Quality Improvement is Hard but Needed: Highlights from the 2018 EndoTool User Group Meeting

On October 18th, Monarch hosted its annual EndoTool User Group Meeting bringing together clients from across the country to discuss inpatient glycemic management and the use of EndoTool. As Monarch President & CEO, Linda Beneze, stated at the beginning of the meeting, “we are much stronger together than apart,” and that became evident throughout the day. From new users to longtime EndoTool advocates, all took part sharing strategies, best practices, and common challenges.  While there were many takeaways from the meeting, there is one that summarizes it best—quality improvement is hard but needed.

Although the industry has made significant advances in glycemic management, there is hope with increased attention being placed on glucose metrics, the opportunity to improve glycemic management continues to be crucial. Hyperglycemia remains pervasive and hypoglycemia episodes occur far too often, negatively affecting outcomes of hospitalized patients.

Where the industry currently stands may be puzzling to some; as Monarch’s EVP and Chief Clinical Officer, Laurel Fuqua, RN, MSN pointed out, the benefits of glycemic management have long been known. In Dr. Banting’s noble prize speech in 1925, he highlighted how glucose management impacted wound healing. Since then there has only been a growing body of scientific studies making the case for glycemic management, including landmark studies. With the Diabetes Control and Complication Trials (DCCT), we’ve known since the 1990s that keeping the blood glucose as close to normal reduces complications for both Type 1 and Type 2 Diabetes. There are even documented studies showing the impact of glycemic management on length of stay and costs. The Portland Diabetes Project showed that each 50 mg/dL increase in blood glucose level added one day to the patient’s length of stay.

Beyond the metrics providing a clear reason for action, shouldn’t we simply be doing what is best for the patient? As Caroline Isbey, RN, MSN, CDE of the Joint Commission asked the audience during her presentation, “What is the psychological message you are sending to your patients if you keep their glucose levels high and do not focus on helping to achieve control?” To her, that meant, we are not setting the patient up to succeed in taking care of themselves outside of the hospital.

So while we have the proof and it clearly sends a better message to patients, why are hospitals still utilizing sliding scale insulin or paper protocols, having trouble tracking down reliable glucose metrics, and not providing individualized treatment and discharge plans for patients with diabetes?

The answer is that quality improvement is hard.

Why is quality improvement so hard?

There are several reasons why quality improvement is so difficult and particularly in the healthcare setting. During a presentation from Dr. Fogel, Medical Director of OR Services at the Carilion Clinic, four major barriers were outlined:

The first is habit. Consistency is key for everyone in the health field, particularly physicians. With a patient’s life in their hands, they want to stick to the tried and true practices that they have used throughout their career. Breaking habits is extremely difficult.

The second is what he called “institutional ennui,” which he summarized as trying to turn around the titanic. Changing practices at a large institution requires a huge, systematic effort, and culture trumps strategy every time.

The third barrier to quality improvement is money. These projects cost a significant amount of money, but the return can be worth the effort. When discussing the glycemic management quality improvement project at Carilion Clinic, which included the use of EndoTool, among other elements, they found a 7 to 1 return on investment. With the clear financial implications, he suggested the project is something that not only clinicians, but administration can get behind.

The final barrier is the time it takes for the literature and research to ignite change. On average, he stated it can take 17 years between established literature and standards of care before there is universal adoption.

While there are clearly barriers to quality improvement, driving adoption of a new standard of care for diabetes is possible and certainly needed. Just as we started our meeting with the adage “we are stronger together than apart,” improving inpatient glycemic management across the industry is going to require we all work together to advance care.