Is Your Organization Providing Quality Care?

Lewis Hooper (2022) has presented findings based on his research that should be of major concern to boards of directors of hospitals and regional health authorities throughout the country. Although his research is based on studies of Ontario hospitals, my experience leads me to believe that the problems and opportunities for improvement can be applied across Canada.

Initiating Insulin in the Emergency Center and Urgent Care to Prevent Hospital Admission for Patients with Hyperglycemia: A Unique Insulin Starter Kit.

BACKGROUND: Clinicians in the Emergency Center (EC) and Urgent Care (UC) can play a vital role in preventing hospital admissions and improving outcomes of patients with newly diagnosed diabetes or pre-existing diabetes who present with hyperglycemia and the need to initiate insulin. METHODS: This article describes a unique EC/UC discharge insulin starter kit protocol with clinician instructions via an Electronic Medical Record (EMR) order set that includes: starting doses for insulin, a prescription for glucose monitoring supplies, and an emergent referral to diabetes education at International Diabetes Center. Patients receive insulin during the EC/UC visit and are provided an insulin pen to take home. Nurses from the EC or UC review and provide educational material on how to use an insulin pen, treating hypoglycemia and healthy eating. The Certified Diabetes Care and Education Specialist (CDCES) sees patients within 24-72 hours after the referral is placed. RESULTS: Within our single healthcare system's EC and UC (multiple sites), the kit has enabled clinicians to metabolically stabilize patients and decrease the need for hospitalization without experiencing hypoglycemia. In the recent three years of use, of 42 patients given the insulin starter kit, there were only 2 patients with repeat EC/UC visits within the first six months (1 hyperglycemia and 1 hypoglycemia). CONCLUSIONS: An insulin starter kit and EMR-based order set initiated in the EC/UC setting is a tool that can be used to improve the quality of care for people with newly diagnosed or pre-existing diabetes experiencing significant hyperglycemia.

Trial of a New Diabetes Education Model: Closing the Gap in Health Disparity for People with Diabetes.

BACKGROUND: Quality measures relating to diabetes care in America have not improved between 2005 and 2016, and have plateaued even in areas that outperform national statistics. New approaches to diabetes care and education are needed and are especially important in reaching populations with significant barriers to optimized care. METHODS: A pilot quality improvement study was created to optimize diabetes education in a clinic setting with a patient population with significant healthcare barriers. Certified Diabetes Care and Education Specialists (CDCES) were deployed in a team-based model with flexible scheduling and same-day education visits, outside of the traditional framework of diabetes education, specifically targeting practices with underperforming diabetes quality measures, in a clinic setting significantly impacted by social determinants of health. RESULTS: A team-based and flexible diabetes education model decreased hemoglobin A1C for individuals participating in the project (and having a second A1C measured) by an average of -2.3%, improved Minnesota Diabetes Quality Measures (D5) for clinicians participating in the project by 5.8%, optimized use of CDCES, and reduced a high visit fail rate for diabetes education. CONCLUSIONS: Diabetes education provided in a team-based and flexible model may better meet patient needs and improve diabetes care metrics, in settings with a patient population with significant barriers.

Effect of Professional CGM (pCGM) on Glucose Management in Type 2 Diabetes Patients in Primary Care.

BACKGROUND: Little data exists regarding the impact of continuous glucose monitoring (CGM) in the primary care management of type 2 diabetes (T2D). We initiated a quality improvement (QI) project in a large healthcare system to determine the effect of professional CGM (pCGM) on glucose management. We evaluated both an MD and RN/Certified Diabetes Care and Education Specialist (CDCES) Care Model. METHODS: Participants with T2D for >1 yr., A1C ≥7.0% to <11.0%, managed with any T2D regimen and willing to use pCGM were included. Baseline A1C was collected and participants wore a pCGM (Libre Pro) for up to 2 weeks, followed by a visit with an MD or RN/CDCES to review CGM data including Ambulatory Glucose Profile (AGP) Report. Shared-decision making was used to modify lifestyle and medications. Clinic follow-up in 3 to 6 months included an A1C and, in a subset, a repeat pCGM. RESULTS: Sixty-eight participants average age 61.6 years, average duration of T2D 15 years, mean A1C 8.8%, were identified. Pre to post pCGM lowered A1C from 8.8% ± 1.2% to 8.2% ± 1.3% (n=68, P=0.006). The time in range (TIR) and time in hyperglycemia improved along with more hypoglycemia in the subset of 37 participants who wore a second pCGM. Glycemic improvement was due to lifestyle counseling (68% of participants) and intensification of therapy (65% of participants), rather than addition of medications. CONCLUSIONS: Using pCGM in primary care, with an MD or RN/CDCES Care Model, is effective at lowering A1C, increasing TIR and reducing time in hyperglycemia without necessarily requiring additional medications.

Using simulation modelling to test the impact of future demand for end-of-life care.

Health systems globally are exploring new models of care to address the increasing demand for palliative, hospice, and end-of-life care. Yet few tools exist at the population level to explore "what if" scenarios and test, in a "cost avoidance environment," the impact of these new care models on policy, workforce, technology, and funding. This article introduces the application of scenario-based "what if" thinking and discrete event simulation in strategic planning for a not-for-profit hospice organization. It will describe how a set of conceptual models was designed to frame discussions between strategic partners about the implications and alternatives in implementing a new, integrated service model for palliative and end-of-life care.

What's all the buzz about change management?

Change management is more important than ever in healthcare. It is an essential part of the management tool box and to downplay its importance is to risk serious challenges, including failure, in implementing and even more importantly, sustaining change. All too often, change management is something that is handed off to a special department or even contracted out, without due consideration of the need to develop the knowledge and skills in and across the organization. Some basics for successful change management are identified and discussed.

