Monday, January 26, 2015

Delivering on a Promise to the Community

Last Thursday, I traveled to Annapolis to address the Senate Finance and Budget and Taxation Committees. I was part of a panel from the Maryland Hospital Association (MHA) that was asked to give the Senators an update on how hospitals are transforming themselves in order to meet the four requirements of the new waiver: to keep hospital cost increases no higher than the rate of increase in the general economy, to improve the quality of inpatient care, to reduce re-admissions and to save money for Medicare.

At the hearing, there were two panels. In the first panel, the Senators heard from John Colmers, the Chairman of the Health Services Cost Review Commission, the body that sets hospital rates and must assure that the State complies with the waiver mandates, and Donna Kinzer, the Executive Director of the Commission. These two leaders did an excellent job of educating the lawmakers on the basic tenets of the waiver and how the State was performing so far.

The Committees then heard from David Horrocks, the Executive Director of CRISP (Chesapeake Regional Information Sharing for our Patients network), our regional health information sharing network. Mr. Horrocks told them of the work of CRISP in sharing patient information across hospitals.

The Chairman of the Finance Committee, Senator Mac Middleton, then invited the hospital panel to address the senators. Carmela Coyle, the President of the MHA, told them that the hospitals had embraced the notion of global revenue budgets as a means to begin converting towards higher value health care and that significant progress had been made in a short period of time. Carmela referenced the waiver “dashboard” ( http://www.mhaonline.org/finance/hospital-2-0-waiver-watch/waiver-watch) that the MHA was updating monthly.

Then it was my turn. I had been invited because of all of our accomplishments to date in building a system of care through the eyes of the patient – a system that can achieve our four aims of the best health outcome with the best care experience with the least waste of resources and the most joy for those providing the care, in other words, the care that you would want for your own loved one. I told the senators a bit about our hospital, our hospice, our excellent physicians and nurses, and our outstanding acute care capability, especially in surgery. I then told them of our vision, our 100+ primary care providers practicing in the patient-centered medical home working with embedded care managers, our extended hours of operation, and our daily use of CRISP to assure that our teams were not missing important information about our patients. I concluded with a few examples of our results so far and I informed them that GBMC has the lowest readmission rate in the State among non-rural hospitals. I had a huge sense of pride as I was speaking. We are delivering on our promise to the community. While I knew that the legislators did not understand everything that I was saying, I also knew that they were grateful for the work of the GBMC family. We were not asking for more money or lamenting our lot in life and telling them how hard our work was (even though it is!) – We were transforming into a company that can deliver better outcomes at lower cost and we had data to prove it. I want to thank all of my GBMC HealthCare System colleagues for being in action on change for the better!

Friday, January 16, 2015

Improvement Across Departments Requires “Boundary Spanners”

The GBMC HealthCare System is making great progress in improving care. Every morning on Lean Daily Management rounds I hear of tests of change that have led to better outcomes under our four aims. We are making performance improvement the way we run our organization.

Dr. Deming taught us the importance of deep process knowledge. Without knowing how the work is actually happening, we have no hope of generating better designs. We must go to the workplace, or as the Japanese call it the “gemba” and observe the process to find the opportunities to make it better.  It is clear to me that when the work is totally within the control of a given unit or department, we make progress quickly. There are many examples of this at in our system of care, but one that I spoke about in this blog is the work of Charlene Mahoney, RN, Lewis Hogge, MD, and their team in the GOR PACU. They quickly identified a design change and got to 100% completion of the final check by the Anesthesiologist before the patient leaves the PACU.

In a complex system, like a hospital, it is much more difficult to improve performance when the process involves more than one unit or group. This is because no one “sees” the whole process. People know the part of the process that they are involved in and are quick to assume what is happening in the rest of the process. An example of this is in our process for medication delivery from the pharmacy to inpatient units. I remember in April 2013, at the Unit 38 LDM board, it was reported that there had been over 30 missing doses of medication the day before. This means that when a nurse went to give a patient a prescribed medication, it was not there at the time it was due. Through the hard work of our nurses, technicians and pharmacists, the rate of missing medications is much lower but we are still not at perfection. It is hard to fix the remaining defects because it requires direct study of each defect across the departments and units involved.

In this blog, I have been talking about mindfulness and the tenets of high reliability and referring to the work of Drs. Karl Weick and Kathleen Sutcliffe. Last week, I commented on the commitment to resilience, or the enhanced ability of high reliability organizations to deal with and overcome the unexpected. Another tenet of mindfulness is the reluctance to simplify.  Weick and Sutcliffe point out that high reliability organizations do not jump to conclusions and they do not allow people who haven’t seen and studied the entire process to suggest changes to the process. They suggest that organizations have “boundary spanners” or people that go from one department to see the part of the process that they don’t know in another department. This is the same concept as going to the “gemba” in Lean terms.

