Monday, February 20, 2017

Helping Patients With Behavioral Health Needs

In my last blog, I discussed the issue of Emergency Department (ED) overcrowding and its causes. One of the reasons why people might wait at the GBMC ED is because we are overwhelmed with behavioral health patients who have nowhere to go because the mental health system is inadequate. What is GBMC doing to improve this situation?

There is a wide range of disorders and severity in the category of mental health and substance abuse. A patient may experience a new onset depression that if we address early may be easy to treat and resolve. At the other end of the spectrum, we have patients with disorders like autism and schizophrenia that are chronic diseases that require long-term attention and treatment.

We have made a promise to our patients in advanced primary care – in our patient-centered medical homes to own the patient’s health with him or her. This goes for all health issues including mental health.

The GBMC advanced primary care practices are conveniently located throughout Baltimore County, with offices both on our hospital campus and in the community.  They have extended weekday and weekend hours to be available to those they serve as the need arises. The typical primary care office is not designed to care for patients with mental health needs. Primary care physicians often lack the time or expertise to effectively counsel patients with behavioral issues.

So, the GBMC HealthCare System received a grant from the Health Services Cost Review Commission to add mental health professionals to the advanced primary care team. The grant is providing the resources for working closely with Sheppard Pratt Health System, Mosaic Community Services, and Kolmac Outpatient Centers to proactively address the behavioral health needs of our patients. Together, we are integrating behavioral health services in GBMC primary care offices and working to better connect patients to specialty programs.

We are in the process of adding new team members to the primary care practices: full-time behavioral health consultants who are licensed social workers and consulting psychiatrists, from Sheppard Pratt, and substance use consultants from Kolmac and Sheppard Pratt. The primary care physicians will refer patients to the onsite behavioral health consultant and he or she will bring in the psychiatrist as needed if counseling (motivational interviewing, behavioral activation, problem-solving therapy) alone is not enough to meet the patient’s needs.

The substance use consultant will be engaging patients in counseling (motivational interviewing) and resource navigation. As part of the collaboration with Kolmac, the advanced primary care sites have access to an addiction psychiatrist.

Currently, our Family Care Associates practice on campus and GBMC Joppa Road have all three services. Our practices at Owings Mills, Hunt Manor, and Internal Medicine on campus have the consulting psychiatrist and the substance use consultant. By the end of March, ALL FIVE of these sites will have all three team members. By July, the full program will be implemented at all of our advanced primary care sites. I am very excited that we are adding these professionals to our patient-centered medical homes. Patients with behavioral health needs will be much better served because of them!

Random Acts of Kindness...
Last week, we celebrated our 2nd “Random Acts of Kindness (RAK) Week.” With this year’s event, we engaged even more of our workforce to help spread kindness throughout our healthcare system. Each hospital department, GBMA practice and Gilchrist Services’ locations received a Kindness Kit, complete with tools to be kind to colleagues and those around you. The kits contained candy, KIND bars (generously donated by KIND), and Kindness cards. The cards came in packs of 12 and each contained a unique kind act. Cardholders were encouraged to either do the action on the card or make up their own, check off that they completed it and then challenging someone else to be kind.  I’m looking forward to finding out how some of the cards fared, where they traveled and what wonderful things our employees did for each other.

This year, we also created a new Random Acts of Kindness Ambassador Award. I was told by the RAK Week planning committee that they received many worthy and outstanding submissions of wonderful acts of kindness by our employees, but two stood out above the rest. Congratulations to Ray Morgan (Security) and Amy Gourley (Unit 57 MICU) in being selected as the co-recipients of our first Random Acts of Kindness Ambassador Award.

Thanks for being kind to each other year round and to everyone who helped with this endeavor and for making it such a success!


Food Drive…
Speaking of kindness, just a reminder that in honor of Black History Month, we’ve been accepting donations of canned goods and non-perishable food will that will help the Assistance Center of Towson Churches (ACTC), a consortium of 50 churches that provide support to needy families in our community.  Donations will be accepted until Friday, Feb. 24.  Please consider dropping off non-perishable food items to one of our various drop-off locations in the main hospital or at all GBMC community primary care offices.  For more information, please visit www.gbmc.org/fooddrive. This is truly an important initiative because many local families are in need of food year round.

Thursday, February 9, 2017

Why Do People Wait in Emergency Departments?