Assessing human diet and movement in the Tongan maritime chiefdom using isotopic analyses.

The rise of stratified societies fundamentally influences the interactions between status, movement, and food. Using isotopic analyses, we assess differences in diet and mobility of individuals excavated from two burial mounds located at the `Atele burial site on Tongatapu, the main island of the Kingdom of Tonga (c. 500 - 150 BP). The first burial mound (To-At-1) was classified by some archaeologists as a commoner's mound while the second burial mound (To-At-2) was possibly used for interment of the chiefly class. In this study, stable isotope analyses of diet (δ13C, δ15N, and δ34S; n = 41) are used to asses paleodiet and 87Sr/86Sr ratios (n = 30) are analyzed to investigate individual mobility to test whether sex and social status affected these aspects of life. Our results show significant differences in diet between burial mounds and sexes. Those interred in To-At-2 displayed lower δ13C values, indicating they ate relatively more terrestrial plants (likely starchy vegetable staples) compared with To-At-1 individuals. Females displayed significantly lower δ15N values compared with males within the entire assemblage. No differences in δ34S values were observed between sexes or burial mound but it is possible that sea spray or volcanism may have affected these values. One individual displayed the strontium isotopic composition representative of a nonlocal immigrant (outside 2SD of the mean). This suggests the hegemonic control over interisland travel, may have prevented long-term access to the island by non-Tongans exemplifying the political and spiritual importance of the island of Tongatapu in the maritime chiefdom.

You just need to get started.

An organization can drive quality only through its people. Too often, we relegate quality to a single department or a small group of evangelical leaders but fail to make it everyone's business. Accountability has become a buzzword, and we have translated it into huge agreements with myriads of measures and indicators, all purporting to have something to do with quality.Institutions need to focus on a few things to improve quality. How do you build a culture? You plan, you pick certain goals to which you aspire, you set targets and you measure against those targets. You provide the skills, knowledge, expertise and infrastructure necessary to enable people to meet those targets, and then you drive for them. And you are transparent about it.I often think that we overcomplicate quality. As I have said repeatedly, it is as simple as choosing a measure, planning to implement some changes and re-measuring to see if your changes have had any impact. You don't need a national council, or even a provincial one, to make quality happen in the day-to-day operations of every healthcare organization in the country. Rather, you just need to get started.

National recommendations for donation after cardiocirculatory death in Canada: Donation after cardiocirculatory death in Canada.

These recommendations are the result of a national, multidisciplinary, year-long process to discuss whether and how to proceed with organ donation after cardiocirculatory death (DCD) in Canada. A national forum was held in February 2005 to discuss and develop recommendations on the principles, procedures and practice related to DCD, including ethical and legal considerations. At the forum's conclusion, a strong majority of participants supported proceeding with DCD programs in Canada. The forum also recognized the need to formulate and emphasize core values to guide the development of programs and protocols based on the medical, ethical and legal framework established at this meeting. Although end-of-life care should routinely include the opportunity to donate organs and tissues, the duty of care toward dying patients and their families remains the dominant priority of health care teams. The complexity and profound implications of death are recognized and should be respected, along with differing personal, ethnocultural and religious perspectives on death and donation. Decisions around withdrawal of life-sustaining therapies, management of the dying process and the determination of death by cardiocirculatory criteria should be separate from and independent of donation and transplant processes. The recommendations in this report are intended to guide individual programs, regional health authorities and jurisdictions in the development of DCD protocols. Programs will develop based on local leadership and advance planning that includes education and engagement of stakeholders, mechanisms to assure safety and quality and public information. We recommend that programs begin with controlled DCD within the intensive care unit where (after a consensual decision to withdraw life-sustaining therapy) death is anticipated, but has not yet occurred, and unhurried consent discussions can be held. Uncontrolled donation (where death has occurred after unanticipated cardiac arrest) should only be considered after a controlled DCD program is well established. Although we recommend that programs commence with kidney donation, regional transplant expertise may guide the inclusion of other organs. The impact of DCD, including pre-and post-mortem interventions, on donor family experiences, organ availability, graft function and recipient survival should be carefully documented and studied.

Impact of modem-transferred blood glucose data on clinician work efficiency and patient glycemic control.

BACKGROUND: Communication of blood glucose (BG) results between patients and health care providers (HCPs) is of established benefit and remains a critical part of the diabetes management process. Currently, HCPs typically receive BG data from patients at the time of clinic visits or by telephone. The Accu-Chek Acculink modem (Roche Diagnostics Corp., Indianapolis, IN) provides an additional and attractive option that can potentially facilitate this communication. METHODS: To assess the impact of modem transfer of BG, we studied 47 participants with diabetes enrolled in a diabetes education program. Subjects were randomized to weekly communication of BG data to their HCP by either telephone (n = 23) or modem (n = 24) for 4 weeks. Mean age (+/- SD) was 44 +/- 15 years, 62% were female, 74% used insulin, 53% had type 1 diabetes, and mean baseline glycosylated hemoglobin (A1C) was 8.8% (range 5.2-13.2%). RESULTS: There were no differences between groups in the amount of time the HCP spent analyzing BG data and communicating with patients (12.6 +/- 6.1 min/week in the telephone group and 11.5 +/- 5.1 min/week in the modem group) or in the number of patient and HCP attempts needed to make contact. There were similar improvements in A1C between groups (change of -0.4 +/- 0.7% in the telephone group and -0.9 +/- 1.4% in the modem group, P = 0.18). BG data provided by telephone had a 6% error rate, in contrast to modem-sent data, which were transmitted without error. CONCLUSIONS: Modem transfer of BG data can provide an accurate and clinically useful option for communication between patients and their HCP and has comparable effects on A1C.