“She gained as much as she gave.” TMC Volunteer contributes to major improvements for diabetics’ care

Marjorie Zismann TMC Volunteer

Marjorie Zismann
TMC Volunteer

“You have diabetes.  Buy a book.”

That’s what Marjorie Zismann’s doctor told her when he diagnosed her with type 2 diabetes in her early 60’s.  Since then, attempts to understand her disease have left her completely frustrated. Every day, she weighs herself, pricks her finger, squeezes out a drop of blood to check her blood sugar and takes her medication. Mealtimes consist of sorting out “yes” foods from “no” foods, which leaves her feeling restricted with little control over her disease.

Now 78 years old and retired, Zismann volunteers at Tucson Medical Center. She was a patient here about a year ago, and was invited to be a patient advocate during what’s called a “kaizen.”  It’s a rapid-improvement workshop made up of about a dozen leaders from different departments who set out to tackle a very specific issue. The meeting is a crucial process of TMC’s journey to a Lean culture, which produces patient-focused, reliable, safe and compassionate care through continuous improvement and the purposeful use of our resources.

The challenge of this particular kaizen: improving glycemic management for TMC patients with type 1 diabetes and keeping them from having multiple hypoglycemic, or low blood sugar, events during their stay. For three days, members from pharmacy, dietary, and the diabetes educators, among others, dug into how to provide better care for these patients. “Every time an idea was pitched, we’d run it by Marjorie to get the patient perspective,” said Pat Ledin, a member of the TMC Lean Team, which organized the kaizen. “We’d ask her, ‘Would that help you? Would that offend you?  How would that make you feel?’ We can’t stress how important it is for us to hear the voice of our patients and involve them in every change and process improvement.”

The visual cue that was created to alert staff to patients at risk for hypoglycemic episodes

The visual cue that was created to alert staff to patients at risk for hypoglycemic episodes

Some improvements were made immediately, including educating the medical staff who are on the front lines. Special signs were created and placed on the doors of patients with diabetes to serve as a reminder to staff that a patient is at risk for hypoglycemia.  Finger sticks are done on a more consistent basis, which allows for more coordination with meal times. Pre-packaged “snack attacks” are readily available for when patients do have an episode. “These have the right number of carbohydrates and protein, so it’s the perfect snack for this type of patient. It’s bulletproof,” said Ledin. Supply kits have been streamlined, there is a standardized approach to what staff does with a patient’s medication, and there is more consistency in how these patients are cared for among different departments.

One thing the team found may be contributing to more hypoglycemic events – TMC’s On Demand Room Service, which allows patients the flexibility to call in their meals whenever they’d like. It’s without a doubt improved overall patient satisfaction scores, but for those with hypoglycemia, it can add confusion about appropriately coordinating meal times. TMC Lean Team leader Cheryl Young explains, “On Demand doesn’t work for these people because their insulin is associated with their mealtime. If they eat at 9 a.m. for example, and want to eat again at 11 a.m., our On Demand service allows them to do that. But if they do, it could cause a hypoglycemic event because the meals are too close together. It’s best to have at least four hours in between meals. So we’re educating these patients that although we have this service, it’s not necessarily the best thing for them and their disease.”  Another little nugget of information that Zismann has found invaluable at home.

“As a result of this kaizen, we now have a standardized approach for the food, medication, education and visuals for these patients,” said Young.

Just one month later – dramatic results.  “With these patients, their disease process causes the hypoglycemic event to happen. But now we are seeing the repetitious events minimized during their stay here, which is a direct result of the improvements put into place from the kaizen,” said Ledin.

Zismann said she learned more about her disease during those three days than she had since her diagnosis more than a decade ago. She discovered TMC has diabetes educators who are available to help patients. “For me, the most frustrating thing has been to try and figure out what I’m supposed to be doing,” said Zismann. “TMC Diabetes Educator Nancy Klug was tremendous. She opened my eyes to the fact that I CAN eat certain foods, I just can’t eat much of them. I left her office feeling so empowered, and relieved that I really didn’t need to be so restrictive!”

Zismann admits she still has a long way to go before fully understanding her disease, but calls the opportunity to join that kaizen “one of the best things that’s ever happened to her.” “I felt like part of the group,” she said. “These people care. They come up with wonderful ideas. They work well together. It was unbelievable to watch them, and I have learned so much from the experience.”

While Zismann is applauding their efforts, the kaizen team leaders insist they’re the ones who were fortunate to have her there.  “We were able to collectively come to better decisions that have already led to better outcomes for our patients because of what Marjorie brought to this process as both a patient and a volunteer,” said Young.  “I think she absolutely gained as much as she gave.”

