[00:00:00] Jordan Messler: Hi everyone. Thanks for joining the session on Glycemic Management Best Practices. I'm Jordan Messler, the Chief Medical Officer here at Glytec and I'll be joined shortly by Dr. Rolih and Dr. Amin from the Novant Health Care System. We're going to be discussing today Elements of a Best-In-Class Glycemic Management Program.
I thought it would help, to spend a couple of minutes just talking about my background and what really brought me to Glytec and my history with glycemic management. So I trained in Internal Medicine at Emory University. I stayed on as faculty there at the Grady Memorial Hospital and, if you'll stay for our keynote speaker at the end of our conference, you'll hear from Dr. Umpierrez and he was down the hall from me. So I got to hear firsthand as the inpatient management of diabetes was really being revolutionized by his work. We were starting to finally get, national studies and guiding how to manage diabetes. So use of basal/bolus insulin from his RABBIT 2 trials, subsequent numerous studies really illustrating how to manage our patients in the hospital with hyperglycemia and diabetes.
In 2005, I moved down to Florida where I'm based now and started running a hospital, a medical program, a hospitalist program here in Florida. And during that time, I wanted to bring this basal/bolus and the, uh, important management of diabetes to our healthcare system. So that was really my first quality improvement project, was managing our patients with diabetes hyperglycemia more safely in the hospital.
Did that locally at my hospital, eventually at our healthcare system. And during that time, I got engaged with the Society of Hospital Medicine's work on helping other sites, nationally, uh, mentor, uh, other hospitals to help improve management of diabetes.
So over the years, uh, working with numerous other sites to really answer these questions. How do we create a best-in-class glycemic management program? What are the people and processes we can put in place to improve? And then really what brought me to Glytec three years ago, was a lot of that work with the addition of technology.
So really tying all three together, how do we get the right people at the table, help our colleagues, improve the care of their patients with diabetes, hyperglycemia, improve the processes and layer on technology so we could, uh, all achieve that best-in-class glycemic management that we want to achieve, uh, at our institutions and for our patients.
So that's what we're going to go through, uh, in this session and really breaking down something fairly complicated, something that complex, glycemic management in the hospital impacting almost 40% in some institutions, over 50% of our patients. So really talking through what's in essence quality improvement, creating a best-in-class glycemic management program involves having the right people with the domain expertise that networking, helping guide practice change with the right processes, standardizing care, reducing variation, and then layering in technology. Your institutions certainly layering on, if you don't have Glucommander currently or other technology, you're using your EMR clinical decision support, other ways to layer on technology.
And we'll talk a little more to this session. Obviously, you're hearing from the other sessions, the technology, we bring a Glytec to help achieve that glycemic management success, where you really need all three: getting the right people, doing the right processes and layering on technology.
One of the key things that excites me here at Glytec is we're not just adding the technology to your workflow, we really take great pride in working with the right people, working with your glycemic management team, helping you identify champions, helping you work through those processes to standardize care.
In addition to the technology that helps bring you to glycemic management success, we have teams that help implement the software and then longitudinally our customer success team to help optimize not just the use of Glucommander, but glycemic management in general at your institution and healthcare system.
So let's talk a little bit on each of those categories and I'll highlight some examples here from each of those categories and things to think about. And then we'll hear, again, from Dr. Rolih and Dr. Amin, the case studies in putting these examples to practice.
So let's think a little bit deeper in these three categories. On the people's side, where we have a group of people where patient safety is prioritized. Cross-functional teams, we'll talk about that in a minute. The importance of multidisciplinary teams getting the right people at the table, truly collaborating. Collaboration culture, may, your institution may be calling it in other ways, a just culture, a safe culture, having the right thought leaders at your institution.
Here at Glytec, we certainly work with a lot of thought leaders nationally. Yes, you're hearing them at the conference today, and finding those right partnerships.