Boundary spanning is hard because we generally don’t have people who have created time in their schedule to do it. Instead, they are put in the position of spending their time fixing the same problem every day like in the movie Groundhog Day. In the medication delivery example, we need to do the hard work of studying the few remaining missing doses to come up with the improvements required to eliminate them. We need boundary spanning and we need to be reluctant to simplify and assume why things are not going well to avoid making the situation worse.

Do you have an example of boundary spanning or going to see the work in another department that has resulted in better care?

Friday, January 9, 2015

Resiliency

In the GBMC HealthCare System, we are students of high reliability. We have to be if we are working towards our vision of patient-centeredness and treating everyone, every time, the way we want our own loved ones treated. The defining characteristic of high reliability organizations, according to Dr. Karl Weick, the internationally recognized expert in this field, is “mindfulness.” You can think of mindfulness as a heightened awareness of what is going on around you coupled with an unwillingness to believe that since everything is going along smoothly, things will continue to progress smoothly. Highly reliable organizations have robust processes (standard work) that can be relied upon, but they also anticipate and become aware of the unexpected faster so that they can deal with it.

In previous blogs I have discussed one of the fundamental underlying concepts of mindfulness - preoccupation with failure. This week, because of the outstanding work that our people have done in dealing with the influenza epidemic, it occurs to me that I should write about another of the concepts – a commitment to resilience. Dr. Weick points out that highly reliable organizations develop better capabilities to detect, contain, and bounce back from unexpected events. They learn from things that don’t go well and refine their processes. They try and plan to be ready for whatever might come their way, but still they can get caught unprepared for a rare event or for the magnitude of a less rare event. Such is the case with our current influenza epidemic.

Over the last 3 winters, we have not had huge increases in demand due to the flu.  One day last week, our emergency department saw 238 patients in a 24 hour period. Our normal average number of patients is around 150 per day. Imagine any business that needs to serve over 50% more customers than the usual! The ED nurses, physicians, nurse practitioners and physician assistants came in early, stayed late, and came in on their days off in order to serve those in need.  

And clearly all of the extra work has not been limited to the Emergency Department. Our hospitalists have also had huge increases in workload. Our hospitalists normally cover around 70 patients per day and they peaked earlier this week at 98. Our inpatient nurses and nursing technicians have also been tirelessly caring for a higher number of patients than usual. We opened Unit 37 to care for more acutely ill patients, and the intensivists and critical care nurses made it work.  All of our other clinicians, from therapists and phlebotomists to lab and radiology technicians, have all dealt admirably with the influx of patients. Of course our environmental services and food services teams have also had to rise to the occasion and cover the increased demand. Every member of the GBMC team has pitched in at some level to get the job done.   

I am very grateful to all of my colleagues for their expertise, hard work, and resiliency. Our patients and our community are so much better off because of their efforts.

Tuesday, December 30, 2014

2014 – Another Year of Great Accomplishments Moving Towards Our Vision

2014 was a year of tremendous accomplishments for the GBMC HealthCare System.  The end of the calendar year is a good time to reflect on our work towards our vision. How much have we progressed in becoming truly patient-centered? What have we done to make it more likely that  every patient, every time, gets the care we want for our own loved ones?

Here are some of our accomplishments in 2014:

•    Lean Daily Management (LDM) continues to be a success story.  LDM has generated many, many improvements throughout our system. We have reduced blood-borne pathogen exposures to our workforce and nearly eliminated splash injuries to the eye because we are now reliably wearing protective eyewear when we should. The average ED patient now waits 90 fewer minutes to get to an inpatient bed.  We beat our goal of having 10 serious safety events in FY14 and had only six. We have only had one in the first 5 months of this fiscal year! We won’t stop until we get to zero, but we are on our way! You may remember the “not so good old days” in fiscal 2012 when we had 20 serious safety events.
•    Our fantastic volunteer auxiliary again contributed thousands of hours of service and  high success in fundraising through our Nearly New sales. Our Foundation ran a spectacular Legacy Chase steeplechase event that showcased our HealthCare system to the community.
•    Gilchrist Hospice Care celebrated its 20th Anniversary and along with Gilchrist Greater Living continued their spectacular work and truly led the region in compassionate, evidence-based care to seniors and those at the end of life. Their year culminated in an outstanding outpouring of support from the community at the 2014 Holly Ball.
•    138 members of GBMC’s medical staff in 60 different specialty areas were recognized in the annual Baltimore Magazine Top Docs issue. Once again, we had more physicians recognized than any other community health system in the region!  We are so fortunate to have outstanding surgeons, internists, pediatricians, family physicians, and other wonderful specialists.
•    We celebrated the opening of the new office of Family Care Associates.  Many are  talking about patient-centeredness but GBMC is delivering it NOW!  I am pleased to see a team of doctors, nurses, and technicians really design care that is less wasteful, delivers better outcomes, and is more fun to be involved in.
•    GBMC is now embarking on its 50th Anniversary and we’re excited to tell the world about our history and where we’re going in the future as we deliver on our vision.