If you are interested in acting as a patient adviser for a particular department or issue, please contact Angie Bush at (520) 324-5512 or Angie.Bush@tmcaz.com.

To contact a TMC Diabetes Educator, please call (520) 324-3526.

Type 1 vs. Type 2 Diabetes: Under new management

No doubt, a diabetes diagnosis changes a person’s life.  They may find themselves doing things they’ve never had to do before, like check their blood sugar multiple times a day, count carbohydrates, and perhaps even give themselves insulin shots.  Even starting an exercise plan may be a first for them.  The good news is that diabetes educators are available to help.  Diabetes educators are health care professionals who teach those with diabetes how to adjust their lifestyle and behavior so that they can successfully manage their disease.

Nancy KlugTMC Certified Diabetes Educator

Nancy Klug
TMC Certified Diabetes Educator

TMC Certified Diabetes Educator Nancy Klug developed her passion for educating others about diabetes after two close family members were diagnosed with it.  She’s been helping diabetics understand their disease, and get their blood sugar under control for more than 25 years.  She shares some valuable information about appropriate diabetes testing, and how the disease is managed.

Type 1 Diabetes

Background:  People with Type 1 diabetes often get strong symptoms that could land them in the emergency room.  Their blood sugar may be 300 or higher.  Many times they are very sick.  They may be vomiting, and even have trouble breathing.  Other symptoms include increased urination.  They may find themselves getting up many times during the night to use the restroom.  They’re also very thirsty, and extremely tired.  Rapid weight loss is another common symptom we see.  Many times Type 1 affects people who are under age 30.  There is a hereditary factor, but it’s not as strong as it is in Type 2.

Appropriate Testing:  A test called c-peptide is done.  This tells a clinician if the patient is making insulin.  They’ll also do some antibody testing to see if the patient has the antibodies that would kill their beta cells. 

Managing Type 1:  Type 1 diabetics will start on insulin right away.  They’ll need at least four shots a day.  A short-acting insulin at each meal, and then a long-acting insulin.  Or, they may be on an insulin pump.  There is no cure for Type 1, but like Type 2, it can be controlled.

Type 2 Diabetes

Background:  With Type 2 diabetes, there s a very strong hereditary factor, but it is possible for someone to develop it without having a family history.  The tricky part with Type 2 is that oftentimes it’s difficult for people to tell they have the disease, as there are no, or very few, symptoms.  Patients may have to get up in the middle of the night to use the restroom.  They also may be a little thirstier or more tired than usual, and have a wound that is slow to heal.  Unlike Type 1 diabetics, Type 2 diabetics do not have weight loss.  If diabetes goes uncontrolled for several years, complications can develop, including kidney, nerve and eye damage.  The biggest complication, however, is heart attack and stroke.

Appropriate Testing:  A physician who suspects a patient has diabetes will order an A1C test.  The blood test gives the physician an average of the patient’s blood sugar over the last three months.  A non-diabetic person may have an A1C around 4-6 percent.  Prediabetes is 5.7-6.4 percent.  A diabetes diagnosis is 6.5 percent or higher.

Managing Type 2:
  The American Diabetes Association recommends patients start on a medication called Metformin.  Patients are advised exercise at least 30 minutes, five times a week, and attend diabetes education classes where they’ll learn how to count their carbs, and keep them down, along with their saturated fat intake.  Eighty percent of Type 2 diabetics are overweight, so losing even a little weight can be very beneficial.

The American Diabetes Association (ADA) suggests Type 2 diabetics have a blood sugar range of 70-130 before meals, and 130-180 two hours after meals.  The American College of Endocrinology (ACE) has even stricter guidelines.  They recommend a blood sugar level of under 110 before meals, and under 140 two hours after meals.  At TMC, Klug says they teach patients both sets of guidelines, encouraging them to get into the ADA range first, and then aim for the ACE range.

In conclusion, Klug says, “The good news is that we know how to control diabetes.  Patients have to learn how to do it, but a diabetes educator and their team can work with you.  If you’re able to keep your numbers down, you can minimize the complications and have a fairly healthy life.  There’s nothing that you can’t do with diabetes.  There is no cure, and it will never go away, but you can get it under control.”

If you or someone you know has diabetes and wishes to speak to a diabetes educator at TMC, please call (520)324-3526 or (520)324-1265.


Tucson Medical Center | 5301 E. Grant Road | Tucson, Arizona 85712 | (520) 327-5461