Friday, February 12, 2016

The Support of a Leader to Help Redesign the Maryland Mental Health Care System

Earlier this week, I had the privilege to participate in a roundtable discussion, spearheaded by U.S. Senator Ben Cardin (D-Md.), that dealt with the challenges of mental health care in the United States. Joining me in representing GBMC were JoAnn Z. Ioannou, DNP, MBA, RN, NEA-BC, our Senior Vice President of Patient Care and Chief Nursing Officer, Robbin Motter-Mast, DO our Chair of Family Medicine and Jeffrey P. Sternlicht, MD, FACEP, Chair of our Department of Emergency Medicine.

The roundtable consisted of many physicians, hospital administrators, community mental health care advocates and providers that discussed ways to improve our mental health care system. The lack of adequate inpatient psychiatric beds and a well-functioning crisis intervention system has gotten the attention of many. Every day in the GBMC Emergency Department, for example, we house 5-12 people who are living there waiting for a psychiatric bed.  The panel’s discussion was led by Dr. Steven Sharfstein, the President and CEO of the Sheppard Pratt Healthcare System. The group discussed the nature of the problem and  potential ways to overcome the many hurdles to delivering the best possible care in cases of mental illness and substance abuse in Maryland and across the nation.

I applaud Sen Cardin’s dedication to reforming mental health care and for treating this as an unwavering priority for our nation.  I look forward to helping the Senator make sure that Americans who require mental health care services have access to them.

Recognition for 10 Years of Great Education
Many years ago, the Executive Director for our Center for Spiritual Support Training, The Rev. Joseph Hart, M.Div., BCC, along with a few of his colleagues, gathered around to examine the issue of ministry preparedness, and its future, in a changing world.  Joe and his group started to look at ways they could impact the larger community and how as a community medical center we could respond not only to the spiritual needs of those who come to us for care, but also to those in need of a clinically challenging educational program, but for whom Clinical Pastoral Education (CPE) programs were not an option.  Well, Joe and his group came up with a new option and that alternative is now approaching a major milestone…its 10th anniversary.

I congratulate Joe and his group in celebrating our Center for Spiritual Training program’s longevity and success.  When it first started it was a 10 week, 40-hour curriculum and it has always received overwhelmingly positive feedback from students. Students have come from a variety of faith traditions as well as vocations, both lay and ordained.  In 2015, the Episcopal Diocese of Maryland approached the Center to explore the possibility that our program could serve as an alternative to CPE for Diaconal Candidates.  In response to their idea, Joe and his team expanded the classes from 10 weeks to 30 and included a broader range of topics. With the approval of the Bishop, we welcomed 5 individuals in the fall of 2014 and they graduated last spring.  Again, lets congratulate Joe, his team and program graduates not only for their 10 years of valuable service and successes, but, for being such a model educational program!

Friday, February 5, 2016

High Reliability: It’s Hard to Get to Zero

By now, most people in health care understand that safety is a system characteristic and that we owe it to our patients to not create harm when they come to us for care. Many people now understand that we operate in a large, complex system and that the system is full of “latent” errors like not knowing what the evidence says is the best care or not following protocols when we do.  When these latent errors align….a patient gets hurt. What those of us who work on this every day now know is that it’s really hard to drive out all of the latent errors in the system. It is really hard to get to zero injuries to patients!

So, when we do get to zero in some area of harm, it's really a cause for celebration. GBMC, our beloved medical center, has now gone 6 months without a single central-line associated blood stream infection! This is phenomenal news. Some hospitals only measure this for central lines in patients in intensive care. We measure this for all patients on all units. As the run chart below shows, as recently as August of 2014, we had a rate of 3.5 infections for every 1,000 patient days with a line in place.

We did not get to this outstanding performance by wishing or hoping. We got there by making a commitment to get to zero and by filling the holes in the “Swiss cheese” - that is, by making sure that we found the weaknesses in our defenses against the central line seeding bacteria into the bloodstream. We have always had excellent doctors, nurses and other clinicians and they really cared and worked hard but we were not always acting according to the evidence on how to avoid these infections. So, we created standard evidence-based work for inserting a line and we audited our performance to make sure the standard work was being followed. We created standard work for how the lines were used and maintained on a daily basis and we checked to see that this work was being followed as well. We also developed standard rules for assuring that the line came out as soon as it was no longer needed. Every time we had an infection, we studied the events to see if we could find the cause to root it out so that it could not cause a future infection.

