I was lucky early in my hospital medicine career to join numerous quality improvement (QI) projects. They gave me the tools to drive change, and taught me teamwork and the importance of having a structured approach.
Many had powerful, lasting impacts. However, QI projects often don’t achieve their aims, and even when they do, they are not sustainable. The success wanes and other teams resurrect the work over and over again.
Leadership, culture and change management are essential. We always look for the right tools to flip the switch for improvement and sustainability. There’s never one tool, but when the right tools are combined to work, it’s magical.
For the past year and a half, I’ve been part of the quality improvement team at Glytec. Now I can pair that QI framework with a powerful technological tool to deliver profound impact.
Some real-world examples of how healthcare professionals are combining technology and process were shared a couple of weeks ago at the virtual DTS (Diabetes Technology Society) event.
Three case stories described the journey to successful glycemic management. The speakers, Dr. Damon Tanton and Dr. Therese Franco, progressively outlined the steps in understanding the problem at the system level, developing solutions at the local level, hardwiring culture change and technology to improve glycemic control and measuring the impact.
Damon Tanton, MD, an endocrinologist at AdventHealth Orlando, shared his insights on how AdventHealth, a large national health system, traversed the glycemic landscape. Insulin is a high-risk medication, contributing to half of medication errors around the country per an ISMP report. (1)
Since insulin is the foundation of glycemic management in the hospital, there needs to be a structured way to use insulin safely. Yet, 40% of hospitals have no glycemic management team and many hospitals have no data to track how well they are doing. (2) Hospitals are driving blind on glycemic management while providers resort to sliding scale insulin only for many patients, which is not the standard of care.
With the potential upcoming CMS measure on hypoglycemia in the works, he noted that AdventHealth had to understand the depth and the breadth of glycemic control in their health system. Dr. Tanton stated, "we can't change what we don't know and what we can't measure.”
AdventHealth looked at 4 categories of glycemic control:
Compared to those at 70-180 mg/dL, they found the other subgroups had consistently higher length of stay (LOS), readmission rates, mortality rates and costs. (3)
Severe hypoglycemia, <40 mg/dl, was associated with $10,405 increased costs, 6.6 increase LOS, 61.5% increase readmissions and 3x higher mortality. The total costs to the system was almost $8 million. (3)
Once they were better armed with their own data on glycemic control and its impact, they had the necessary data and story to drive change. They implemented 4 new strategies to target glycemic control:
The glycemic data, known as glucometrics, were a necessary part of improvement. This work prompted them to create a system-wide glucometrics system including the development of daily report cards, real-time feedback to front-line providers and monthly reports.
Dr. Tanton stated that, “institutional prioritization of glycemic management, with utilization of integrated technology to track glucometrics, is imperative to patient safety, quality of care and the achievement of clinical and operational excellence.”
Once armed with this information, they brought the need to improve control to the local level. AdventHealth discussed their results implementing Glucommander IV and SubQ at a hospital north of Orlando, AdventHealth Waterman, in Tavares, FL.
This 300 bed hospital transitioned from one insulin management software, EndoTool, to Glucommander in 2018. They recognized high amounts of hypoglycemia, hyperglycemia and frequent nursing calls to providers. The team uncovered several barriers to care:
Waterman focused on areas of culture change while instituting new technology to augment the process. They did the usual and necessary improvement steps: leadership buy-in, assembling a multidisciplinary team, updating policies, broad educational programs and instituting highly-reliable strategies, such as mandatory use of the eGMS for any insulin requiring patient.
They faced the typical barriers to change. Early on, they heard that “nurses already have too much to do.” Yet, with a successful implementation, they improved insulin safety, increased adherence to policies and reduced clinical inertia. In the process, they saved the organization $350,000, driven by reductions in severe hypoglycemia of <40 mg/dL. (3)
Providers initially in opposition became proponents as they noted the safety results, as well as a 75% reduction in calls related to glycemic management. (3) The Waterman glycemic team worked through the common stories about the difficulty of change, the time commitment and the necessity of multidisciplinary support. They are now celebrating wins and continuing to spread their improvements throughout the hospital.
Dr. Franco, a hospitalist at CHI, an 8-hospital system in the Puget Sound-area of Washington State, shared the journey her organization took with a similar process to Waterman. Their driver for change came from a leadership decision, which was a call to action to address challenges in glycemic management.
Their glycemic committee launched Glucommander IV and SubQ in 2018 to address these challenges.
She outlined several key first steps:
The results showed their efforts made an impact. They saw a 44% reduction in hypoglycemia, defined as <50 mg/dL, as well as a 1.4 day reduction in LOS for DKA/HHS patients. These efforts also reduced hospital costs. (4)
Glucommander extended added benefits that she highlighted:
QI is clearly a journey, and not always an easy one. These stories highlighted the importance of all of the necessary pieces of change management:
Taking these steps is essential for quality improvement efforts across the spectrum. The addition of Glucommander, a technology solution that provides insulin dosing recommendations, takes away clinical inertia and introduces a highly reliable strategy that allows efforts to sustain. (3,4) The results demonstrated by Dr. Tanton and Dr. Franco speak for themselves, with clear patient safety benefits and financial impacts. Dr. Tanton’s presentations and Dr. Franco’s presentation explored excellent models for change management within the hospital system.