On the process side, you're certainly gonna be measuring outcomes. Measurement is key. Defining those quality improvement process steps that are tied to those goals, those outcome metrics that you want to see. Getting that right training, the importance of education, reports of updating that education. Best practice treatment protocols within your order sets or other processes to maintain that best practice.
We know that the literature, the research, the way we manage patients changes regularly. And the preventative care. We're talking about preventing hypoglycemia. So what are the guardrails that we have in place within our processes? And then certainly in our technology, those guardrails to help prevent hypoglycemia, treat hyperglycemia.
So using technology, having EMR integrated decision support is certainly where a lot of places are going around different disease states and particularly around diabetes. Certainly have we got a lot of it, EMR integrated tools to help with DVT prevention, uh, heart failure management. And I think we're seeing more and more around management of diabetes.
Patient safety-focused technology. Data Analytics is so key.
We've given talks just on the data and analytics, being able to measure, you can't improve what you can't measure, and the importance of getting that right analytics to the frontline in real time, to the frontline staff ,feedback to your glycemic team. And there's existing solutions that you likely have that may need to be reconfigured or are updated and you may have solutions already in place. When you have that right collaborative culture, you can identify these and use them correctly.
I want to talk a little bit deeper about the teams. This is, uh, seemingly basic, but often an area that's overlooked or after a period of time, forgotten about and getting that right cross-functional team.
When we're thinking about glycemic management, you often want to have a glycemic management committee that's clearly in place at the system. If you have multiple hospitals in your system, you're going to want to have some form of a glycemic management team at each hospital as well. Maybe for small hospitals, that's only a couple of people, but when you have a glycemic management committee at a large health system, a large hospital, we're talking about a multidisciplinary team, but a minimum have your clinicians, your providers, endocrinology, an area that you're focused on. If it's IV insulin, you might have the Intensivist there. You're going peri-operative, you'll have Anesthesia. And most instances, certainly the Hospitalist on the team, nursing, nursing leadership, pharmacy, the CDCES', the Clinical Diabetes Educators. And certainly the right additions, if you're doing improvement, quality improvement, the right specialist, the right subject matter experts, other hospital leaders and IT an informatics. And getting that right committee together to manage glycemic management longitudinally.
And now you might have special projects where you bring in a smaller team to work on a specific area. You're bringing in Glucommander, you're working on a mealtime triad workflow. Maybe you have other, subject matter experts. SMEs being brought in, dietary nutrition should probably be on your committee, but they're certainly going to come in when you're working on a special project with a clear timeline on the mealtime triad.
So having a committee, having a system-wide committee, certainly would check that at each hospital, if you have a multi-hospital system, they have some version of a committee as well. I also like to check with our teams that they have an accountability structure, that the team has a layer above them that they're reporting to, might be just an executive. It might be a committee like a P and T committee.
We're having the same goals that you're having on your committee is also being verified at another committee level as well. So you have some accountability. On the executive end, having that accountability because the executives help break down some barriers, help you get your resources, but then that feedback loop of also having that accountability structure.
So in some ways, these elements seem basic, but they're really essential to moving a project forward and keeping that optimal glycemic management longitudinally. And you're going to hear great examples of this from the Novant Healthcare System, how they have deployed this across their health system.
Under the process umbrella, one point is really highlighting the best practice treatment protocols, the importance of standardizing insulin dosing protocols. We know we have a lot of variation. We have a lot of providers and clinicians that work their own processes to manage different disease states, in particular managing insulin.
Well, we know the importance of standardizing care. So when we measure processes, we know where the variation is and we know areas where we need to improve. So having those standardized approach for IV insulin. Standardized approach for DKA, obstetric population, bypass surgery population, perhaps different surgical population, uh, certainly on the sub Q side as well.
You might have various order sets for various populations and being sure that all these insulin dosing protocols are evidence-based and standard of care and updated when new guidelines or new evidence comes out. We certainly want our processes, best practice treatment protocols to be personalized.