Last week, there were stories in the media that focused on emergency department (ED) wait times across the country.  One story was about the data collected, from April 1, 2015, through March 31, 2016, by the Centers For Medicare & Medicaid Services (CMS) which showed that Maryland Emergency Department (ED) wait times are the longest in the nation.  According to CMS, patients waited for an average of 53 minutes in Maryland before they were seen by a medical professional compared to the national average of 22 min.  At GBMC, the CMS stats showed that we had an average of 60 minutes during that year before a patient was seen by a doctor or nurse.

To understand the problem of ED overcrowding we should consider the diagram below:


A number of years ago, the Robert Wood Johnson Foundation created this diagram to help people understand the underlying reasons that people wait in emergency departments. Fundamentally, it’s a problem of supply and demand and flow.  Anything that increases the number of patients arriving to be seen will increase the chance of waiting (input), and anything that slows down the assessment and treatment of patients (throughput) or anything that prevents their departure (output) will increase the waiting.

If we want to reduce ED overcrowding. we can start by trying to reduce the number of patients coming to the ED (like we have at GBMC) by making it easy for patients with real needs but who don’t have true emergencies to be seen in primary care. We are now open well into the evening and on Saturday and Sunday. We can also work to make sure everyone has health insurance since people without health insurance come to the ED because many physician offices won’t take them without insurance or they cannot afford to pay out of pocket.

Once we have reduced the number of patients arriving at the ED to only those with true emergencies we should work on the processes within the ED like registration, assessing the patient, and getting needed tests done expeditiously. A recent change that has slowed patient assessment within the ED somewhat is our desire to send more patients out with home care. This requires taking more time with the chronically ill in particular, to assure that they can be safely discharged.

But everyone who has ever studied ED overcrowding knows that the real culprit in ED waiting is the outflow of patients. In most hospitals historically, the single biggest cause of patients waiting in the ED is because patients who need to be admitted are waiting for an inpatient bed to be vacated and cleaned. These patients take up valuable ED space and “block” other patients from being seen. This problem is improved by improving the flow from admission to discharge to bed cleaning on the inpatient units. Sometimes a clean bed is available but a nurse to care for the patient is not, this is being made more common by the nursing shortage.

A relatively new cause of waiting due to outflow from the ED is the lack of mental health beds, especially in the state of Maryland, and notably at GBMC because of our proximity to Sheppard Pratt. On most days in our ED, we have from 5-12 patients waiting for a mental health placement and taking up beds that could be used for the next sick patient coming to the ED. With our present mental health system, there just are not enough beds to cover those in need. Hospitals, like Sheppard Pratt, are always full. When one patient is discharged, there are always others waiting to fill the bed.

In next week’s blog, I will talk about what GBMC is doing to identify and treat behavioral problems earlier to try and reduce the need for mental health beds.

Friday, February 3, 2017

Let’s Give Them Something to Talk About… How About Love?

These days we know that there’s a lot going on in Washington as our lawmakers and the executive branch of government approach our country’s issues. Everywhere you go, people are talking about this. I often turn to music when I am trying to make sense of things. Last week, my wife, Tracey, and I had the good fortune of hearing a concert by John Hiatt and Lyle Lovett. Mr. Hiatt is not very well known as a singer, but he’s written many excellent songs that others have made famous. Bonnie Raitt had a hit, with his song, Something to Talk About. The line in the song “Let’s give them something to talk about - how about love?” is ringing true to me especially now. We need less talk about borders, barriers, blockages, fear and hatred and more about love and kindness.

Just stop and think about all of the acts of love and kindness every day at our hospital, our physician offices and everywhere we care for a hospice patient. What would happen if we got united around stories about love and kindness in our HealthCare system? Could this create a ripple effect that might bring more people together to find workable solutions to our problems?

Earlier this week, I addressed our new GBMC colleagues at new employee orientation. My job at orientation is to begin to enroll my new colleagues in our vision. I always try to engage new employees in a conversation about our transformation towards being the healthcare system that treats everyone, every time the way we want our own loved ones treated. This week, there were nearly 30 new employees joining the GBMC HealthCare family.

Let me share with you some of what I learned about two of our new people.

I had the pleasure of speaking with one of our new Registered Dieticians, Nancy Glaser, who told me that she is excited about bringing diabetes education directly to patients in our Patient-Centered Medical Homes.

Q: Why did you choose to work at GBMC?
A: As a diabetes educator, working with the community is very important to me. GBMC is a community health system and feels like a community health system.  I will be working in the outpatient diabetes center, but also getting out into primary care offices where people with diabetes are seen most often. We're taking the care to the patient and meeting them where they're already comfortable.

