successful models of implementation

Successful Models of Implementation

Successful Models of Implementation

Hyperglycemia: A Common Comorbidityin Medical-Surgical Patients in a

Community Hospital

Hyperglycemia: A Common Comorbidityin Medical-Surgical Patients in a

Community Hospital

Umpierrez G., et al. J Clin Endocrinol Metab. 2002;87:978–982.

Normoglycemia

Known Diabetes

NewHyperglycemia

Normoglycemia

Known Diabetes

NewHyperglycemia

62%26%

12%

n=2,020

* Hyperglycemia: Fasting BG ≥126mg/dL or random BG ≥200 mg/dL x 2

Umpierrez G., et al. J Clin Endocrinol Metab. 2002;87:978-982; Levetan CS, et al. Diabetes Care. 1998;21:246-249; Krinsley JS. Mayo Clin Proc. 2003;78:1471-1478; Falciglia M, et al. Abstract Presented at: American Diabetes Association 66th Annual Scientific Sessions; June 11, 2006; Washington, DC. Abstract 19-LB.

Hyperglycemia is Common in Hospitalized Patients

Hyperglycemia is Common in Hospitalized Patients

• Noncritically ill medical/surgical: 38%

• Intensive care units (ICU): 29%–100%

• Episode of glucose >110 mg/dL: 100%


• Mean glucose >145 mg/dL: 39%

• Noncritically ill medical/surgical: 38%

• Intensive care units (ICU): 29%–100%



• Mean glucose >145 mg/dL: 39%

Number (in Thousands) of HospitalDischarges with Diabetes, US, 1980–2003

Number (in Thousands) of HospitalDischarges with Diabetes, US, 1980–2003

CDC. Available at http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. Accessed March 5, 2006.

From 1980 through 2003, the number of hospital discharges with diabetes as any-listed diagnosis morethan doubled (from 2.2 million to 5.1 million discharges)

From 1980 through 2003, the number of hospital discharges with diabetes as any-listed diagnosis morethan doubled (from 2.2 million to 5.1 million discharges)

Obstetrics

And thesepatients are

locatedthroughout the

hospital.

And thesepatients are

locatedthroughout the

hospital.

Cardiac Care

Dialysis

Emergency

Med-Surg Unit

Rehab

Home Health

Pediatrics

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

Hyperglycemia in the HospitalHyperglycemia in the Hospital

• A quality of care issue

• A patient safety issue

• A length of stay issue and a cost issue

• There is an increased awareness among multiple stakeholders and a desire to change the current practice

• There remain multiple challenges and barriers to practice change

• A quality of care issue

• A patient safety issue

• A length of stay issue and a cost issue

• There is an increased awareness among multiple stakeholders and a desire to change the current practice

• There remain multiple challenges and barriers to practice change

Perceived Barriers to Managementof Inpatient Hyperglycemia

Perceived Barriers to Managementof Inpatient Hyperglycemia

• Knowing what insulin type or regimen works best

• Unpredictable timing of patient procedures

• Risk of causing patienthypoglycemia

• Knowing how to adjust insulin

• Unpredictable changes in patient diet and mealtimes

• Knowing best options to treathyperglycemia

• Knowing what insulin type or regimen works best

• Unpredictable timing of patient procedures

• Risk of causing patienthypoglycemia

• Knowing how to adjust insulin

• Unpredictable changes in patient diet and mealtimes

• Knowing best options to treathyperglycemia

• Glucose management notadequately addressed on rounds

• Patient not in hospital long enough to control glucose adequately

• Lack of guidelines on how totreat hyperglycemia

• Preferring to defer managementto outpatient care or to anotherspecialty

• Knowing how to start insulin

• Knowing when to start insulin

• Glucose management notadequately addressed on rounds

• Patient not in hospital long enough to control glucose adequately

• Lack of guidelines on how totreat hyperglycemia

• Preferring to defer managementto outpatient care or to anotherspecialty

• Knowing how to start insulin

• Knowing when to start insulin

Improving Inpatient Diabetes Care:A Call to Action Consensus Conference


• January 30–31, 2006

• Washington, DC

• www.aace.com

• January 30–31, 2006

• Washington, DC

• www.aace.com

Sponsors

• American College of Endocrinology,American Association of Clinical Endocrinologists and American Diabetes Association

