Cheryl O'Malley, MD

Hospital medicine is an emerging specialty comprised predominantly of early‐career faculty, often less than 5 years postresidency and predominately at instructor or assistant professor level.[1] Effective mentoring has been identified as a critical component of academic success.[2, 3] Published data suggest that most academic hospitalists do not have a mentor, and when they do, the majority of them spend less than 4 hours per year with their mentor.[2] The reasons for this are multifactorial but largely result from the lack of structure, opportunities, and local senior academic hospitalists.[1, 4] Early‐career faculty have difficulty establishing external mentoring relationships, and new models beyond the traditional intrainstitutional dyad are needed.[3, 4] The need for mentors and structured mentorship networks may be particularly high in hospital medicine.[5]

The Visiting Professorship in Hospital Medicine Program was designed to promote cross‐institutional mentorship, share hospitalist innovations, and facilitate academic collaboration between hospitalist groups. We describe the design and early experience with this program across 5 academic hospital medicine programs.

PROGRAM DESIGN

RESULTS

To date, 5 academic medical centers have participated in the visiting professorship program, with 7 visiting professors interacting with 29 early‐career faculty. Of the 29 early‐career faculty, 72% (21/29) were at the rank of assistant professor, 17% (5/29) instructor, 7% (2/29) residents with plans to hire, and 3% (1/29) associate professor. The median was 2 years in academic medicine and 1 year at current academic rank. Forty‐one percent (12/29) were women and 7% (2/29) identified as ethnic minority. Of the 7 visiting professors, 57% (4/7) were assistant professor and 43% (3/7) were associate professors. The median was 5 years in academic medicine, 29% (2/7) were women, and none identified as ethnic minority.

Immediate postvisit survey response was obtained for all participating faculty. In the immediate postvisit survey, on a 5‐point Likert scale, the 29 early‐career faculty rated the visit: 4.4 for promoting cross‐institutional dissemination of innovations, 4.2 for advancing my academic career, 4.2 for fostering cross‐institutional mentor‐mentee relationships, and 4.4 for promoting cross‐institutional collaborations. Ninety‐three percent (26/28 accounting for 1 nonresponse to this question) reported the visiting professorship had high potential to disseminate innovation (rated greater than 3 on the 5‐point Likert score). Eighty‐three percent (24/29) of the early‐career faculty rated the visit highly useful in advancing their career, 76% (22/29) responded that the visit was highly likely to foster external mentorship relationships, and 90% (26/29) reported the visit highly effective in promoting cross‐institutional collaborations. In the immediate postvisit survey, the 7 visiting professors rated the visit 4.9 for promoting cross‐institutional dissemination of innovations, 4.3 for advancing my academic career, 4.0 for fostering cross‐institutional mentor‐mentee relationships, and 4.3 for promoting cross‐institutional collaborations.

Free‐text comments from both visiting professors and early‐career faculty were generally favorable (Table 1). Some comments offered constructive input on appropriate matching of faculty, previsit preparation, or desire for more time in sessions (Table 1).

One‐year follow‐up was obtained for all but 1 early‐career faculty member receiving the follow‐up survey, and all 3 visiting professors. Of the 3 visiting professorships that occurred more than 1 year ago, 16 mentorship contacts occurred in total (phone, e‐mail, or in person) between 13 early‐career faculty and 3 visiting professors in the year after the initial visits (range, 04 contacts). Follow‐up contact occurred for 3 of 4 early‐career faculty from the first visiting professorship, 3 of 5 from the second visiting professorship, and 2 of 4 from the third visiting professorship. One early‐career faculty member from each host academic medical center had 3 or more additional contacts with the visiting professor in the year following the initial visit. Overall, 8/13 (62%) of early‐career faculty had at least 1 follow‐up mentoring discussion. On 1‐year follow‐up, overall utility for professional development was rated an average of 3.5 by early‐career faculty (with a trend of higher ratings of efficacy with increasing number of follow‐up contacts) and 4.7 by visiting professors. Half (8/16) of the involved faculty report having seen evidence of cross‐institutional dissemination of innovation. Ninety‐four percent (15/16) of participants at 1‐year follow‐up felt there was benefit to their institution in continuing the program for the next year.

