The Society of Hospital Medicine (SHM) is now accepting applications for the Glycemic Control Mentored Implementation (GCMI) Program. Mentors with QI and glycemic control expertise will work alongside your QI team to coach you through best practices. The GCMI Program aims to support sites in optimizing the care of inpatients with hyperglycemia and diabetes and in preventing hypoglycemia. Accepted sites will participate in a 12 month program which includes an assigned mentor to help coach your team, approximately 6-10 mentor/mentee calls, a site visit, access to SHM’s Data Center for glucometrics and benchmark reports, webinars, and an online community to share information through a national Discussion Forum. The tuition is $19,000 per hospital.

Please contact Sara Platt after you complete the application process to confirm your application has been submitted properly and to discuss next steps 267-702-2672.

**Please note that if you are a part of a health system discounts are offered for multiple sites enrolling into the program and  that each hospital must submit an individual application.**

* 1. Hospital Name

* 2. Contact Name

* 3. Credentials (if applicable)

* 4. Job Title

* 5. Hospital Address, City, State and Zip Code

* 6. Email Address

* 7. Phone Number

* 8. If you would like to include the contact information for additional team members, please provide the following: name(s), credential(s), title(s), and email address(es).

* 9. Are you or any member of your team an SHM member in good standing? (This is not required but is preferred.)

* 10. Type of facility?

* 11. Number of staffed beds?

* 12. Does the hospital have computerized physician order entry?

* 13. Do you have an electronic medical/health record system?

* 14. How/where did you first hear about the GCMI program?

* 15. Are you now or have you been active in QI work, either within your hospital medicine group or at the hospital where the Glycemic Control improvement effort will be implemented?

* 16. Has Glycemic Control Improvement been recognized as a QI or safety priority by clinical or administrative leaders at your site?

* 17. Do you plan to apply for The Joint Commission’s Advanced Certification in Diabetes?

* 18. Please describe the status of Glycemic Control improvement efforts at this site.

* 19. If no program is in place, have there been prior attempts to improve glycemic control at the hospital?

* 20. Which of the following areas are you looking to improve with in your institution?

Note: It is NOT required or expected that applicants will have completed the processes outlined in sections below. However, please answer each question so we have an accurate description of your current program.

* 21. Briefly summarize the institutional support that has been offered or provided to your program.

* 22. Have you identified an executive champion for the program?

* 23. Do you currently have a glycemic team that sees patients for management purposes?

* 24. Do you currently have a glycemic team that sees patients for educational purposes?

* 25. Do you have specific aims or goals that you would like to see reached or achieved?

* 26. Briefly summarize your program goals and the process used to develop them.

* 27. What aspect of inpatient diabetes management would you like to prioritize for this program?

* 28. Do you have a measurable goal and means to collect the data necessary?

* 29. Have you defined the scope of your program (which hospital units or patient populations you will focus on)?

* 30. Please indicate which hospital units you will focus on?

* 31. Have you mapped the current processes for implementing your program?

* 32. Have you redesigned any of those processes?

* 33. Briefly summarize your process map findings, and any redesign work you have done. Be sure to mention any high­leverage points you identified (i.e. areas where you’ll get the most bang for your buck from redesign).

* 34. Will your institution allow de­identified patient data (point of care tests results) to be uploaded into a quality improvement data base to assist with the mentoring process?

* 35. Do you have an Information Technology contact (or other) who will be able to provide support in data collection (i.e. identifying data sources, accessing data, etc.).

* 36. Have you collected baseline data describing any of the following:

* 37. Have you determined which stakeholders will want to see data describing program outcomes, and when and how you will report to them?

* 38. Briefly summarize your data collection, metrics, management, analysis and reporting efforts.

* 39. Using the following Likert Scale, please provide us with the status of your order sets and protocols: (1- No standardized protocol/order sets in place yet, 3- Protocols/order sets have been designed and implemented but is not reliably used, 5- Hard wired protocols/order sets are in place and reliably used.)

  1 Not in place yet 2 3 In place but not reliably used 4 5 In place and reliably used
Basal / bolus SC insulin
Insulin infusion
Transition from infusion to SC insulin
Transition out of the hospital
Perioperative management

* 40. Have you measured baseline MD/NP/PA awareness attitudes, or knowledge about inpatient glycemic control issues?

* 41. Have you undertaken any educational efforts aimed at raising MD/NP/PA awareness or knowledge about inpatient diabetes / hyperglycemia management?

* 42. Have you measured baseline nursing awareness attitudes, or knowledge about inpatient glycemic control issues?

* 43. Have you undertaken any educational efforts aimed at raising nursing awareness or knowledge about inpatient diabetes / hyperglycemia management?

* 44. If you are using new order sets or protocols, have you taken steps to orient MDs and nursing staff to your intervention(s)?

* 45. Briefly summarize your education and outreach efforts, in particular efforts to promote awareness and buy­in from opinion leaders or skeptics. Please include any baseline or post intervention data to assess these educational efforts if available.

* 46. Weaknesses: List the aspects of your hospital or program team that might impede or prevent your success. This might be lack of protected time to pursue the effort, a history of failed attempts to improve glycemic control, strong opposition from opinion leaders or other stakeholders, lack of sufficient staff, etc. What have been your successes to date? Please describe any significant barriers your program has encountered. Is there anything else you would like to tell us?

* 47. Strengths: List the attributes of your hospital or program team that will help you achieve your goals. These might be the personnel who are participating in or leading the program, a culture that supports quality improvement, strong senior leader motivation to address this issue at this time, etc.

The last step of this application will be a Letter of Support. A letter of support is required to come from a senior administrator or executive champion stating their support for your institutions involvement with the GCMI Program. The letter can be e­mailed (preferred) or faxed to Sara Platt at the Society of Hospital Medicine. Please contact Sara Platt for a sample Letter of Support.

Again, please contact Sara Platt after you complete the application process to confirm your application has been submitted properly and to discuss next steps 267-702-2672.

Thank you for completing this portion of the GCMI Program Application!

Sara Platt, Project Manager
F: (267) 702­-2690
P: (267)-702-2672