Co-Sponsors

• American Association of Critical-Care Nurses

• American Association of Diabetes Educators

• American Heart Association

• American Society of Anesthesiologists

• Joint Commission on Accreditationof Healthcare Organizations

• Society of Critical Care Medicine

• Society of Hospital Medicine

• Veterans Health Administration

Participating Organization

• American College of Cardiology

Sponsors

• American College of Endocrinology,American Association of Clinical Endocrinologists and American Diabetes Association

Co-Sponsors

• American Association of Critical-Care Nurses

• American Association of Diabetes Educators

• American Heart Association

• American Society of Anesthesiologists

• Joint Commission on Accreditationof Healthcare Organizations

• Society of Critical Care Medicine

• Society of Hospital Medicine

• Veterans Health Administration

Participating Organization

• American College of Cardiology



AACE/ADA Consensus Conference Statement

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

• ACE/ADA Task Force on Inpatient Diabetes.Diabetes Care. 2006;29:1955–1962.

AACE/ADA Consensus Conference Statement

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

• ACE/ADA Task Force on Inpatient Diabetes.Diabetes Care. 2006;29:1955–1962.

ACE/ADA Major Recommendations forOptimal Glycemic Management in

Hospitalized Patients

ACE/ADA Major Recommendations forOptimal Glycemic Management in

Hospitalized Patients• Identify elevated blood glucose in all hospitalized

patients

• Establish a multidisciplinary team approach todiabetes management in all hospitals

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

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

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

• Identify elevated blood glucose in all hospitalized patients

• Establish a multidisciplinary team approach todiabetes management in all hospitals

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

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

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

ACE/ADA: Standardize Insulin Therapyto Reduce Errors

ACE/ADA: Standardize Insulin Therapyto Reduce Errors

• Single Insulin Infusion Concentration

• Single Insulin Infusion Protocol

• SC Insulin order set

• Hypoglycemia Protocol

• Guidelines for Transitions

• IV to SC

• Back to ambulatory regimen

• Guidelines for Special Situations

• Enteral Nutrition

• Parenteral Nutrition

• Single Insulin Infusion Concentration

• Single Insulin Infusion Protocol

• SC Insulin order set

• Hypoglycemia Protocol

• Guidelines for Transitions

• IV to SC

• Back to ambulatory regimen

• Guidelines for Special Situations

• Enteral Nutrition

• Parenteral Nutrition

IV = intravenous; SC = subcutaneous.

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

Clement S., et al; ADA Diabetes in Hospitals Writing Committee. Diabetes Care. 2004;27(2):553–591.

ADA. Diabetes Care. 2008;31:S12–S54.


Successful Strategies for ImplementationSuccessful Strategies for Implementation

• A champion is needed to lead the multidisciplinary steering committee to drive the development of initiatives

• Medical staff, nursing and case management, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, administration

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

• A champion is needed to lead the multidisciplinary steering committee to drive the development of initiatives

• Medical staff, nursing and case management, pharmacy, nutrition services, dietary, laboratory, quality improvement, information systems, administration

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


A Champion is Needed to Lead the Development of the…

A Champion is Needed to Lead the Development of the…

• Standardized order sets

• Protocols, algorithms

• Policies

• Educational programs (physicians and nurses)

• Metrics for evaluation

• A system to track hospital glucose data in an ongoing basis

• Assess the quality of care delivered

• Continuous improvement of processes and protocols

• Standardized order sets

• Protocols, algorithms

• Policies

• Educational programs (physicians and nurses)

• Metrics for evaluation

• A system to track hospital glucose data in an ongoing basis

• Assess the quality of care delivered

• Continuous improvement of processes and protocols

Successful Models

Successful Models

• Consultant Model

• Diabetes Team Model

• System-Wide Model

• Consultant Model

• Diabetes Team Model

• System-Wide Model

Endocrinologist as a Consultant

Endocrinologist as a Consultant

• Endocrinologist is called in to consult on patients identified with DM / hyperglycemia

• Writes orders and communicates the planto others

• Follows patients through hospital stay,makes therapeutic adjustments

• Coordinates discharge and follow-up visits

• Endocrinologist is called in to consult on patients identified with DM / hyperglycemia