Objective evidence of cross‐institutional scholarship, assessed by email query of both visiting professors and senior hospitalists coordinating the visits, includes 2 collaborative peer reviewed publications including mentors and mentees participating in the visiting professorship.[6, 7] Joint educational curriculum development on high‐value care between sites is planned. The Visiting Professorship in Hospital Medicine Program has resulted in 1 external letter to support a visiting professor's promotion to date.

Figure 1

DISCUSSION

Hospital Medicine is a young, rapidly growing field, hence the number of experienced academic hospitalist mentors with expertise in successfully navigating an academic career is limited. A national study of hospitalist leaders found that 75% of clinician‐educators and 58% of research faculty feel that lack of mentorship is a major issue.[1] Mentorship for hospitalist clinician‐investigators is often delivered by nonhospitalists.[2, 8] There is little evidence of external mentorship for academic clinician‐educators in hospital medicine.[1] Without explicit programmatic support, many faculty may find this to be a barrier to career advancement. A study of successfully promoted hospitalists identified difficulty identifying external senior hospitalists to write letters in support of promotion as an obstacle.[9] Our study of the Visiting Professorship in Hospital Medicine Program found that early‐career faculty rated the visit as useful in advancing their career and fostered external mentorship relationships. Subsequent experience suggests more than half of the early‐career faculty will maintain contact with the visiting professor over the year following the visit. Visiting professors rate the experience particularly highly in their own career advancement.

The hospitalist movement is built on a foundation of innovation. The focus of each presentation was on an innovation developed by the visiting professor, and each visit showcased an innovation of the visited institution. This is distinct from traditional Hospital Grand Rounds, which more often focus on basic science research or clinical pathophysiology/disease management based on subspecialty topics.[10] The Visiting Professorship in Hospital Medicine Program was judged by participants to be an effective means of spreading innovation.

Insights from experience with the Visiting Professorship in Hospital Medicine Program include the importance of preliminary work prior to each visit. Program directors need to attend closely to the fit between the interests and career path of the visiting professor and those of the early‐career faculty. The innovations being shared should be aligned with organizational interests to maximize the chance of subsequent spread of the innovation and future collaboration. Providing faculty information about the objectives of the program in advance of the visit and arranging an exchange of curricula vitae between the early‐career faculty and the visiting professor allows participants to prepare for the in‐person coaching. Based on comments from participants, prompting contact from the visiting professor after the visit may be helpful to initiate the longitudinal relationship. We also found that early‐career faculty may not be aware of how to effectively use a mentoring relationship with an external faculty member. Training sessions for both mentors and mentees on effective mentorship relationships before visiting professorships might improve early‐career faculty confidence in initiating relationships and maximize value from mentor coaching.

A key issue is finding the right level of career maturity for the visiting professor. Our approach in selecting visiting professors was congruent with utilization of midcareer peer coaches employed by intrainstitutional hospital medicine mentoring programs.[11] The visiting professor should have sufficient experience and accomplishments to be able to effectively counsel junior faculty. However, it is important that the visiting professor also has sufficient time and interest to take on additional mentees and to be a full participant in shared scholarship projects emerging from the experience.

This study represents the experience of 5 mature academic hospitalist groups, and results may not be generalizable to dissimilar institutions or if only the most senior faculty are selected to perform visits. There is an inherent selection bias in the choice of both visiting professor and early‐career faculty. The small sample size of the faculty exposed to this program is a limitation to generalizability of the results of this evaluation. Whether this program will result in greater success in promotion of academic hospitalists cannot be assessed based on the follow‐up available. The Visiting Professorship in Hospital Medicine Program has continued to be sustained with an additional academic medical center enrolled and 2 additional site visits planned. The costs of the program are low, largely air travel and a night of lodging, as well as nominal administrative logistical support. Perceived benefits by participants and academic medical centers make this modest investment worth considering for academic hospitalist groups.