Q: So far, as an employee, what are your top 3 impressions of GBMC?
A: 1) Friendly:  Just simple hellos and smiles from so many people really help make GBMC a place where I want to be.
2) Clean and bright:  Walking through the hallways, I see a shine that stood out to me.  The brightness can really help bring cheer to patients that need it.
3) Energetic:  Throughout my hiring process, I have felt the energy in the department of people truly wanting to make a difference.

Q: How do you see your job relating to the organization's mission?
A:  Health, Healing, and Hope:  My goal is to help patients stay as healthy as they can. By finding out what they typically eat and what their daily life is like, together, we can find ways to keep their blood sugars (and blood pressure, weight and other health measures) under control. By working with the patients, they become empowered and it gives them hope that yes, they can do it.

Q:  What do you think will be the best part of working in your department?
A:  Working with a team of educators where we can learn from each other and from the patients to maximize the effectiveness of diabetes education.

Q: Give us a FUN fact about you.
A:  I love to ski, swim and run, and I love watching my kids play soccer and lacrosse and NFL football (Go Ravens!).  I played water polo in high school, but if I tried to play it now, I would probably drown.

I also had the pleasure of meeting Antonio Wood, Sr., who is joining our environmental services team. 

Q: Why did you choose to work at GBMC?

A:  I choose to work at GBMC because the people are friendly and helpful.

Q:  So far, as an employee, what are your top 3 impressions of GBMC?
A:  My top 3 impressions of GBMC are the quality of care, cleanliness and the concern for patients.

Q:  How do you see your job relating to the organization's mission?
A:  In assuring that the patients’ rooms are cleaned properly and sanitized, I will prevent germs spreading from one patient to another. 

Q:  What is/do you think will be the best part of working in your department?
A:  I will do my best in my department to maintain a pleasant work environment.

Q:  Give us a FUN fact about you.
A:  I love eating hard red delicious apples. I enjoy watching football and baseball.

…and Back to Kindness
The start of Random Acts of Kindness Week, February 12–18, is just nine days away! Although we focus on kindness all throughout the year, GBMC HealthCare is celebrating by encouraging kindness among our coworkers.

This year, staff members are asked to submit nominations for the new Random Acts of Kindness Ambassador Award. This is an opportunity to share stories about and recognize a coworker who has gone above and beyond in being kind to coworkers and patients throughout the year. Submissions will be accepted from now until Monday, February 13. Click here to submit a nomination. The winner will be announced on Thursday, February 16.

Friday, January 27, 2017

A Hospital with Everything in its Place

I am so proud of my colleagues in the GBMC HealthCare system for all the progress we have made towards high reliability (what should happen always happens and what should never happen doesn’t happen). An example of this progress, that we have discussed previously, is our reduction of catheter-associated urinary tract infections (CAUTI’s). Back in 2011, CAUTI’s happened a few times a month at GBMC. Since then, because of the creation of standard methods for deciding who will really benefit from a catheter and standard methods for maintaining the catheter once it is put in, these hospital-acquired infections are now rare. But we still have work to do.

We are still prone to want to do things the way it feels comfortable to us in the moment. This is especially true of people like me who have been in health care quite a while and can remember when nothing was standardized. Back in the “good old days” almost everything was happening by chance and almost nothing was happening by design. We had workarounds for everything. When I was a resident back in Massachusetts in the 1980’s we didn’t trust the lab to get us results in a timely fashion, so we ordered almost every lab test “stat.” We didn’t realize that once every test was ordered stat, nothing was truly stat. Our work-around corrupted the system and actually made things worse. It is very hard to get people to understand that when they drift, cut corners and do not follow the design, it just creates problems for themselves or others although it may not be apparent to them in the moment.

Last week, I was having a discussion with a colleague about a broken bed being left in a narrow corridor on a nursing unit. I was concerned that this bed was blocking the egress of our patients if there was ever a fire. My colleagues on the unit, who were all outstanding doctors, nurses and techs and who were all working very hard, had come to accept the fact that beds would occasionally be blocking the corridor. They knew that the system for expeditiously removing unneeded beds was unreliable. What they didn’t understand was that their “tolerance” of the beds not being where they belonged was actually making the problem worse.