• Writes orders and communicates the planto others

• Follows patients through hospital stay,makes therapeutic adjustments

• Coordinates discharge and follow-up visits

Advantages of theConsultant ModelAdvantages of theConsultant Model

• Positions Endocrinologists as leading experts in inpatient glycemic control practice

• Can bill for services

• Positions Endocrinologists as leading experts in inpatient glycemic control practice

• Can bill for services

Disadvantages of theConsultant Model

Disadvantages of theConsultant Model

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

• Must wait for a consulting request

• May not be called each time it is appropriate

• Knowledge and skills are limited to few personnel

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

• Must wait for a consulting request

• May not be called each time it is appropriate

• Knowledge and skills are limited to few personnel

Keys to Success with theConsultant Model

Keys to Success with theConsultant Model

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

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

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

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

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

Diabetes Team ModelDiabetes Team Model

• Nurses (NP or APN) / case managers interact daily with residents, attending physicians, and nursing staff to improve glycemic management

• Conducts patient screenings to identify those with elevated glucose levels

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

• Nurses (NP or APN) / case managers interact daily with residents, attending physicians, and nursing staff to improve glycemic management

• Conducts patient screenings to identify those with elevated glucose levels

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

Endocrinologist as the Medical Director; leads a multidisciplinary team to manage patient careon an ongoing basis.

Endocrinologist as the Medical Director; leads a multidisciplinary team to manage patient careon an ongoing basis.

Advantages of the Team ModelAdvantages of the Team Model

• Strengthens multidisciplinary approach to careof DM / hyperglycemia patients

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

• Clinical staff can become more specialized in effective DM management. Enhanced opportunities for higher level training

• Strengthens multidisciplinary approach to careof DM / hyperglycemia patients

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

• Clinical staff can become more specialized in effective DM management. Enhanced opportunities for higher level training

Disadvantages of the Team ModelDisadvantages of the Team Model

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

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

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

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

Keys to Success withthe Team Model

Keys to Success withthe Team Model

• Must have streamlined, effective communication between team members

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

• Continuous education must be provided systematically throughout the institution – can be a combination of didactics, online learning, bedside rounds, etc.

• Must have streamlined, effective communication between team members

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

• Continuous education must be provided systematically throughout the institution – can be a combination of didactics, online learning, bedside rounds, etc.

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

System-Wide ModelSystem-Wide Model• Endocrinologist oversees hospital-wide program,

which trains all clinical staff to identify and assist in managing patients with diabetes

• Systematic hospital-wide program with allmembers of the clinical team enhancing diabetesknowledge / skills

• Endocrinologist serves as “champion” and oversees development / implementation of protocols. Available as resource for complex cases

• All clinical staff undergo training on DM / hyperglycemia, diabetes nurses serve as resources to house staff, and floor nurses manage routine care based on protocols

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

• Systematic hospital-wide program with allmembers of the clinical team enhancing diabetesknowledge / skills

• Endocrinologist serves as “champion” and oversees development / implementation of protocols. Available as resource for complex cases

• All clinical staff undergo training on DM / hyperglycemia, diabetes nurses serve as resources to house staff, and floor nurses manage routine care based on protocols

Advantages of theSystem-Wide ModelAdvantages of the

System-Wide Model

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

• Effective resource utilization by disseminating skill / knowledge throughout the hospital

• Facilitates standardization while respecting unit culture

• Offers opportunities for systematic program roll-out. Evidence-based training can be offered hospital-wide. Or it can be rolled out gradually by coordinating between units “linked” by routine flow of patients(ie, Surgery ► Intensive Care ► Med Surg.) for consistency of care

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

• Effective resource utilization by disseminating skill / knowledge throughout the hospital

• Facilitates standardization while respecting unit culture

• Offers opportunities for systematic program roll-out. Evidence-based training can be offered hospital-wide. Or it can be rolled out gradually by coordinating between units “linked” by routine flow of patients(ie, Surgery ► Intensive Care ► Med Surg.) for consistency of care

