Friday, March 27, 2015

Evidence of an Improved Culture of Safety

A marvelous thing happened on Lean Daily Management rounds today. My LDM Team is “Team A.”  Deloris Tuggle and I are the senior leaders on this team. Deloris was away today, so Kevin Creaby, our Manager of Benefits, was standing in for Deloris and we were accompanied on the walk by Ishmel Fulton, our new Lean Facilitator. We were on our way to the PACU board, rounding the corner, passing the family waiting room desk for the General Operating Room, when we heard: “Gentlemen, stop! You must clean your hands before entering the PACU!” I turned to see that this message had been delivered by one of our superb volunteers. She and a colleague were looking at us with smiles on their faces, but, they were not kidding. We thanked them for the reminder, cleaned our hands, and proceeded into the PACU.

Readers of the blog may remember my posting: A Just Culture Fosters a Safer Culture (Dec. 11, 2013) In that blog post, I spoke about the Tenerife crash, the worst disaster in the history of commercial aviation, where the belief is that the two co-pilots could have prevented the event, but they were afraid to say anything that might upset the captain. The unwillingness of “subordinates,” people lower down in the organizational hierarchy, to speak up is a detriment to safety and a sign of a poor safety culture. So, as we were entering the PACU after having cleaned our hands, I was really delighted that volunteers felt comfortable speaking up to the President and CEO of the organization. I was very proud of them and happy that we are making progress towards our vision!

Continually Improving Lean Daily Management

Lean Daily Management (LDM) has been a huge success for GBMC HealthCare. But there is always room for improvement. The Senior Team has been studying the groups that make the most improvement to find ways to help others. When the local manager and his or her team understand that LDM is about problem solving, much more improvement happens as opposed to groups that act as if telling the story of “red” or “green” is the end. We on the Senior Team now see that in our zeal to “help” by asking questions about the specific problem, we may actually be slowing down the problem solving.

On the LDM walk, some teams are celebrating when a metric is “green” even though they have not changed anything since it was last “red” and they apologize when the performance is “red.” We frequently have to remind them that if something is “green” but nothing in the process was changed that it is likely to return to “red.”

I have written before in this blog ( about how “red” should not be looked upon as being bad – it is merely an opportunity to problem solve so there is no need to say that they are sorry or feel that they have to defend themselves.

The job of the Senior Team is to hold managers accountable and ask questions to generate problem solving, NOT to offer advice to fix the specific problem.  The Senior Team must make sure that the manager and the unit or department have what they need to get the job done and then say thank you.

So, we on the Senior Team have committed to ask questions like “What have you learned?” and “What are you going to try next and when?” and not get involved in suggesting fixes. This should help us get more out of a tool that has already been immensely helpful! What do you think? I would love to hear your thoughts.

Friday, March 20, 2015

It Takes The Whole Team to Meet Our Patients’ Needs

I recently had an experience with a loved one in a hospital in another state that really bothered me. I went to visit my family member who was a very sick inpatient, and he told me that earlier in the day he had had a very acute need. He had pushed his call button to get help, but unfortunately, no one came to his aid for more than an hour.

It wasn’t that the staff in that hospital didn’t care. My relative’s nurses were very polite and hard working, but, they were also very busy. It was clear to me that there was no real sense of collaboration. The unit secretaries, housekeepers, nursing support technicians, other nurses and even the occasional administrator who came to the unit did not see responding to the call light as part of their job descriptions. I also got the sense that there was no attempt to anticipate my relative’s needs. When someone came into his room, they had one thing in mind. They did that one thing and that one thing only, and then left the room. In that hospital, my loved one did not get the care that I wanted him to get.

I wondered if this could happen at GBMC? I know how hard our nurses and support technicians work and that our patients – especially the very sick and elderly – have many needs. I asked myself the question, “Did I always go to answer a call light when I was a practicing physician on the unit if the staff was busy doing other things?” The answer was clearly that I did not.