Some of our other accomplishments in 2014 included:
•    GBMC HealthCare was selected again as winners of Practice Greenhealth’s 2014 Emerald Partner for Change Award and with the organization’s first Circle of Excellence Award for environmentally preferable purchasing.
•    In June, over 400 employees, patients and volunteers participated in our Pink Glove Dance. Because of their efforts WE WON the national Pink Glove Dance competition. As a result, our community partner, The Red Devils, received $10,000 to support their work helping breast cancer patients and families.
•    Bonnie B. Stein, a member of the Board of Directors since 2009, was appointed as the Chair of the Board of Directors replacing Harry S. Johnson following the completion of his three-year term.
•    We celebrated the official opening of the Ehlers-Danlos National Foundation Center for Clinical Care and Research.  Under the leadership of Dr. Clair Francomano, the Center will provide comprehensive clinical care for patients, professional education and cutting-edge research.
•    For a second time, we received the Delmarva Foundation Excellence Award for outstanding performance in inpatient care.  To achieve this recognition a hospital must meet specific performance improvement criteria on ten quality measures in two clinical services: medicine and surgery. 
•    Dr. Janet Sunness received the 2014 Envision Award in Low Vision Research and was recognized for her expert work and as a prolific clinician-researcher in the area of maculopathy and for her significant contributions, most specifically in the understanding of and defining the parameters in clinical trials for the “dry” form of advanced age related macular degeneration.
•    Greater Baltimore Medical Center (GBMC) was designated as a Center of Excellence in Minimally Invasive Gynecologic (COEMIG) Surgery by the American Association of Gynecologic Laparoscopists (AAGL), the leading association of minimally invasive gynecologic surgeons, and Surgical Review Corporation (SRC).
•    Our Primary Stroke Center was once again recognized by the American Heart Association/American Stroke Association’s (AHA/ASA) Get With The Guidelines® (GWTG) program for our commitment to quality patient care.  Additionally, we achieved the Target: Stroke Honor Roll designation for meeting specific achievement levels and for improving stroke care.  This is the first year we have received this award for outstanding teamwork in our ED to identify and treat Acute Ischemic Stroke patients safely and rapidly.
•    GBMC was named Top Performer on Key Quality Measures® for 2013 by The Joint Commission, the leading accreditor of health care organizations in America.  Less than one-third of U.S. hospitals earn this distinction.
•    Chairman of Radiation Oncology, Dr. Robert K. Brookland, was awarded the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control and his department was also awarded a three-year term of re-accreditation in radiation oncology as the result of a recent review by the American College of Radiology (ACR).
•    Linda A. Walsh, MD, a GBHA board member and family physician at Jarrettsville Family Care, was recently awarded the 2014 Humanitarian Award by the American Academy of Family Physicians (AAFP).

So I think the evidence is clear. GBMC HealthCare made great progress towards our vision in 2014! We have many, many people to thank for this. Our doctors, our nurses, other clinicians, and all of our non-clinical employees have done a fabulous job.  And lastly, we must thank our patients – you are the reason we do what we do. We are honored and grateful that you have chosen GBMC for your care.  

I realize that these things only represent a small fraction of what the GBMC family did in 2014 to move us closer to our vision. All I can say is thank you! I look forward to all of our accomplishments to come in 2015. What others do you want to mention? Please share your thoughts below.

Influenza A Outbreak

Let me also thank everyone who has been resilient through our recent increase in the number of patients served during the Influenza A outbreak. Special thanks go out to everyone that works in the ED and on inpatient medical units.

Best wishes to you and your loved ones for a Happy and Healthy 2015!!

Tuesday, December 23, 2014

In The Spirit of Giving

I had the unfortunate and fortunate opportunity to accompany family members to GBMC for emergent care this week. Unfortunate for the obvious reason that my loved one was in distress; fortunate because it is always good for us to experience care from the perspective of the patient and family member.

True to form, the GBMC Team was exemplary. The calm and friendly professionalism allayed our fears from the minute we arrived. Decisions were made expediently and colleagues were called in for specialty expertise. I was so impressed with the resiliency of the emergency department team members. I was reminded how easy it is to take them for granted.

I was also reminded that working in medical care is a calling. Those that do it best display the spirit of giving. They are working their “tails off,” but, somehow managed to show that it is not a burden and it is joyful. I am so lucky to be associated with so many wonderful care-givers. In this season of giving, my colleagues gave us a lot and we are grateful. Merry Christmas and Happy Holidays to all!