CONCLUSIONS

The Visiting Professorship in Hospital Medicine Program offers structure, opportunities, and access to senior mentors to advance the development of early‐career hospitalists while spreading innovation to distant sites. It is assessed by participants to facilitate external mentoring relationships and has the potential to advance the careers of both early‐career faculty as well as the visiting professors.

Hospital medicine is an emerging specialty comprised predominantly of early‐career faculty, often less than 5 years postresidency and predominately at instructor or assistant professor level.[1] Effective mentoring has been identified as a critical component of academic success.[2, 3] Published data suggest that most academic hospitalists do not have a mentor, and when they do, the majority of them spend less than 4 hours per year with their mentor.[2] The reasons for this are multifactorial but largely result from the lack of structure, opportunities, and local senior academic hospitalists.[1, 4] Early‐career faculty have difficulty establishing external mentoring relationships, and new models beyond the traditional intrainstitutional dyad are needed.[3, 4] The need for mentors and structured mentorship networks may be particularly high in hospital medicine.[5]

The Visiting Professorship in Hospital Medicine Program was designed to promote cross‐institutional mentorship, share hospitalist innovations, and facilitate academic collaboration between hospitalist groups. We describe the design and early experience with this program across 5 academic hospital medicine programs.

PROGRAM DESIGN

RESULTS

To date, 5 academic medical centers have participated in the visiting professorship program, with 7 visiting professors interacting with 29 early‐career faculty. Of the 29 early‐career faculty, 72% (21/29) were at the rank of assistant professor, 17% (5/29) instructor, 7% (2/29) residents with plans to hire, and 3% (1/29) associate professor. The median was 2 years in academic medicine and 1 year at current academic rank. Forty‐one percent (12/29) were women and 7% (2/29) identified as ethnic minority. Of the 7 visiting professors, 57% (4/7) were assistant professor and 43% (3/7) were associate professors. The median was 5 years in academic medicine, 29% (2/7) were women, and none identified as ethnic minority.

Immediate postvisit survey response was obtained for all participating faculty. In the immediate postvisit survey, on a 5‐point Likert scale, the 29 early‐career faculty rated the visit: 4.4 for promoting cross‐institutional dissemination of innovations, 4.2 for advancing my academic career, 4.2 for fostering cross‐institutional mentor‐mentee relationships, and 4.4 for promoting cross‐institutional collaborations. Ninety‐three percent (26/28 accounting for 1 nonresponse to this question) reported the visiting professorship had high potential to disseminate innovation (rated greater than 3 on the 5‐point Likert score). Eighty‐three percent (24/29) of the early‐career faculty rated the visit highly useful in advancing their career, 76% (22/29) responded that the visit was highly likely to foster external mentorship relationships, and 90% (26/29) reported the visit highly effective in promoting cross‐institutional collaborations. In the immediate postvisit survey, the 7 visiting professors rated the visit 4.9 for promoting cross‐institutional dissemination of innovations, 4.3 for advancing my academic career, 4.0 for fostering cross‐institutional mentor‐mentee relationships, and 4.3 for promoting cross‐institutional collaborations.

Free‐text comments from both visiting professors and early‐career faculty were generally favorable (Table 1). Some comments offered constructive input on appropriate matching of faculty, previsit preparation, or desire for more time in sessions (Table 1).

One‐year follow‐up was obtained for all but 1 early‐career faculty member receiving the follow‐up survey, and all 3 visiting professors. Of the 3 visiting professorships that occurred more than 1 year ago, 16 mentorship contacts occurred in total (phone, e‐mail, or in person) between 13 early‐career faculty and 3 visiting professors in the year after the initial visits (range, 04 contacts). Follow‐up contact occurred for 3 of 4 early‐career faculty from the first visiting professorship, 3 of 5 from the second visiting professorship, and 2 of 4 from the third visiting professorship. One early‐career faculty member from each host academic medical center had 3 or more additional contacts with the visiting professor in the year following the initial visit. Overall, 8/13 (62%) of early‐career faculty had at least 1 follow‐up mentoring discussion. On 1‐year follow‐up, overall utility for professional development was rated an average of 3.5 by early‐career faculty (with a trend of higher ratings of efficacy with increasing number of follow‐up contacts) and 4.7 by visiting professors. Half (8/16) of the involved faculty report having seen evidence of cross‐institutional dissemination of innovation. Ninety‐four percent (15/16) of participants at 1‐year follow‐up felt there was benefit to their institution in continuing the program for the next year.