I was very happy to hear of the rollout this week of the GBMC “NO PASS ZONE” (NPZ), a new hospital policy regarding how our clinical and non-clinical staff respond to our patients in need. If an alarm goes off or a call bell light is seen and/or heard, someone – even a nonclinical employee – will respond immediately. The concept of an NPZ has helped prevent falls and aid workers in responding more quickly to patients in need when it has been implemented elsewhere.

How does the NO PASS ZONE work? If you see a call light on, you CAN do the following for a patient:

  • Reposition the call light, telephone, bedside table, chairs, trash can, tissues or other personal items within reach.
  • Assist with making phone calls or answering the telephone.
  • Change TV channels or turn the TV on or off.
  • Turn the lights on or off.
  • Obtain personal items such as blankets, pillows, towels, washcloths, toiletries, pens, pencils, books, magazines, etc.
  • Reduce clutter.
  • Perform and encourage hand hygiene.
  • Alert the clinical staff for all clinical needs.

We should always use AIDET communication standards (Acknowledge, Introduction, Duration, Explanation, Thank You) upon entering the patient’s room. If you need a reminder about the AIDET communication standards, they are listed and explained on the small Service Excellence and AIDET card behind your GBMC badge.When entering an isolation room, we must also follow the proper personal protective equipment (PPE) requirements which will be displayed outside of the room.  If you do not have an AIDET badge please contact Courtney Hendon in Service Excellence.  She would be more than glad to provide you with one.

I know that some of my non-clinical colleagues are nervous about assisting a patient, but there is no expectation that a non-clinical person do anything clinical. Everyone can help meet the patient’s other needs or get help from a clinician if the problem is clinical. It takes the whole team to work together to get the job done. Thanks in advance for making NPZ work!

Thursday, March 12, 2015

Gray and Son Construction and GBHA – A New Partnership for the Quadruple Aim

The United States has one of the most complex health insurance systems in the world. An individual could be covered through a governmental program like Medicare, Medicaid or the Veterans Administration; they could be covered because their employer buys a health insurance plan for them or they could buy their own health insurance policy. In addition, many of us are covered because our employer pays our healthcare bills directly. I get coverage through GBMC. GBMC does not actually buy health insurance for its employees….it pays the bills for care as they come in. We contract with a company that handles the payment and we buy what is called “stop loss” insurance for very large claims. So we are able to say that GBMC is “self-insured”. We are not alone in this practice. Most larger companies are self-insured.

It is in the interest of the self-insured company to get the most value for the healthcare dollar spent. But until now, most companies didn’t pay much attention to what they were paying for a service. It was almost as if the employer was assuming that all services were the same, no matter who the provider was and that the costs were about the same. Well we know that this is not true. Some providers of care can charge as much as 60% more for the same service and the quality of the care received is not always the same.

So a few weeks ago I was very happy to meet with many of the employees of Gray and Son Construction.   Gray and Son is a leading contractor in the Baltimore area for both private and public projects, specializing in paving, excavating, utilities, and soil stabilization. It is a family-owned business steeped in tradition that dates back to 1908. I learned that the company intends to remain independent and looks out for its people. I realized that GBMC HealthCare and Gray and Son had a lot in common-both are local, independent- and relatively small, giving both companies an agility that makes it easier to get the job done and provide greater value to those that they serve.

Gray and Son saw the value that the Greater Baltimore Health Alliance could provide. They understood that advanced primary care with a team of caregivers led by a physician that was available and accountable could help them with prevention and the management of chronic disease. They knew of the great specialists at GBMC and that our outstanding hospital is lower cost than most in the area. Gray and Son learned of GBMC’s success in keeping the healthcare of its employees within the GBMC family while lowering out-of-pocket costs to its employees and they decided to do the same. So, Gray and Son employees will now have a “GBMC tier.”  If they use GBMC doctors and GBMC facilities, they will pay less. We will deliver improved clinical outcomes and better care experiences, showing them that we believe providing healthcare is a joyful pursuit.

Please join me in welcoming the people of Gray and Son into this partnership for better health and better care with the least waste and the most joy for those providing the care….our quadruple aim!