Disadvantages of theSystem-Wide Model

Disadvantages of theSystem-Wide Model

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

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

• Staff turn-over creates need for ongoing training / awareness

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

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

• Staff turn-over creates need for ongoing training / awareness

Keys to Success with theSystem-Wide Model

Keys to Success with theSystem-Wide Model

• Commitment from top levels of clinical and administrative teams

• Ongoing results monitoring of clinical and financial improvement. Sharing results system-wide

• Active involvement of all key departments… nursing, lab, information services, billing, dietary, education and so on…

• Communication and maintaining a high level of awareness among staff and physicians throughoutthe system

• Commitment from top levels of clinical and administrative teams

• Ongoing results monitoring of clinical and financial improvement. Sharing results system-wide

• Active involvement of all key departments… nursing, lab, information services, billing, dietary, education and so on…

• Communication and maintaining a high level of awareness among staff and physicians throughoutthe system

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

The Next Step:

Joint Commission’s Disease Specific Certification

The Next Step:

Joint Commission’s Disease Specific Certification

The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCInformation. Accessed February 5, 2008.

Joint Commission’sDisease-Specific Care Certification


• The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate disease management and chronic care services provided by direct care providers such as hospitals

• Organizations may seek certification for clinical programs for virtually any chronic disease or condition

• The Joint Commission’s Disease-Specific Care Certification Program, launched in 2002, is designed to evaluate disease management and chronic care services provided by direct care providers such as hospitals

• Organizations may seek certification for clinical programs for virtually any chronic disease or condition

The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCInformation. Accessed February 5, 2008.



• Disease-Specific Care Certification uses a model that is flexible enough to apply to any disease management program.

• The evaluation and resulting certification decision is based on an assessment of

• Compliance with consensus-based national standards

• Effective use of evidence-based clinical practice guidelines to manage and optimize care

• An organized approach to performance measurement and improvement activities.

• Disease-Specific Care Certification uses a model that is flexible enough to apply to any disease management program.

• The evaluation and resulting certification decision is based on an assessment of

• Compliance with consensus-based national standards

• Effective use of evidence-based clinical practice guidelines to manage and optimize care

• An organized approach to performance measurement and improvement activities.

The Joint Commission. http://www.jointcommission.org/CertificationPrograms/cert_benefits.htm. Accessed February 6, 2008.

Benefits of Joint CommissionDisease-Specific Care Certification


• Attaining Joint Commission Disease-Specific Care Certification

• Strengthens community confidence in the quality and safetyof care, treatment and services

• Provides a framework for program structure and management

• Provides a competitive edge in the marketplace

• Validates compliance with nationally recognized standards by the preeminent health care evaluator

• Improves risk management and risk reduction

• Attaining Joint Commission Disease-Specific Care Certification

• Strengthens community confidence in the quality and safetyof care, treatment and services

• Provides a framework for program structure and management

• Provides a competitive edge in the marketplace

• Validates compliance with nationally recognized standards by the preeminent health care evaluator

• Improves risk management and risk reduction

Joint Commission Disease-Specific Care Certificationis a measure of achievement

The Joint Commission. http://www.jointcommission.org/CertificationPrograms/cert_benefits.htm. Accessed February 6, 2008.



• Attaining Joint Commission Disease-SpecificCare Certification

• Provides education on good practices to improvebusiness operations

• Provides professional advice and counsel, thereby enhancing staff education

• Can be a tool to attract and retain quality personnel

• Recognized by select insurers and other third parties

• Can fulfill regulatory requirements in select states

• Attaining Joint Commission Disease-SpecificCare Certification

• Provides education on good practices to improvebusiness operations

• Provides professional advice and counsel, thereby enhancing staff education

• Can be a tool to attract and retain quality personnel

• Recognized by select insurers and other third parties

• Can fulfill regulatory requirements in select states

The Joint Commission. Disease-Specific Care Certification Guide. 1–30.