Since it's so hard in a large complex organization to get everyone to follow a disciplined and standard process, most improvement experts believe that leaders should start with the technique known as 6S, that we have discussed in this blog a number of times before.

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.

6S is seen as part of our foundation because the daily practice of making sure that your workspace is clean and organized takes discipline and the effects are easy for all to see. When the senior team goes on LDM rounds, we all look for litter on the floor and we pick it up and dispose of it when we find it. We are also intolerant of clutter and we are in action to get everything in its place. Here is a photo of a linen cart that was left in a corridor right next to a sign (an “affordance”, a reminder that is visible in the moment, also known as level two mistake proofing) that says “No equipment storage allowed in this area.”

Why do you think one of our colleagues left the linen cart there? Of course I don’t know but I suspect that the person was working hard and needed to go and do something else and decided in the moment that it was ok and probably did not think of the downstream effect of leaving it there. It was not blocking an egress but what if a few hours later a colleague needed a cart and couldn’t find it? What if a patient’s family member saw it and thought less of GBMC because of the clutter?

We have set cleanliness as an annual individual goal for all GBMC employees in this fiscal year. We each need to own 6S in our workspace wherever that is. What can we do to make this happen? Please let me know your thoughts.

GBMC United Way 2017

Finally, I encourage all GBMC HealthCare employees to consider participating in our United Way campaign which started this past Monday and runs through Sunday, Feb. 5th   Each year we partner with the United Way to give back to those who need our help the most, whether it be contributing to your favorite GBMC program or giving to the community and helping families stay in their homes and out of shelters, for example.

This year's campaign will feature a raffle, special Jeans Days, and a "ski-off" competition between various groups within our system.

Click here to view instructions on how you can make an ePledge today.

With your help, we can reach more people than ever! Thank You.

Friday, January 20, 2017

Do we ask the patient: “What matters to you?”

Recently, I was having a conversation with a friend about the care of his elderly relative. My friend was a bit annoyed that his relative was not following all of the advice of his physicians. My friend obviously loved his family member and was really concerned about his health. He told me that he had had a frank conversation with this loved one and that if he did not follow all of the advice of the physicians, that he “was done.” By this, my friend meant that he would not be as attentive when his loved one called for help.

I asked my friend if he had asked his relative what mattered to him. My friend looked perplexed at my question. People are used to following their doctors’ recommendations, as they should be, but is following every well-intentioned recommendation really the “bottom line?” Shouldn’t we start any conversation about a plan for people with chronic disease, especially those towards the end of life, by asking “What matters to you?”

In my friend’s example, he was most annoyed by his loved ones’ dietary indiscretions. Well, the loved one was already frail and eating his favorite things was one of the few pleasures he had left. So eating what he liked, meant more to him than possibly shortening his life by a few days or hours.

Maureen Bisognano, the former president of the Institute for Healthcare Improvement (IHI), first began encouraging clinicians to change the question to the patient from “what is the matter with you?” to “what matters to you?” The ultimate decision about diagnostic tests or therapies lies with the patient, not the physician. The role of the physician, or advanced practitioner, is to lay out the choices along with the evidence as to their efficacy. Knowing matters most to the patient will help guide the dialogue between the provider and the patient and has a better chance of resulting in a plan that the patient will actually adhere to.

At GBMC we have learned a lot through our study of people who leave our hospital “against medical advice,” in other words leaving when we think they need to stay for some diagnostic procedure or therapy. We have met patients who leave rather than get fired from their job and patients who leave rather than miss a family celebration. Knowing what matters most to the patient may not change our primary recommendation, but it may get us to a common ground that ends up in a better plan.

So, let’s work to make the conversation about “What matters to you?” to be part of our standard work with people with chronic disease. What do you think about this? Please give me your thoughts.
___________________________________________
Helpful links to IHI and “what matters to you?”
http://www.ihi.org/Topics/WhatMatters/Pages/default.aspx

http://www.ihi.org/resources/Pages/AudioandVideo/WIHIWhatMatters.aspx

http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=185&utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=29625149&_hsenc=p2ANqtz-8ua6m2Zfez7vKnAdeilcr7UOR4fLgWWfTZjEesoPO2aQ4DQQ6V_RB7EJwwiEu7oLy2FUEyoSPuALf-Owm6gOfHACls9B6uWQB6BhhuCDQAElnUjLQ&_hsmi=29625149

Friday, January 13, 2017

Remembering a Man of Peaceful Discourse, Learning and Reflection

Earlier today, GBMC hosted its 3rd annual Martin Luther King Jr. Day celebration which commemorated Dr. King’s life and vision. This year’s program, titled “Hear My Voice, Engage My Soul,” featured a keynote presentation by the Rev. Dr. Tim Tooten, who is also the education reporter at WBAL-TV, along with live music from the Cristo Rey Choir. I would like to begin my blog post with my introductory remarks from the celebration.

