each other, as in those disciplines, you know, going back to pointing fingers. But try to get some people that are passionate, Betsy, because you said that if you have folks on this team that is intended to drive you on.

Not just better glycemic care, but a full spectrum of patient satisfaction and health care quality. You have to have people that are determined to see that. So whether they are living with diabetes and they want to be involved, or they, you know, work in quality and safety and are driven by that, make sure those are the folks you have on your team, and don't just think that your patients are the only folks you have to look out for, because your team members also need someone to look out for them, and that's why looking at those workflows is important.

Betsy Kubacka: Excellent, excellent, excellent points you both made throughout your answers to these questions. I think that our audience really can come away understanding what others have done and give them some ideas of how they may want to proceed, but, but I really do thank you both for just this session and sharing your experience.

I think it's invaluable for us as diabetes care and education specialists, you know, to share these and to share what we can do to improve glycemic management across this country. Thank you so much.

Sylvia Elledge: Thank you. Thank you.

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