Will we ever have another central line infection? We probably will because our systems are much better but they are not perfect and we still have humans working in health care. Our people are very smart and work very hard but they are sometimes distracted. There are also uncommon “special causes” that arise that are beyond our control – like the rare patient with mental illness who was purposefully contaminating a line. But I am so proud of our team for the outstanding accomplishment of 6 months without a CLABSI. Zero – 100% reliability - is hard but it is not impossible.

Our patients do not usually thank us for not harming them (when was the last time you thanked a pilot for not crashing your plane when it landed) but let me thank all of our clinicians for getting us closer to our vision.

Monday, January 25, 2016

Once Again, Our Staff Shows Their Commitment to Our Patients and Their Resiliency

Baltimore is now digging out from the largest recorded snowfall in its history. This past weekend, Team GBMC again demonstrated its commitment to its mission of health, healing and hope for the community. I witnessed the teamwork, camaraderie and “can do” attitude of our people first hand.

I am writing this late Monday morning. I have been on campus, along with many, many others since Friday night.

Stacey McGreevy, our incident commander, did a remarkable job coordinating everyone’s actions. Cate O’Connor-Devlin oversaw the complexity of 24-hour nurse staffing for over 200 patients. Michelle Tauson and Dan Tesch tirelessly exhibited their expertise in disaster management for the duration of our “code yellow” event. Dr. John Saunders, our Chief Medical Officer, was the administrator on-call and has also been on campus since Friday morning. This leadership team did a fantastic job to the point that a nurse told me that she had been with us for over 30 years but this was the best handled weather event in her tenure.

For sure, there are things that we have learned from this event…. our supply of cots, once numbering 500 is now too few for our needs – we will order more. We did a good job of telling people where to sleep, but, we need to generate a map of who will be where. But for the most part, things went smoothly and every patient got the care they needed.

Our environmental service and food service workers were extraordinary in their ability to keep GBMC clean and all of us fed (Dr. Saunders and I each gained a few pounds because we did not miss a meal.) Our grounds crew did their usual phenomenal job of clearing snow and our facilities team made sure that everything remained in working order.

Most of the nurses and nursing techs worked 36 hours in three days. Many physicians trudged on foot through snow to get here. After going to pick-up one of our essential physicians, who had walked a couple of miles to the interstate and dropping him off at the ED door, a patient asked me if I could give him a lift to the center of Towson. When I accommodated him, he was very grateful to not be among the stranded at our hospital. Our communications team, staff at Gilchrist Hospice Care and the pharmacy were exemplary.

All of our other clinicians, patient access reps, secretaries and other support staff did their jobs well and remained focused on our patients under trying circumstances.

Late Sunday night, we got a special treat when members (pic left) from the Chesed Fund/Project Ezra, Hatzalah, Shomrim and Chaveirim all brought us fresh bagels!

So, I am in awe of all of my GBMC colleagues. Thanks again for all you did for our patients! Is summer almost here?

Friday, January 22, 2016

Making Sure Our Patients Know What to Do When They Go Home

It is very hard for a patient to know precisely what they should do and what they should look out for when they are discharged from the hospital. I have spoken many times, in this blog, about the biggest failing of the U.S. health care system being its inability to efficiently coordinate care for those with chronic disease. Patients are often not sure what to do in the transition from inpatient to outpatient. (This morning, I learned of a patient who had prescriptions for 48 separate medications when she arrived at our hospital!)

To try to get U.S hospitals to fix the problem of poor coordination and other issues, the Center for Medicare and Medicaid Services (CMS) requires that hospitals participating in Medicare participate in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. The survey has 32 questions ( seven of them are demographic) that ask about things like care from nurses, care from doctors, cleanliness and communication. There are two questions that directly inquire about the discharge process for those not going to another health care facility. The questions are: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

I encourage all blog readers to go to the Hospital Compare website and see how GBMC measures up against others on HCAHPS and other quality of care metrics:

Well, since our outstanding physicians, nurses and other staff members have been testing changes to better inform our patients when they are going home, like having the physician and nurse give the instructions together, we have made great progress! Just look at this run chart that combines the score on the two questions:
We are not at perfection yet…this work is difficult….but we have made great progress. Please join me in thanking our great clinicians for helping our patients to better understand what they need to know when they get home.