Each of our patients are different. They have different level of insulin sensitivity. They have different medical conditions. You're going to base dose insulin differently, whether it's kidney issues, type one diabetes, et cetera. And then ideally in the importance of those various teams at the hospital level at the system level, is that you're going to want to standardize across the hospital and across the health system as well, so you can find that variation and improve that variation and continue to push those efforts to standardize care across the healthcare system.
And the third category again is technology. Patient safety focused technology, always with the patient in mind. The work that we're doing is really trying to improve the care of our patients.
And in this case, reducing that preventable hypoglycemia, one of the biggest areas. So can you put those guardrails in place to prevent user error? Here at Glytec certainly highlighter examples with Glucommander. We have some of those guardrails. One of the common things that we concerned about with insulin management is insulin stacking.
So we have guardrails in place within our software to prevent insulin stacking, certain alerts, uh, based on blood sugar measurement, blood sugar testing. Making sure that patients get the right dose based on the, the actual carbohydrates that they eat so you're not giving patient too much insulin that's scheduled for mealtime when they only eat a small amount of carbohydrates.
Certainly again, alerts for safety concerns, those automated reminders to prioritize timely treatment. Having that decision support that leverages relevant data and those workflows that guide best practice and coordinate care. We spent a lot of time working with our sites within the technology to optimize the workflow.
For instance, of the mealtime triad, which involves people, processes, and this technology to help get that right, to meet those timeliness of getting the blood sugar check, the insulin dose, the insulin delivered within that 30 or 45 minute timeframe window, which is challenging to do. So you combine, uh, the, the people, the process, technology, trying to get towards that optimal glycemic management state, having this kind of framework helps think through the different areas that you're working on constantly with your glycemic committee, with special projects that you're doing to help optimize glycemic management.
I think some of this really helps to hear from case studies. And I'm going to pass this along to Dr. Rolih and Dr. Amin uh, following her. We're going to talk about the work they've done at Novant. And we'll hear initially from Dr. Rolih, from her clinical leadership perspective and putting some of these elements in practice.
I will now hand it off to you, Dr. Rolih.
[00:11:40] Catherine Rolih: Thank you, Dr. Messler for the invitation. I appreciate the opportunity to share my perspective as a leader. Um, And some examples of how we at Novant Health are addressing the complexity of diabetes care delivery. So my name is Catherine Rolih. I'm an endocrinologist and I'm the Clinical Physician Executive of the Diabetes Center of E xcellence for Novant Health. I've been in this role for six years and as such, I lead a system-wide focus on quality, safety uh, access to care and health equity for people with diabetes across a large integrated health system.
So by way of introduction, Novant Health is a large and growing system, composed of 16 acute care facilities across North Carolina. We have hospitals ranging from a 70 bed community hospitals to surgical hospitals, to 700 bed tertiary care centers. Uh, As well as over 600 affiliated practices, a number of ambulatory surgical centers and outpatient imaging facilities.
Like most hospital systems over the last couple of years, we've been extremely busy. And in 2020 we cared for over 160,000 hospital admissions. Also like most hospital systems, a large percentage of our patients, more than 25%, have diabetes. So as you might imagine it's a complex undertaking to manage the care of that many diabetes patients.
So how are we approaching this challenge?
First, it's been important for us to be clear on our goals. First and foremost has always been patient safety. And by this we really mean hypoglycemia. We've been working on hypoglycemia identification, management, and prevention uh, for as long as I have been in this role.
Equally important is our focus on quality of diabetes care delivery.
To us, this means a focus on percentage of the time spent in target range, as well as reduction of readmissions and addressing length of stay. Also important in our strategy has been the identification and promotion of best practices. So while we recognize that professional organizations like the American Diabetes Association and Society of Hospital M edicine really have elucidated some best practices or a number of best practices for inpatient diabetes care delivery.