Objective evidence of cross‐institutional scholarship, assessed by email query of both visiting professors and senior hospitalists coordinating the visits, includes 2 collaborative peer reviewed publications including mentors and mentees participating in the visiting professorship.[6, 7] Joint educational curriculum development on high‐value care between sites is planned. The Visiting Professorship in Hospital Medicine Program has resulted in 1 external letter to support a visiting professor's promotion to date.

Figure 1

DISCUSSION

Hospital Medicine is a young, rapidly growing field, hence the number of experienced academic hospitalist mentors with expertise in successfully navigating an academic career is limited. A national study of hospitalist leaders found that 75% of clinician‐educators and 58% of research faculty feel that lack of mentorship is a major issue.[1] Mentorship for hospitalist clinician‐investigators is often delivered by nonhospitalists.[2, 8] There is little evidence of external mentorship for academic clinician‐educators in hospital medicine.[1] Without explicit programmatic support, many faculty may find this to be a barrier to career advancement. A study of successfully promoted hospitalists identified difficulty identifying external senior hospitalists to write letters in support of promotion as an obstacle.[9] Our study of the Visiting Professorship in Hospital Medicine Program found that early‐career faculty rated the visit as useful in advancing their career and fostered external mentorship relationships. Subsequent experience suggests more than half of the early‐career faculty will maintain contact with the visiting professor over the year following the visit. Visiting professors rate the experience particularly highly in their own career advancement.

The hospitalist movement is built on a foundation of innovation. The focus of each presentation was on an innovation developed by the visiting professor, and each visit showcased an innovation of the visited institution. This is distinct from traditional Hospital Grand Rounds, which more often focus on basic science research or clinical pathophysiology/disease management based on subspecialty topics.[10] The Visiting Professorship in Hospital Medicine Program was judged by participants to be an effective means of spreading innovation.

Insights from experience with the Visiting Professorship in Hospital Medicine Program include the importance of preliminary work prior to each visit. Program directors need to attend closely to the fit between the interests and career path of the visiting professor and those of the early‐career faculty. The innovations being shared should be aligned with organizational interests to maximize the chance of subsequent spread of the innovation and future collaboration. Providing faculty information about the objectives of the program in advance of the visit and arranging an exchange of curricula vitae between the early‐career faculty and the visiting professor allows participants to prepare for the in‐person coaching. Based on comments from participants, prompting contact from the visiting professor after the visit may be helpful to initiate the longitudinal relationship. We also found that early‐career faculty may not be aware of how to effectively use a mentoring relationship with an external faculty member. Training sessions for both mentors and mentees on effective mentorship relationships before visiting professorships might improve early‐career faculty confidence in initiating relationships and maximize value from mentor coaching.

A key issue is finding the right level of career maturity for the visiting professor. Our approach in selecting visiting professors was congruent with utilization of midcareer peer coaches employed by intrainstitutional hospital medicine mentoring programs.[11] The visiting professor should have sufficient experience and accomplishments to be able to effectively counsel junior faculty. However, it is important that the visiting professor also has sufficient time and interest to take on additional mentees and to be a full participant in shared scholarship projects emerging from the experience.

This study represents the experience of 5 mature academic hospitalist groups, and results may not be generalizable to dissimilar institutions or if only the most senior faculty are selected to perform visits. There is an inherent selection bias in the choice of both visiting professor and early‐career faculty. The small sample size of the faculty exposed to this program is a limitation to generalizability of the results of this evaluation. Whether this program will result in greater success in promotion of academic hospitalists cannot be assessed based on the follow‐up available. The Visiting Professorship in Hospital Medicine Program has continued to be sustained with an additional academic medical center enrolled and 2 additional site visits planned. The costs of the program are low, largely air travel and a night of lodging, as well as nominal administrative logistical support. Perceived benefits by participants and academic medical centers make this modest investment worth considering for academic hospitalist groups.