Our Housekeepers Are Preventing Infections!
We have now gone twenty-four days without a hospital-acquired Clostridium Difficile (C. diff.) infection. This is a fantastic accomplishment. C. diff. is a serious infection that causes abdominal pain and diarrhea that can be severe. Our Environmental Service team began a test of change recently where they are now sanitizing all rooms of discharged patients with bleach and it is working! Please thank our EVS staff when you see them. They are truly helping us treat everyone every time as it they were our own loved ones.

Friday, January 15, 2016

Celebrating the Accomplishments of our Nurses, Physicians and other Clinicians in Creating a Safer Hospital

Those of us who have been in health care for a while remember the days when we believed that infections that people acquired in the hospital were unavoidable. Because of this, we did not measure how often those in our care got a urinary tract infection because we had inserted a urinary catheter, as an example.  Now, we routinely measure hospital acquired infections (HAI’s) and we have been working hard to eliminate them.

Thanks to the outstanding collaborative improvement work of our nurses, physicians, and other clinicians, many of our units have gone months, and in some cases, years without any of the prevalent HAIs!  This accomplishment is truly a great cause for celebration because if it was your loved one, you wouldn’t want them to get an infection because they are sick and in the hospital.  The goal of coming to the hospital is to get better not to get a new problem.

Below is a list of the respective Units and their HAI Prevention Milestones:

Central Line Associated Bloodstream Infection (CLABSI):  
Without incident since 2008:  Unit 39 and Unit 54
Three-plus years without incident:  Unit 58 
Two-plus years without incident:  Unit 34, Unit 36 and Unit 59
One-plus year without incident:  Unit 38, NICU and Unit 48
Less than one-year without incident:  Unit 35 (six months), Unit 45 (seven months) and Unit 57 (10 months)

Catheter Associated Urinary Tract Infection (CAUTI):
Without incident since 2012:  Unit 39 and Unit 54
Three-plus years without incident:  Unit 36, Unit 38, Unit 45
Two-plus years without incident:  Unit 35, Unit 48 and Unit 58
One-plus year without incident:  Unit 34
Less than one-year without incident:  Unit 57 (10 months) and Unit 59 (three months)

One of the major reasons that we are much less likely to have HAI’s is because we have a 95 percent Hand Hygiene Compliance rate house-wide! Our remarkable hand hygiene rate plays an integral role in the prevention of all infections, not just CLABSIs and CAUTIs.  Maintaining the standard work of “washing in” and “washing out” is critical to our success!

Again this is great cause for celebration of the hard work of our nurses, doctors and other clinicians but especially to our nurses and nursing support technicians who maintain the catheters and lines, turn the patients to avoid bedsores and who make sure that the ventilator bundle is followed to prevent ventilator associated pneumonia.

Great job everyone and thank you!

Thursday, January 7, 2016

Reducing Missing Medications By Studying The Incidents As They Happen

I remember one of our first visits to Unit 38, during Lean Daily Management (LDM) rounds, in April of 2013. The clinical unit coordinator reported that there had been 35 missing medications the previous day. This meant that 35 separate times, within a 24-hour period, a nurse went to give a patient his or her medication and it was not present. This report really bothered me. The nurses on that unit work incredibly hard. The beds are always full and the patients are very sick. There was nothing odd about that day…nurses were looking for meds that were not there about that many times every day! There had been an acceptance that this was just the way things were and nothing could be done about it.

Reliability means that what should happen happens and what should not happen … doesn’t. A highly reliable medication delivery system would have all of the medications present for the nurse as they were needed. Our nurses found themselves in a very unreliable medication delivery system.

The “old” way to fix this problem was to find out who made the mistake. There must have been someone in the pharmacy who didn’t know what they were doing or didn’t care or both. But nothing could have been farther from the truth.

GBMC has always had outstanding pharmacists and technicians who really care and work as hard as the nurses. The real problem is that moving thousands of doses of medications from the pharmacy to the nursing units in the correct doses, and always on time, as patients are being discharged and new patients are arriving is a really, really complex problem. Our processes were not reliable enough to get the job done.

We have made phenomenal strides in reducing missing medications over the past three years. The missing meds team, which includes nurse managers and pharmacy staff, began working with individual units, like Unit 38, to study the causes of missing medications and test system changes to reduce them.