And we also recognize that within our own facilities, We have centers of knowledge and expertise uh, that we have found is useful to identify and share across our system. Uh, Also important has been the need to reduce unnecessary clinical variation.
So while the practice of medicine really has to be, by necessity, focused on an individual patient and the needs of that patient, it's also important to know where, uh, similar situations or needs are arising uh, and to apply a standard uh, principle approach to the same situation across the system. And this is one of the things that allows us to achieve efficiency.
A second important strategy has been to assemble our team. Early on in our process or in our journey of developing a system wide focus on diabetes safety and quality in the acute setting, was really to identify and engage the key stakeholders and to elicit their support for the work that we were embarking on.
As part of this process, we created a multidisciplinary team, which I'll tell you a little bit more about in a moment. This is a team of experts from across the system. Which really helps to guide and oversee work.
And finally, in the last, uh, year, uh, year and a half, that we have found it's been extremely important for us to be able to create new teams to meet our evolving needs.
So one of the most important teams that we have assembled in the last five or six years has been the Diabetes BPET, our Best Practice Exchange Team. This is our multidisciplinary system-wide team that was launched in 2016 in response to the recognition that we had inconsistencies in our approach to diabetes care delivery across our system and oftentimes even within units of a single facility. This team's primary goal really is to promote the safety and quality and adoption of best practice processes or approaches that I just mentioned.
We also have a very large and effective data analytic component. So we collect, analyze, and report diabetes quality and safety data at a facility, a level as well as a system level, our group meets monthly to drive change. The group is really very multidisciplinary and I think that's one of the most important features really. It's composed of hospitalists, endocrinologists, nurses, pharmacists, diabetes educators, data analysts uh, clinical improvement specialists, dieticians, as well as members of our IT or electronic health record team.
The team has been very fluid and dynamic and has been able to adapt as system needs evolve. So as an example, one of our important initiatives in the last year really was to come up with best practice of how to address glycemic management in the COVID patient treated with steroids.
We developed a subgroup or stood up a subgroup of our BPET team which conducted a small quality improvement project at one of our hospitals.
We analyze the data and were able to develop best practices, which we then were able to roll out at a system level.
The last two years certainly have been years of learning. Some key takeaways for us in successfully managing a complex problem like diabetes uh, in the face of a constantly evolving situation, such as a pandemic, that have been three.
Most importantly in my mind has been culture. Uh, We were fortunate to enter this last two year timeframe, with a very patient-centric collaborative and problem-solving culture. And I think that really has been one of the most important features uh, for us to successfully manage these challenges.
The second important takeaway is the importance of teams. We recognize that all of our team members and all of our points of view are certainly important and it is crucial for us to not only optimize our existing teams, help them figure out ways to act more collaboratively in a more integrated way, but also to uh, maintain our ability to be agile and create new teams as needs require.
The third, most, important, and probably the most crucial really I think, has been passion. We have seen the importance of having a group of highly passionate individuals who are able to work above and beyond their traditional job descriptions and go from what we were to what we can be.
Now I'd like to introduce uh, a member of our BPET team Dr. Aman Amin. Dr. Amin is a hospitalist and leader for physician engagement and our Glucommander initiative. He exemplifies the passion and dedication of our diabetes team, and he has been an important driver of our ongoing success
[00:20:17] Aman Amin: Uh, Thank you, Dr. Rolih. Appreciate that very kind introduction. My name is Aman Amin, I'm one of the hospitalists at Novant Health Huntersville Medical Center, happen to be a Clinical Lead here as well and became Glucommander Champion approximately year and a half ago.
So as Glucommander Champion, which is something that was created in response to having Glucommander here. It was an idea and a plan to incorporate providers who are utilizing Glucommander on the front lines with the components of IT, which is obviously a big part of Glucommander, using artificial intelligence to manage blood sugars.