CONCLUSIONS

The Visiting Professorship in Hospital Medicine Program offers structure, opportunities, and access to senior mentors to advance the development of early‐career hospitalists while spreading innovation to distant sites. It is assessed by participants to facilitate external mentoring relationships and has the potential to advance the careers of both early‐career faculty as well as the visiting professors.

Hospital medicine is an emerging specialty comprised predominantly of early‐career faculty, often less than 5 years postresidency and predominately at instructor or assistant professor level.[1] Effective mentoring has been identified as a critical component of academic success.[2, 3] Published data suggest that most academic hospitalists do not have a mentor, and when they do, the majority of them spend less than 4 hours per year with their mentor.[2] The reasons for this are multifactorial but largely result from the lack of structure, opportunities, and local senior academic hospitalists.[1, 4] Early‐career faculty have difficulty establishing external mentoring relationships, and new models beyond the traditional intrainstitutional dyad are needed.[3, 4] The need for mentors and structured mentorship networks may be particularly high in hospital medicine.[5]

The Visiting Professorship in Hospital Medicine Program was designed to promote cross‐institutional mentorship, share hospitalist innovations, and facilitate academic collaboration between hospitalist groups. We describe the design and early experience with this program across 5 academic hospital medicine programs.

PROGRAM DESIGN

RESULTS

To date, 5 academic medical centers have participated in the visiting professorship program, with 7 visiting professors interacting with 29 early‐career faculty. Of the 29 early‐career faculty, 72% (21/29) were at the rank of assistant professor, 17% (5/29) instructor, 7% (2/29) residents with plans to hire, and 3% (1/29) associate professor. The median was 2 years in academic medicine and 1 year at current academic rank. Forty‐one percent (12/29) were women and 7% (2/29) identified as ethnic minority. Of the 7 visiting professors, 57% (4/7) were assistant professor and 43% (3/7) were associate professors. The median was 5 years in academic medicine, 29% (2/7) were women, and none identified as ethnic minority.

Immediate postvisit survey response was obtained for all participating faculty. In the immediate postvisit survey, on a 5‐point Likert scale, the 29 early‐career faculty rated the visit: 4.4 for promoting cross‐institutional dissemination of innovations, 4.2 for advancing my academic career, 4.2 for fostering cross‐institutional mentor‐mentee relationships, and 4.4 for promoting cross‐institutional collaborations. Ninety‐three percent (26/28 accounting for 1 nonresponse to this question) reported the visiting professorship had high potential to disseminate innovation (rated greater than 3 on the 5‐point Likert score). Eighty‐three percent (24/29) of the early‐career faculty rated the visit highly useful in advancing their career, 76% (22/29) responded that the visit was highly likely to foster external mentorship relationships, and 90% (26/29) reported the visit highly effective in promoting cross‐institutional collaborations. In the immediate postvisit survey, the 7 visiting professors rated the visit 4.9 for promoting cross‐institutional dissemination of innovations, 4.3 for advancing my academic career, 4.0 for fostering cross‐institutional mentor‐mentee relationships, and 4.3 for promoting cross‐institutional collaborations.

Free‐text comments from both visiting professors and early‐career faculty were generally favorable (Table 1). Some comments offered constructive input on appropriate matching of faculty, previsit preparation, or desire for more time in sessions (Table 1).

One‐year follow‐up was obtained for all but 1 early‐career faculty member receiving the follow‐up survey, and all 3 visiting professors. Of the 3 visiting professorships that occurred more than 1 year ago, 16 mentorship contacts occurred in total (phone, e‐mail, or in person) between 13 early‐career faculty and 3 visiting professors in the year after the initial visits (range, 04 contacts). Follow‐up contact occurred for 3 of 4 early‐career faculty from the first visiting professorship, 3 of 5 from the second visiting professorship, and 2 of 4 from the third visiting professorship. One early‐career faculty member from each host academic medical center had 3 or more additional contacts with the visiting professor in the year following the initial visit. Overall, 8/13 (62%) of early‐career faculty had at least 1 follow‐up mentoring discussion. On 1‐year follow‐up, overall utility for professional development was rated an average of 3.5 by early‐career faculty (with a trend of higher ratings of efficacy with increasing number of follow‐up contacts) and 4.7 by visiting professors. Half (8/16) of the involved faculty report having seen evidence of cross‐institutional dissemination of innovation. Ninety‐four percent (15/16) of participants at 1‐year follow‐up felt there was benefit to their institution in continuing the program for the next year.