March is Professional Social Work month and I want to thank our dedicated group of social workers (pic below) who serve GBMC.  I am constantly impressed and humbled by the creativity and determination of this group. Our social workers carefully arrange for care of patients after they leave the hospital. Our social workers and care managers have helped GBMC reach the lowest readmission rate in the state and have designed a system that assures that our patients with advanced illness receive the continued support they need after they leave our hospital. Please take the time to say “thank you” for all they do.

Thursday, March 5, 2015

How did our checkup go?

GBMC recently underwent its triennial survey by The Joint Commission (TJC), an independent, not-for-profit organization that accredits health care organizations.

GBMC is working towards its vision of perfection: treating every patient, every time the way we would want our own loved ones treated. For this reason, we don’t dread the unannounced arrival of the surveyors. Having outside experts check to see if the processes are all in place to deliver perfect care is very helpful. Outsiders might see things that we miss. As a learning organization, we welcome the identification of defects so that we might fix them.

The five-member survey team visited our inpatient units, procedural areas, and outpatient settings providing a thorough and comprehensive assessment of our policies and procedures, documentation, and environment of care. They rated us on the national patient safety goals, our leadership and governance oversight.

We did very well on our checkup. The surveyors applauded us for our quality improvement work, especially Lean Daily Management. They told us that we were well on our way to becoming a high reliability organization. The surveyors did find areas where we need to improve. In an area where we have had no infections, they found that our standard disinfection work was not following best practice to assure sterility. Changes were made on the basis of this learning before the surveyors left GBMC and a team will be returning in 30 to 45 days post survey to assure that our new designs are firmly in place.

Throughout the process TJC surveyors commented on our staff’s professionalism and engagement and their commitment to do what is best for their patients and their families. The surveyors also praised the overall cleanliness of the hospital environment.  At the final session, surveyors recognized GBMC as an organization to which they would confidently send their own loved ones!

So, congratulations and thank you to all for an excellent checkup!

GBMC concluded the celebration of Black History Month. During February we had a number of events that incorporated decorating the display case on the 5th floor to highlight excerpts from famous speeches and poems by African Americans, daily physician trivia, our annual Sweet Potato Pie Bake-Off (Congrats to Marcia Tepper for winning this year’s contest!) and the canned food drive for the Bea Gaddy Shelter in Baltimore.

Our celebration culminated with a visit from Dr.  Raymond A. Winbush, Director of the Institute for Urban Research at Morgan State University, and entertainment from the Cristo Rey Student Steppers (pic right). Dr. Winbush gave a passionate speech on how GBMC over the last 50 years has progressed from its humble beginnings to a jewel of the community it serves.  Dr. Winbush emphasized our long history of treating patients well regardless of race or gender. This rich history is something that we, as GBMC employees, should be proud of.  I would be remiss if I didn’t mention the great work of the Cristo Rey Student Steppers (pic right).  It is very important that we take time at least annually to recognize the contributions made to our country by our African-American brothers and sisters.

Monday, February 23, 2015

A Trip to Verona, Wisconsin in the winter?

Last week, I traveled to the Midwest with Dave Hynson, GBMC’s Chief Information Officer, Dr. Fred Chan, our Chief Medical Information Officer, Cindy Ellis, the Epic Project Director, and Mary Swarts, the Epic Nurse Champion. We went to Verona, Wisconsin, a suburb of Madison, the capital of Wisconsin, to visit the headquarters of Epic Systems Corporation. It was quite a trip.

Epic, the vendor of the new information system that we are about to begin building and implementing, has the reputation of being the company that is out in front of the others in the creation of a medical record that meets the needs of the patient, care providers, and those leading enterprises to deliver care. After meeting Judy Faulkner, principal owner of Epic and the person who started the company, I now can see how Epic got to the point of being the leader in this field. Judy described the origins of the company (1979) when she was helping create databases for clinical faculty members at the University of Wisconsin. People kept telling her that she should start a company. As a mathematician and computer scientist, she really didn’t know how to do this or even if it was a good idea. She took the advice and built a company with the motto: “Do good and have fun.” (Later she added “and make money”). Today, her company employs 8,000 people, 1,500 of the employees are programmers, on a sprawling 1,200 acre campus. 