And then the other component I think that we realized later on, was also engagement with the other part of the frontline providers, which is the nurses. You know, first it was between providers and IT, in a sense of providing information of how the actual system is being utilized and It can be easier for providers to utilize certain changes from an IT standpoint.
And then as we learned more, we also realized that it was important to understand what the nurses were doing. Although we're not actually doing the nurse's bedside management of it, we had to understand what they were encountering and what kind of processes that they had to go through to, to better understand their questions and answer their questions when they're utilizing Glucommander. And so I think the biggest part of this was improving communications across all three units as listed there.
So all that grows into the Glucommander Champion role. It has started with engaging with the IT department along with, as Dr. Rolih pointed out, with the BPET group as well to better allow open communication between all three groups that I had mentioned earlier so that we have a process in place to build the relationship with IT, but along with that, but be able to improve the Glucommander function as we learn things, both from providers as well as nursing.
By having a Glucommander Champion, we have a person in place to offer ownership of the program as well, because as a frontline provider, I mainly provide bedside knowledge, as well as the frontline knowledge of the importance of how Glucommander is utilized and how it is changing patient's blood sugar management.
By having this role, it helps give ownership to the physicians as well, to buy into the process. They have a person who understands what's happening on the front lines and they can communicate that upwards. And I think that allows a lot of uh, ability to build on the program that's already in place.
And as part of the Glucommander Champion role increases, one of the things that we are trying to implement and are currently implementing is having a process of sharing information both from top down, which is how it initially started, where executive leaders were making decisions and then providing the information through me, to the colleagues that I have.
But now also having these colleagues at the frontline have a way to provide information back up to the executive leaders as well as the IT department so that they can see that changes that are being made are both effective and impactful to the patients that we're treating.
um, Engagement and provider buy-in is, I think, the biggest part of what I do as well as what the program is supposed to do. So again, instead of it being a Glucommander Champion, it's a Glucommander Champions program now, whereas we are trying to have people at the frontline of all the different hospitals providing information both to their providers at the facility and again, providing us information from their facilities and how we can make changes.
As Dr. Rolih had mentioned, it's a big system with 16 hospitals and not every hospital works the same way. And so we need to have information from both our smaller hospitals, which have a hospital size of 60 beds, up to some of our large hospitals that have the size up to a thousand beds. And by having people at each hospital levels, being able to provide that information back, is crucial in how we're able to implement this.
It also has provided those clinicians, again, a way to make changes in the way that we are delivering Glucommander. A lot of the new things that we've been able to add to the Glucommander program to make it easier to use and more practical to use, have a lot of times come from ideas that come from the bedside when providers are trying to put in orders themselves.
Other part of that is, you know, developing relations early on, which was something that we tried to focus, helps the process grow as a whole. So the earlier I think we could have implemented this,um, I think it would have made our challenges less and made the program more effective sooner.
The last thing with the Glucommander Champions program is, is, as being a big system, information is not always easy to deliver in a person-to-person way, which I think is the most effective way sometimes to learn things. And so by having Glucommander Champions at every level of the facility, we have more of a, what I call an elbow to elbow teaching opportunity where I can, or as the other Glucommander Champions can now, you know, sit next to providers and show them in real time how we can impact patients. Not only how do you realize Glucommander, but it also gives an opportunity to share and information on how best to manage somebody's diabetic care. Sometimes that information is just as important as you know, being able to put in the right orders, but also to know, you know, what's the best way to manage diabetes for this particular patient. Having more input on it from other clinicians.
I'd like to take the opportunity to thank everyone for participating in this conference. I hope we were able to provide you some information on real world applications of this and How we were trying to approach it here at Novant Health.
[00:26:01] Catherine Rolih: Thank you uh, to everyone who was able to join us today. Once again, very appreciative to Glytec for the opportunity to share our journey with you. And we'd like to invite any participants in this conference who has questions to reach out to us directly. And uh, our uh, email addresses are provided here.
We're happy to answer any questions and uh, do what we can to support you. Thank you.
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