Objective evidence of cross‐institutional scholarship, assessed by email query of both visiting professors and senior hospitalists coordinating the visits, includes 2 collaborative peer reviewed publications including mentors and mentees participating in the visiting professorship.[6, 7] Joint educational curriculum development on high‐value care between sites is planned. The Visiting Professorship in Hospital Medicine Program has resulted in 1 external letter to support a visiting professor's promotion to date.

Figure 1

DISCUSSION

Hospital Medicine is a young, rapidly growing field, hence the number of experienced academic hospitalist mentors with expertise in successfully navigating an academic career is limited. A national study of hospitalist leaders found that 75% of clinician‐educators and 58% of research faculty feel that lack of mentorship is a major issue.[1] Mentorship for hospitalist clinician‐investigators is often delivered by nonhospitalists.[2, 8] There is little evidence of external mentorship for academic clinician‐educators in hospital medicine.[1] Without explicit programmatic support, many faculty may find this to be a barrier to career advancement. A study of successfully promoted hospitalists identified difficulty identifying external senior hospitalists to write letters in support of promotion as an obstacle.[9] Our study of the Visiting Professorship in Hospital Medicine Program found that early‐career faculty rated the visit as useful in advancing their career and fostered external mentorship relationships. Subsequent experience suggests more than half of the early‐career faculty will maintain contact with the visiting professor over the year following the visit. Visiting professors rate the experience particularly highly in their own career advancement.

The hospitalist movement is built on a foundation of innovation. The focus of each presentation was on an innovation developed by the visiting professor, and each visit showcased an innovation of the visited institution. This is distinct from traditional Hospital Grand Rounds, which more often focus on basic science research or clinical pathophysiology/disease management based on subspecialty topics.[10] The Visiting Professorship in Hospital Medicine Program was judged by participants to be an effective means of spreading innovation.

Insights from experience with the Visiting Professorship in Hospital Medicine Program include the importance of preliminary work prior to each visit. Program directors need to attend closely to the fit between the interests and career path of the visiting professor and those of the early‐career faculty. The innovations being shared should be aligned with organizational interests to maximize the chance of subsequent spread of the innovation and future collaboration. Providing faculty information about the objectives of the program in advance of the visit and arranging an exchange of curricula vitae between the early‐career faculty and the visiting professor allows participants to prepare for the in‐person coaching. Based on comments from participants, prompting contact from the visiting professor after the visit may be helpful to initiate the longitudinal relationship. We also found that early‐career faculty may not be aware of how to effectively use a mentoring relationship with an external faculty member. Training sessions for both mentors and mentees on effective mentorship relationships before visiting professorships might improve early‐career faculty confidence in initiating relationships and maximize value from mentor coaching.

A key issue is finding the right level of career maturity for the visiting professor. Our approach in selecting visiting professors was congruent with utilization of midcareer peer coaches employed by intrainstitutional hospital medicine mentoring programs.[11] The visiting professor should have sufficient experience and accomplishments to be able to effectively counsel junior faculty. However, it is important that the visiting professor also has sufficient time and interest to take on additional mentees and to be a full participant in shared scholarship projects emerging from the experience.

This study represents the experience of 5 mature academic hospitalist groups, and results may not be generalizable to dissimilar institutions or if only the most senior faculty are selected to perform visits. There is an inherent selection bias in the choice of both visiting professor and early‐career faculty. The small sample size of the faculty exposed to this program is a limitation to generalizability of the results of this evaluation. Whether this program will result in greater success in promotion of academic hospitalists cannot be assessed based on the follow‐up available. The Visiting Professorship in Hospital Medicine Program has continued to be sustained with an additional academic medical center enrolled and 2 additional site visits planned. The costs of the program are low, largely air travel and a night of lodging, as well as nominal administrative logistical support. Perceived benefits by participants and academic medical centers make this modest investment worth considering for academic hospitalist groups.