Joint Commission Standards forDisease-Specific Care Certification:

Overview

Joint Commission Standards forDisease-Specific Care Certification:

Overview

• Joint Commission Standards for Disease-SpecificCare Certification

• Program management

• Delivering or facilitating clinical care

• Supporting self-management

• Clinical information management

• Performance measurement

• Joint Commission Standards for Disease-SpecificCare Certification

• Program management

• Delivering or facilitating clinical care

• Supporting self-management

• Clinical information management

• Performance measurement

The Standards: Program ManagementThe Standards: Program Management


• Designing, implementing and evaluatingthe program

• Defining leadership roles

• Creating a relevant program for participants

• Providing adequate access to care

• Conducting the program in an ethical manner

• Supplying reference resources to staff

• Designing, implementing and evaluatingthe program

• Defining leadership roles

• Creating a relevant program for participants

• Providing adequate access to care

• Conducting the program in an ethical manner

• Supplying reference resources to staff


The Standards: Delivering orFacilitating Clinical Care

The Standards: Delivering orFacilitating Clinical Care

• Using qualified, competent staff

• Delivering or facilitating the delivery of care using clinical practice guidelines that are evidence-based

• Individualizing care to meet the participant’s needs

• Improving practice and services based on the use of performance measurement

• Using qualified, competent staff

• Delivering or facilitating the delivery of care using clinical practice guidelines that are evidence-based

• Individualizing care to meet the participant’s needs

• Improving practice and services based on the use of performance measurement


The Standards: Supporting PatientSelf-Management

The Standards: Supporting PatientSelf-Management

• Assessing patients’ self-management capabilities

• Providing support for patients in self-management activities

• Involving patients in developing the plan of care

• Educating patients in the theory and skills necessaryto manage their disease(s)

• Recognizing and supporting self-management efforts

• Assessing patients’ self-management capabilities

• Providing support for patients in self-management activities

• Involving patients in developing the plan of care

• Educating patients in the theory and skills necessaryto manage their disease(s)

• Recognizing and supporting self-management efforts

Joint Commission standards mirror those of diabetes organizations with regard to patient self-management

The Standards: Clinical InformationManagement

The Standards: Clinical InformationManagement

• Proactively gathering and sharing information across the continuum to coordinate care across settings and over time

• Providing easy access to participant-related information

• Preserving participant confidentiality

• Maintaining data quality and integrity

• Integrating and interpreting data from various sources

• Proactively gathering and sharing information across the continuum to coordinate care across settings and over time

• Providing easy access to participant-related information

• Preserving participant confidentiality


• Integrating and interpreting data from various sources


The Standards:Performance Measurement


• Having an organized, comprehensive approach to performance improvement

• Trending and comparing data to evaluate processes and outcomes

• Using information garnered from measurement datato improve or validate clinical practice

• Using participant-specific, care-related data

• Evaluating the participants’ perceptions of qualityof clinical care


• Having an organized, comprehensive approach to performance improvement

• Trending and comparing data to evaluate processes and outcomes

• Using information garnered from measurement datato improve or validate clinical practice

• Using participant-specific, care-related data

• Evaluating the participants’ perceptions of qualityof clinical care

• Maintaining data quality and integrity The Joint Commission. Disease-Specific Care Certification Guide. 1–30.



The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DCSPM/.Accessed February 6, 2008.

• Effective July 1, 2007, specific performance measurement requirements were implemented for all certified programs including:

• Collection of monthly data points for both standardized and nonstandardized measures

• Prior to initial certification, collection of a minimum of4 months of performance measure data for each standardized and/or nonstandardized measure submitted at the time of application

• Effective July 1, 2007, specific performance measurement requirements were implemented for all certified programs including:

• Collection of monthly data points for both standardized and nonstandardized measures

• Prior to initial certification, collection of a minimum of4 months of performance measure data for each standardized and/or nonstandardized measure submitted at the time of application



The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DCSPM/.Accessed February 6, 2008.

• An additional performance measurement requirement for standardized measure data reporting is anticipated in 2008, following enhancements tothe Joint Commission Connect™, which will afford certified programs the capability for electronic data submission

• The Joint Commission will aggregate the data submitted electronically and return it to certified organizations for comparative performance evaluation

• An additional performance measurement requirement for standardized measure data reporting is anticipated in 2008, following enhancements tothe Joint Commission Connect™, which will afford certified programs the capability for electronic data submission

• The Joint Commission will aggregate the data submitted electronically and return it to certified organizations for comparative performance evaluation

ADA = American Diabetes Association

The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Inpatient+Diabetes.Accessed February 4, 2008.

Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care


• The Joint Commission and the ADA have identified that the most successful inpatient diabetes programs possess the following critical attributes:

• Specific staff education requirements

• Written blood glucose monitoring protocols

• Plans for the treatment of hypoglycemia and hyperglycemia

• Data collection of incidence of hypoglycemia

• Patient education on self-management of diabetes

• An identified program champion or program champion team

• The Joint Commission and the ADA have identified that the most successful inpatient diabetes programs possess the following critical attributes:

• Specific staff education requirements

• Written blood glucose monitoring protocols

• Plans for the treatment of hypoglycemia and hyperglycemia

• Data collection of incidence of hypoglycemia

• Patient education on self-management of diabetes

• An identified program champion or program champion team

The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf. Accessed February 6, 2008.

Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care: A Caveat

Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care: A Caveat

• This program applies to patients who have a medical history of diabetes: diabetes diagnosedand acknowledged by the treating physician

• This program does not apply to hospital-related hyperglycemia attributed to medications or other factors

• This program applies to patients who have a medical history of diabetes: diabetes diagnosedand acknowledged by the treating physician

• This program does not apply to hospital-related hyperglycemia attributed to medications or other factors

1. The Joint Commission. http://www.jointcommission.org/CertificationPrograms/Inpatient+Diabetes.Accessed February 4, 2008

2. The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf. Accessed February 4, 2008.


Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care• Joint Commission’s Certificate of Distinction for Inpatient

Diabetes Care links their expectations to those of the ADA1

• The major elements of The Joint Commissionexpectations are2

• General recommendations

• Blood glucose targets

• Preventing hypoglycemia

• Diabetes care providers

• Joint Commission’s Certificate of Distinction for Inpatient Diabetes Care links their expectations to those of the ADA1

• The major elements of The Joint Commissionexpectations are2

• General recommendations

• Blood glucose targets

• Preventing hypoglycemia

• Diabetes care providers

•Diabetes self-management education

•Medical nutrition therapy

•Blood glucose monitoring

•Diabetes self-management education

•Medical nutrition therapy

•Blood glucose monitoring

Joint Commission’s Certificate:General Recommendations

Joint Commission’s Certificate:General Recommendations

NPO = Nothing by mouth.


• The Joint Commission: Patients with diabetes are identified ashaving diabetes in the medical record, at admission, andat discharge

• Documentation reflects the • Type of diabetes (if known)

• Preadmission medications fordiabetes control (including dosages)

• Preadmission and current weight

• Degree of control prior to admission;severity of hyperglycemia on admission

• The Joint Commission: Patients with diabetes are identified ashaving diabetes in the medical record, at admission, andat discharge

• Documentation reflects the • Type of diabetes (if known)

• Preadmission medications fordiabetes control (including dosages)

• Preadmission and current weight

• Degree of control prior to admission;severity of hyperglycemia on admission

•Level of comprehensionand competence related todiabetes self-managementactivities

•Nutritional screening resultsand nutrition management plan

•Current and anticipatednutritional status (eg. NPO)

•Level of comprehensionand competence related todiabetes self-managementactivities

•Nutritional screening resultsand nutrition management plan

•Current and anticipatednutritional status (eg. NPO)


Joint Commission’s Certificate:Blood Glucose Targets

Joint Commission’s Certificate:Blood Glucose Targets

• Joint Commission Expectation

• An A1c is drawn at the time of admission, unless the results of the patient’s A1c drawn within the last 60 days are known, or the patient has a medical condition or has received therapy that would confound the results


• An A1c is drawn at the time of admission, unless the results of the patient’s A1c drawn within the last 60 days are known, or the patient has a medical condition or has received therapy that would confound the results


Joint Commission’s Certificate:Preventing Hypoglycemia

Joint Commission’s Certificate:Preventing Hypoglycemia


• Plans for the treatment of hypoglycemia and hyperglycemiaare established

• A plan for coordinating administration of insulin and deliveryof meals is implemented

• Episodes of hypoglycemia are identified and contributingreasons for these are captured

• Contributing reasons for episodes of hypoglycemia are evaluated for systemic trends

• Written protocols are developed for management of patientson intravenous insulin infusions


• Plans for the treatment of hypoglycemia and hyperglycemiaare established

• A plan for coordinating administration of insulin and deliveryof meals is implemented

• Episodes of hypoglycemia are identified and contributingreasons for these are captured

• Contributing reasons for episodes of hypoglycemia are evaluated for systemic trends

• Written protocols are developed for management of patientson intravenous insulin infusions

The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67C2-72A6-4DC3-A047-15BEB394FE3C/0/Diabetes_Addendum.pdf. Accessed February 4, 2008. APN = Advanced practice nurse.