The company moved to its present location in the early 2000’s and the buildings each have a Disney-esque feel and theme. Unlike most companies that use the conventional wisdom that individual offices for staff are not necessary and therefore build cubicles for their people, Epic has offices for just about everyone under the belief that a quiet space is necessary for people to maximize their productivity. 

We met with many people who explained to us the capabilities of the software and the importance of building it for GBMC in a way that will allow us to get the most out of it. We got a “test drive” of the software and we were all really impressed. When I last cared for patients I was using an electronic record but the capabilities of Epic are very advanced. Our colleagues demonstrated how easy it is to use telemedicine to communicate test results to a patient using their mobile app. They also showed us how notes can be created to maximize the discreet data that is captured for analysis later while allowing the provider to use voice recognition software to minimize typing.

Technology cannot create a vision or change a culture, but, it certainly can accelerate the rate of change toward a vision. I am very excited about implementing Epic so that each patient will only have one record at GBMC and it will make it easier to treat everyone the way we want our own loved ones treated. We have a lot to do between now and October, 2016 when we go live. Thanks to all who will help us get there and beyond!

Join the GBMC 50th Team for the Aids Walk & Run Baltimore on Sun. May 3rd

My good friend, Dr. Sam Ross, President of Bon Secours Hospital, asked me to support a cause that really needs help from the community. While some of us have not been focused on it, the AIDS/HIV epidemic has raged on, especially in the City of Baltimore. There are many undiagnosed cases of this terrible and treatable disease. On Sunday, May 3rd at 8AM there will be a walk and 5K run at the Maryland Zoo in Baltimore to raise money for AIDS awareness and testing.
I have started a team called GBMC 50th and I am asking all of my GBMC colleagues to consider coming out and walking or running with me as another fun way to celebrate our 50th Anniversary and give back to our community. If you want to get some exercise that morning or lend financial support (or both!) click on this link and follow the directions under “join a team”:


Thursday, February 12, 2015

Our People are Safer on the Job

The GBMC vision includes becoming the healthcare system where our team derives more joy from helping people. We have recognized that if our staff is not safe on the job, they clearly will not experience the joy in their work. For this reason, since fiscal 2013 we have had an annual goal to reduce employee injuries. In fiscal 2012 we had 370 injuries – more than 1 per day! In fiscal 2013 we had 327 and last fiscal year we had 231. This fiscal year, through January we have had 92. In the month of January, we had 7 employee injuries, the lowest since we started measuring!

We have not accomplished this by wishing or hoping or by lecturing our people. We did it by a thoughtful study of each individual injury. Mindy Beckwith, our Manager of Employee Health and our Employee Injuries Team have done a fabulous job in overseeing this system. When an employee is injured, his or her manager immediately studies the event and completes a form that includes a narrative about what happened. Every morning, the day’s injuries from 2 days prior (to allow adequate time for study) are reported on the Executive Lean Daily Management board. Our senior team looks for the learning from the injury and shares it at each of the LDM boards (we now have 30 of them) and later in the day, an email goes out to all that explains the nature of the injuries with suggestions for preventing them.  We have had major success in reducing employee strains and sprains especially from lifting. In addition, our learning from splash injuries and making the use of protective eyewear standard work, has almost eliminated blood borne pathogen exposures to the eyes.

We should celebrate everyone’s hard work in making us all safer but we cannot stop until we get to zero employee injuries. Thanks to all and keep up the great work!

Follow-up on the Timely Reading of EKGs

Last October, I wrote a blog about how Phil Komenda, our Director of Imaging and Cardiac Services, and his team were working to move our electrocardiogram (EKG) reading closer to 100% reliability and in turn moving us closer to our vision.
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Since that posting, Phil and a selection committee made up of nurses, biomed techs, cardiology techs, and IT, purchased 21 ELI 350 EKG carts that were distributed to the inpatient units, Emergency Department, and the Diagnostic Center.  Upon their arrival they were successfully configured and tested on the network. 

So, why is this important?