CONCLUSIONS

The Visiting Professorship in Hospital Medicine Program offers structure, opportunities, and access to senior mentors to advance the development of early‐career hospitalists while spreading innovation to distant sites. It is assessed by participants to facilitate external mentoring relationships and has the potential to advance the careers of both early‐career faculty as well as the visiting professors.

Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.

Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.

Inpatient glycemic control and hypoglycemia are issues with well deserved increased attention in recent years. Prominent guidelines and technical reviews have been published,13 and a recent, randomized controlled trial demonstrated the superiority of basal bolus insulin regimens compared to sliding‐scale regimens.4 Effective glycemic control for inpatients has remained elusive in most medical centers. Recent reports57 detail clinical inertia and the continued widespread use of sliding‐scale subcutaneous insulin regimens, as opposed to the anticipatory, physiologic basal‐nutrition‐correction dose insulin regimens endorsed by these reviews.

Inpatient glycemic control faces a number of barriers, including fears of inducing hypoglycemia, uneven knowledge and training among staff, and competing institutional and patient priorities. These barriers occur in the background of an inherently complex inpatient environment that poses unique challenges in maintaining safe glycemic control. Patients frequently move across a variety of care teams and geographic locations during a single inpatient stay, giving rise to multiple opportunities for failed communication, incomplete handoffs, and inconsistent treatment. In addition, insulin requirements may change dramatically due to variations in the stress of illness, exposure to medications that effect glucose levels, and varied forms of nutritional intake with frequent interruption. Although insulin is recognized as one of the medications most likely to be associated with adverse events in the hospital, many hospitals do not have protocols or order sets in place to standardize its use.

A Call to Action consensus conference,8, 9 hosted by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), brought together many thought leaders and organizations, including representation from the Society of Hospital Medicine (SHM), to address these barriers and to outline components necessary for successful implementation of a program to improve inpatient glycemic control in the face of these difficulties. Institutional insulin management protocols and standardized insulin order sets (supported by appropriate educational efforts) were identified as key interventions. It may be tempting to quickly deploy a generic insulin order set in an effort to improve care. This often results in mediocre results, due to inadequate incorporation of standardization and guidance into the order set and other documentation tools, and uneven use of the order set.

The SHM Glycemic Control Task Force (GCTF) recommends the following steps for developing and implementing successful protocols and order sets addressing the needs of the noncritical care inpatient with diabetes/hyperglycemia.

• Form a steering committee for this work, and assess the current processes of care.

• Identify best practices and preferred regimens to manage diabetes and hyperglycemia in the hospital.

• Integrate best practices and preferred institutional choices into an inpatient glycemic control protocol. Crystallize your protocol into a one page summary.

• Place guidance from your protocol into the flow of work, by integrating it into standardized subcutaneous insulin order sets and other documentation and treatment tools.

• Monitor the use of your order sets and protocol. Intervene actively on nonadherents to your protocol and those with poor glycemic control, and revise your protocol/order sets as needed.

IDENTIFYING AND INCORPORATING KEY CONCEPTS AND BEST PRACTICES

A protocol is a document that endorses specific monitoring and treatment strategies in a given institution. This potentially extensive document should provide guidance for transitions, special situations (like steroids and total parenteral nutrition [TPN]) and should outline preferred insulin regimens for all of the most common nutritional situations. One of the most difficult parts of creating a protocol is the assimilation of all of the important information on which to base decisions. Your protocol and order set will be promoting a set of clinical practices. Fortunately, the current best practice for noncritical care hyperglycemic patients has been summarized by several authoritative sources,13, 811 including references from the SHM Glycemic Task Force published in this supplement.4, 12

Table 1 summarizes the key concepts that should be emphasized in a protocol for subcutaneous insulin management in the hospital. We recommend embedding guidance from your protocol into order sets, the medication administration record, and educational materials. Although the details contained in a protocol and order set might vary from one institution to another, the key concepts should not. The remainder of this article provides practical information about how these concepts and guidance for how preferred insulin regimens should be included in these tools. Appendices 1 and 2 give examples of an institutional one‐page summary protocol and subcutaneous insulin order set, respectively.