Joint Commission’s Certificate:Diabetes Care Providers

Joint Commission’s Certificate:Diabetes Care Providers


• A multidisciplinary program team is identified witha designated team leader

• The following groups working with patients with diabetes have had education specific to the management of diabetes

• Dieticians and others involved in medical nutrition therapy

• Staff involved in point of care testing

• Medical staff

• Nursing staff, including APNs

• Pharmacists

• Physician assistants


• A multidisciplinary program team is identified witha designated team leader

• The following groups working with patients with diabetes have had education specific to the management of diabetes

• Dieticians and others involved in medical nutrition therapy

• Staff involved in point of care testing

• Medical staff

• Nursing staff, including APNs

• Pharmacists

• Physician assistants


Joint Commission’s Certificate:Self-Management Education

Joint Commission’s Certificate:Self-Management Education

• Patients with newly diagnosed diabetes or educational deficits have atleast the following educational components reflected in the plan of care

• Medication management, including how to administer insulin (when appropriate)and potential medication interactions

• Nutritional management, including the role of carbohydrate intake inblood glucose management

• Exercise

• Signs and symptoms of hyperglycemia and hypoglycemia

• Treatment of hyperglycemia and hypoglycemia

• Importance of blood glucose monitoring and how to obtain a blood glucose meter

• Instruction on use of blood glucose meter, if available

• Sick day guidelines

• Information for who to contact in case of emergency or for more information

• Plan for post-discharge education or self-management support

• Patients with newly diagnosed diabetes or educational deficits have atleast the following educational components reflected in the plan of care

• Medication management, including how to administer insulin (when appropriate)and potential medication interactions

• Nutritional management, including the role of carbohydrate intake inblood glucose management

• Exercise

• Signs and symptoms of hyperglycemia and hypoglycemia

• Treatment of hyperglycemia and hypoglycemia

• Importance of blood glucose monitoring and how to obtain a blood glucose meter

• Instruction on use of blood glucose meter, if available

• Sick day guidelines

• Information for who to contact in case of emergency or for more information

• Plan for post-discharge education or self-management support


Joint Commission’s Certificate:Medical Nutrition Therapy

Joint Commission’s Certificate:Medical Nutrition Therapy


• Nutritional consultations are conducted for patientsnot consistently reaching glucose targets


• Nutritional consultations are conducted for patientsnot consistently reaching glucose targets


Joint Commission’s Certificate:Blood Glucose Monitoring

Joint Commission’s Certificate:Blood Glucose Monitoring

• Joint Commission Expectation • Written blood glucose monitoring protocols for patients with known diabetes are

developed and include, at a minimum, the following:

• Measuring blood glucose upon admission

• A plan for subsequent monitoring based on the patient’s

• Type of diabetes

• Desired level of control

• Current treatment(s) (eg., use of steroids, TPN, etc)

• Comorbidities and medical illnesses

• Dietary status including patients who are NPO

• Results of blood glucose monitoring are available to all members of the health care team

• The patient and the practitioner managing his or her diabetes care after discharge are informed about the patient’s A1c results and any unresolved issues related to glucose management

• Joint Commission Expectation • Written blood glucose monitoring protocols for patients with known diabetes are

developed and include, at a minimum, the following:

• Measuring blood glucose upon admission

• A plan for subsequent monitoring based on the patient’s

• Type of diabetes

• Desired level of control

• Current treatment(s) (eg., use of steroids, TPN, etc)

• Comorbidities and medical illnesses

• Dietary status including patients who are NPO

• Results of blood glucose monitoring are available to all members of the health care team

• The patient and the practitioner managing his or her diabetes care after discharge are informed about the patient’s A1c results and any unresolved issues related to glucose management

TPN = total parenteral nutrition.

successful models of implementation

Health & Medicine

inpatient diabetes care

outpatient care

quality of care issue

number of hospital discharges

episode of glucose

intensive care units

mean glucose

patient safety issue