These new carts will offer significant enhancement for our staff and patients by improving operational efficiency and patient safety.  They will transmit the EKG tracing wirelessly by the push of a button; eliminating the previous wasteful steps where staff on our inpatient units had to find a wall jack, plug the cart into the jack, and then transmit electrocardiograms. These new machines transmit wirelessly once the study is completed thereby freeing up the staff member to do other work and eliminate waste in the system, as well as reduce transmission delays.

The second important enhancement is that all the demographic and clinical information is entered automatically through work list management. The nurse can either scan the patient’s bracelet with a barcode reader or type in a few letters of the patient’s last name to call up the patient from a list of orders on the EKG work list.  This process eliminates the time it takes to type in all the demographic and clinical information, as well as reduces error rates. When demographic information is typed incorrectly, the EKG cannot be matched to the order.

Training with the new carts is close to completion and will GO LIVE on Wed. Feb 18th. We expect that this enhancement will bring more joy to the areas providing care, and improve care by reducing transmission delays and the probability of the EKG not being read within 24 hours of the study.
I want to thank Phil and his colleagues for all their hard work and their commitment to our quadruple aim. 

Television Stars

Last week, Bonnie B. Stein, our HealthCare Board Chair, and I participated in a taped interview with our media partner, WMAR-TV, regarding the 50th anniversary celebration for GBMC HealthCare.  More on this at a later date.

What made me really proud was the touching story, on WMAR-TV, that highlighted the integral role GBMC played in meeting the healthcare needs and enhancing the quality of life for one family.  If you haven’t seen this clip, please watch it by clicking on the link below.  It will make you proud  to be part of a big team that delivers the care that one would want for their own loved ones!

Tuesday, February 3, 2015

Making It Easier (and Safer) to Get the Work Done on an Inpatient Unit

In August of 2012, I wrote a blog about the 6S process. ( Since then, we have used this Lean tool to improve the work environment in a number of areas from physician office practices to the operating room support areas.

Last week, a Team led by our new Lean facilitator, Ishmel Fulton, and the Nurse Manager, Cecelia Gayhardt,  made the workplace more organized and safer on Unit 48. To refresh your memory, 6S stands for:
1.    Sort: eliminating everything not required for the work being performed.
2.    Separate: efficiently placing and arranging equipment and material.
3.    Shine: tidying and cleaning.
4.    Standardize: standardizing and continually improving the previous three.
5.    Sustain: establishing discipline in sustaining workplace organization.
6.    Safety: creating a safe work environment.

The Team applied this methodology to the manager’s office (which became an equipment room), the supply room (which became the manager’s office), the med bays, the nursing station, and the break room….all in all 506 square feet of space. They filled 3 dumpsters with “stuff” that was outdated or no longer needed. The Team added 90 new storage solutions including bins and file holders and marked them with 190 labels. They managed 16 wires to make them less of a hazard and created 31 visual controls such as signs, standardized locations and color coding.

A neat and clean workspace where everything is in its place reduces inventory costs, frees up space for other uses, eliminates some types of error, reduces motion and time searching for things and can significantly improve morale. Just look at the before and after photos!

I am very grateful for the hard work of the Unit 48 6S team. They have made it easier to get the job done. The Team will now be creating the standard work to sustain their efforts. Team members include (from left to right): Ishmel Fulton; Lilian Isabor; Cecilia Gayhardt; Christine Collier; Rikki Pullet; Susan Stevens; Courtney Hendon; Rachel Olsen; Beverly Edwards and Teresa Schorr (not pictured).


Internal Medicine Residents Demonstrate Their Knowledge
This weekend, a team from our Internal Medicine Residency Program won second place in the Doctors' dilemma contest at the Maryland Chapter of the American College of Physicians (ACP) meeting. Our Team will now be moving on to the competition at the National ACP meeting at Boston in April.

While other teams consisted of 3rd and 2nd year residents, the GBMC team consisted of three 1st year and one 2nd year resident. Our team included: Dr. In kyu Yoo (2nd year), Dr. Azharuddin Soudagar (1st Year), Dr. Faizan Babar(1st year), and Dr. Laurel Cummings (Preliminary year, Dermatology).

Please join me in congratulating our team and in wishing them luck in Boston!