PULLING IT ALL TOGETHER: MAKE SURE YOUR PROTOCOL/ORDER SET IS EASY TO USE AND WIDELY UTILIZED

When standardizing hospital management of diabetes and hyperglycemia, we recommend building the full protocol first, then crystallizing the protocol into a one‐page summary that can be widely disseminated. The protocol guidance is then incorporated into the order set and nursing medical administration record (MAR). Again, we recommend the most proscriptive and protocol‐driven order set feasible within the constraints of medical staff support. The example order set in Appendix 2 illustrates this approach along with other desirable features:

• 1

  Check‐box simplicity on when to order appropriate glucose monitoring.

• 2

  Prompt for the proper hyperglycemia‐related diagnosis.

• 3

  Prompts to document diagnosis and to order HbA1c level.

• 4

  Use of encouraged insulin terminology: basal, prandial (or nutritional), and correction. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.

• 5

  Statement/reminder of a glycemic goal.

• 6

  Prompts and contact information for appropriate consultation.

• 7

  Elimination of unapproved abbreviations (such as U for units).

• 8

  Stating both generic and brand names of insulin preparations.

• 9

  Important timing cues for administration of insulin.

• 10

  Several correction‐dose scales suitable for different insulin sensitivities. One size does NOT fit all.

• 11

  Incorporation of a simple hypoglycemia protocol into the order set.

• 12

  Insulin dosing guidelines available at the point of care (in this case, on the back of the order set).

Additional nursing‐specific cues (such as an admonition to never mix glargine insulin with other types of insulin) can also be included in the MAR whenever glargine is ordered.

Once you have protocols and order sets to guide providers, you need to assure that they are used for the majority of hyperglycemic patients. Educational programs should introduce your interventions and the rationale for them. In order to make your method the default method of care, your team should survey all preprinted or CPOE insulin order sets of your institution. A review of postoperative, transfer, and admission order sets that all services use may reveal a half‐dozen or more embedded sliding‐scale insulin order sets that should be removed, with prompts to use the standardized insulin order set being placed in their stead.

Computerized order sets present both challenges and opportunities. Wording limitations and the scrolling nature can make concepts less clear, yet there is a capability for incorporating a hierarchical structure that allows for guiding the user through a more algorithmic approach. There is also a capacity to provide assistance with dosing calculations that do not exist in the paper world. Education remains of key importance for both methods.

MONITOR THE USE AND EFFECTIVENESS OF YOUR PROTOCOLS AND ORDER SETS

Creating and implementing protocols, order sets, and other tools is not the end of the journey to improve care. It is important to monitor order set utilization, insulin use patterns, and parameters measuring glycemic control and hypoglycemia, as outlined in more detail in another article in this supplement.16 In addition to summary data every month or so, we recommend daily reports that spur action in near real time. Triggers such as uncontrolled hyperglycemia, markedly elevated HbA1c levels, and nonphysiologic insulin regimens should initiate consultation, extra diabetes education, or referral to a glucose control team. If appropriate consultation is not readily available, the glycemic control steering group should lobby the administration to bolster this capability. Qualitative feedback from the frontline caregivers, as well as this quantitative data, can assist the local glycemic control champions in designing even more effective protocols, order sets, focused educational efforts, and concurrent mitigation of suboptimal care.

CONCLUSION

Diabetes, hyperglycemia, and iatrogenic hypoglycemia are common and important conditions affecting the noncritically ill inpatient. Interventional trials to validate the recommended noncritical care unit glycemic targets are needed. Although there is a growing consensus on best practices to care for these patients, numerous barriers and the complexity of caring for inpatients hamper the reliability of best practice delivery. Institutional protocols and protocol driven subcutaneous insulin orders, when implemented with the strategies outlined here, can be the key to delivering these best practices more reliably.