Thursday, December 18, 2014

Synchronizing Our Work to Improve Patient Flow

Today, during Lean Daily Management Rounds, Melissa Nichols, the Clinical Unit Coordinator in the Surgical Intensive Care Unit (SICU) was explaining to me how they had tested a change to their process for moving patients from the SICU to a floor bed. The SICU team had initially taken a design from another unit, but they were frequently missing their goal of 30 minutes from “ready to move” until patient departure. 

When the SICU team was studying the causes of missing the goal, they saw on their Pareto chart that transport was frequently arriving late. They asked the question "Why is transport arriving late?" What they learned was that transport was not being given enough time to get to the unit because they were being called too late in the process.

Synchronization is a change concept that brings the players or processes in a design into “harmony.” When we synchronize processes in patient flow, we allow the operators to organize their work so they can be ready to act at a specified time. Melissa, Jen McDonald, the SICU Nurse Manager, and their team moved the notification to transport to a point earlier in the process, allowing transport to “synchronize” its work. Transport can now be prepared to move the SICU patient at the “ready to move” time. You can see that since the SICU changed their design a few days ago, they have not missed a transfer time!

 On a separate note, one of our beloved employees will be leaving us soon. We have all heard the phrase “their work is their passion.”  Those words were written to describe Linda Kelly and her years of service as the Clinical Program Manager for our Sexual Assault Forensic Examiners (SAFE) Program. 

Linda has been the leading force of our SAFE Program since 2006 and has provided an extremely valuable service to the victims of sexual assault in Baltimore County.  Linda established our SAFE Program as a comprehensive service in conjunction with the Baltimore County Police Department, the Baltimore County State Attorney's office, local universities and sexual assault counseling providers to ensure victims are treated professionally and compassionately.  Under Linda’s leadership, the staff at the SAFE Program has provided community outreach and educational programs pertaining to safe dating and recognizing and dealing with violence in a relationship.  Linda has done an excellent job representing GMBC in public appearances and has made a difference in the lives of our patients as well as the community at large.

Please join me in wishing Linda and her husband, Pat, all the best in their retirement.  Linda will truly be missed.

I am also pleased to announce that Laura Clary, RN, will assume the position vacated by Linda.  Laura completed her forensic nursing training at GBMC and joined the SAFE Program as the Clinical Program Manager in 2010.  Please join me in congratulating Laura in her new role!

Thursday, December 11, 2014

How Did We Improve Our Hand Hygiene Rates?

I arrived at GBMC in the summer of 2010 shortly after we received our first “secret shopper” measurement of hand hygiene and learned that it was a toss-up if someone coming into your daughter’s room at GBMC had washed his or her hands before entering. I remember thinking that it wasn’t that people didn’t know to wash their hands nor was it that they didn’t care. The rate was only about 50% because people’s minds were elsewhere…they were busy or they were distracted. I wondered how we would ever get closer to clean hands every time? I couldn’t think of a design change that was likely to work.
 

We tried the “technology” route in the MICU. We worked with a vendor that had software that would measure the rate and prompt the individual. We ended the test concluding that the MICU rate was no better than rates without the technology. We started to get traction when units started doing audits on a few trips in and out of a room on a daily basis. It seems that the staff doing audits generated better engagement and it started to lock in the habit.

Our run chart of hand hygiene compliance is one of the best examples of healthcare improvement that I have ever seen. I am still reflecting on the drivers of this change so I asked some GBMC colleagues. More awareness and people looking out for each other…measuring on a unit LDM board…extra focus…spreading knowledge about hand hygiene….culture change…the realization that we were not washing our hands….making it more personal for you…. turning handwashing into a fun game….calling it out among colleagues….these are the reasons my colleagues listed for this great improvement. The rate of almost every hospital acquired infection that we measure has been reduced as our hands have been getting cleaner. I am very grateful to all of my GBMC colleagues for this improvement work.
 

I would love to hear your ideas on how we accomplished this because it is in learning what works that we can make more improvements faster!

Gilchrist Hospice Care and Gilchrist Greater Living continue their spectacular work in leading the region in compassionate, evidence-based care to seniors and those at the end of life. I applaud all the hard work that Gilchrist Hospice has done over the years to help so many individuals and families through the end of life. Gilchrist not only provides world class medical care to patients in their final days, but they also provide emotional and spiritual support.  In the past 20 years, Gilchrist Hospice Care has cared for over 40,000 patients and approximately 100,000 loved ones.
 

Please come and show your support for Gilchrist’s work by attending the Holly Ball this Friday, Dec. 12 at the Baltimore Marriott Waterfront.  This year’s black-tie event, which starts at 7:00 p.m., will benefit the Gilchrist Towson inpatient center. For more information on the Holly Ball, please go to http://gilchristhospice.org/hollyball . I hope to see you there!
 

Wishing all those who celebrate the Festival of Lights next week a very Happy Hanukkah!