Have you watched television talk shows recently where the participants take turns shouting over each other? This is why they are called talk shows. Have you heard of television shows that are called “hear” shows or “listen” shows? I have not. We may only have talk shows because our society is full of people who “know” and want to “tell”.

I believe that our difficulty listening to and hearing others is one of the main reasons why we have such huge divides between groups of people today whether the line of demarcation is race, religion, income level, or rural vs urban habitat. Those who would divide us continue to talk without hearing.

Men and Women of good will must stop listening to their own voices and hear the voice of others. This is a message of Dr. King that we must take time to listen to what others are saying in order to understand and engage them to improve their lives and our own and improve our communities. We at GBMC must work hard to assure that all of our voices are heard, that we engage everyone and that everyone feels included.

I am grateful to Jennifer Marana, our new Director of Diversity and Inclusion and all of my colleagues on the Diversity and Inclusion Council for helping to drive us closer together. United, we can achieve our vision of being the healthcare system where everyone, every time is treated the way we want our own loved ones treated. If we don’t hear each other and engage each other we have no hope of achieving this lofty goal.

I want to thank Dr. Tooten, members of the Cristo Rey Choir and our Black History Month committee that put together today’s magnificent celebration!

How much can anyone “know” if they are only listening to their own voice?  Dr. King was a well-read man who knew the importance of gathering information and reflecting on it prior to speaking and of the importance of hearing the voice of others. Let us all remember this as we move towards our vision at GBMC and we move into the next chapter in the leadership of our country.



Friday, January 6, 2017

A New Year’s Resolution

No reader of this blog will be surprised to hear that I have been a bit concerned lately about maintaining the gains that we, in the GBMC HealthCare System, and others across our nation have made towards the national triple aim of better health, better care, and lower costs.

Since the passage of the Affordable Care Act (ACA), also affectionately known as Obamacare, our nations’ hospitals, physicians, nurses and the rest of the healthcare team have generated significant improvements in our care. Medicare has seen the smallest annual cost increases in its history. Employers, like GBMC, have also seen annual health care cost increases barely above the rate of inflation in the overall economy. Much of this has been stimulated by the ACA and the agency it created: The Centers for Medicare and Medicaid Innovation. Millions of Americans who did not have insurance before passage of the ACA now do and people who have significant illness, so-called “pre-existing conditions” can now get insurance when before they could not. Adult children can stay on their parent’s insurance plans, until the age of 26, when before they could not be covered after the age of 22. Insurance companies must spend at least 85 cents of the premium dollar on care and limiting the administrative costs and profit to 15 percent when before there was no such requirement. Now, if they spend on administration or have as profit more than 15 percent, they must return the difference it to the purchaser of the insurance. The concern that the ACA would be a “job killer” has proven not to be true. The unemployment rate is now much lower than it was at the time of the passage of the ACA.

It is sad that the part of the ACA that is not working well, the sale of individual policies to people who don’t qualify for the government subsidies, is the only part that is getting much “air time.” The price of these policies has gone up significantly because the “individual mandate” is not working. Too many healthy people are not buying the coverage leaving only the sick people in the pool thereby driving the cost up and making it likely that more people will stop buying the coverage.

The wonderful thing about the triple aim is that it transcends politics. I have not met anyone, Republican, Democrat or Independent that does not want better health and better care at lower cost. So, we in the GBMC HealthCare System must put the rhetoric aside, ignore the distractions and redouble our efforts towards our vision phrase: to every patient, every time, we will provide the care we would want for our own loved ones. What we want for our own loved ones is: we want them to get better; we want them to have the best care experience; we don’t want their resources wasted and we want them to know that we get it that it is a gift to serve them and this is a joyful pursuit.

So please join me in a resolution for 2017: The GBMC HealthCare Family resolves, in the New Year, to rise above all distractions and bring more joy to each other and our patients as we move faster towards the national triple aim.

If you would like to share your personal new year’s resolution, or goal, that you’ve set aside for this year, please go to https://gbmc.formstack.com/forms/new_years_resolutions to share.