Over the past year, under the leadership of Pharmacy Director Cherryl Peterson and Lead Clinical Pharmacist Vaishali Khushalani, the team has been studying individual missing doses as soon as they happen to heighten the learning and find more specific process improvements to test. The Pharmacy has worked with SICU, under the direction of its nurse manager Jen McDonnell, and they have made incredible progress toward 100 percent reliability. The SICU, which added ‘missing meds’ to its LDM board in June 2015, started with a monthly average of 28 missing meds. A pharmacist began conducting a real-time assessment to find the cause of the defect. Representatives of the SICU team and pharmacy began meeting with the missing meds team weekly to share the previous week’s learning.  This has helped identify unit-specific and house-wide issues and solutions. One of the earliest interventions was the addition of an extra tower to the SICU’s Acudose machine, housing electrolytes and other IV medications that would often be missing.  Another recurring issue was that of missing medications on transfer from the ED or GOR PACU.  The Pharmacy developed a process to ensure delivery of medications to the appropriate unit after such transfers by getting an hourly transfer report. There were only 11 missing medications in the SICU in the entire month of December. What great improvement!
Let me particularly thank all of the staff of our pharmacy and the clinical unit coordinators of the SICU for their great work in making our processes more reliable to drive out wasted steps, improve our care, and make GBMC a better place to work!

Wednesday, December 30, 2015

2015 Was a Spectacular Year for the GBMC HealthCare System!

As we come to the end of the year we should reflect on all that the GBMC HealthCare System has accomplished in 2015.  We celebrated our 50th anniversary and finished our celebrating with a beautiful gala with over 1,300 friends of GBMC in attendance.  The magical evening, which highlighted GBMC’s service to our community and vision for the future, was a smashing success. That night we announced that we exceeded our anniversary fundraising goal by raising over $54.7 million.  This will allow the GBMC HealthCare system to continue to build on the work of the mothers and fathers of GBMC some 50 years ago and to help us move even faster toward our vision. All those who worked hard to make our 50th celebration deserve my sincere thanks!

Here are some of our other accomplishments and highlights during 2015:

--We continued our transformation to an outstanding community health system that our patients experience as a system. We reduced serious safety events from 21/year a few years ago to 2 in the year ending June 30, 2015! We became the only health system in Maryland to know precisely what our diabetes composite score is for our more than 4,000 diabetics and we achieved the national 80th percentile in their care! Our employed physician group achieved their highest satisfaction scores ever for delivering patient-centeredness by increasing hours of availability and reducing waits and delays of all kinds! GBMC Hospital achieved its highest overall HCAHPS (satisfaction) scores ever! Gilchrist Hospice Care grew by more than 20% and is now serving 750 patients every day! We were recognized by Chet Burrell, president of CareFirst Blue Cross/Blue Shield, as being a lower cost health system with very high quality!

--Our Epic Team completed the build of our new electronic record and will now begin the testing phase prior to our October 2016 go-live. In October we will realize: One patient…One record for all served by our employed and GBHA aligned physicians, our hospital, and our hospice!

--More than 160 members of GBMC’s medical staff in 80 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.

-- In 2015, the Baltimore Magazine released a second list of exceptional medical providers, recognizing 50 of the region’s top nurses for their extraordinary contributions to healthcare. The inaugural “Excellence in Nursing” issue featured seven GBMC HealthCare nurses among the 50 awardees!

--Our fantastic volunteer auxiliary again contributed thousands of hours of service and tremendous 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.

-- We had the pleasure of having United States Senator Ben Cardin (D-Md.) join us for a tour of GBMC HealthCare’s Family Care Associates (FCA) and for a town hall conversation on helping families find novel healthcare options, the future of the Maryland Medicare waiver, and the continued evolution on the Affordable Care Act (ACA).

Some of our other achievements in 2015 included:

--Named as one of America’s Best Stroke Centers by the Women’s Choice Awards. The Comprehensive Stroke Center Certification recognizes centers that meet high standards for stroke care as determined by the American Heart Association/American Stroke Association.

--Our very own Laura Clary, RN, FNE-A/P, SANE-A, CPEN, Clinical Program Manager for our SAFE (Sexual Assault Forensic Examination) Program was invited by U.S. Vice President Joseph Biden to join him for his visit to the Maryland State Police forensics lab.

--CareFirst BlueCross BlueShield (CareFirst) recognized GBMC as a Blue Distinction Center for Bariatric Surgery, Spine Surgery and Knee and Hip Replacement. The designation is based on rigorous, evidence-based selection criteria established in collaboration with recommendations from expert physicians and medical organizations.

--We earned Gold Commendation and the 2015 Outstanding Achievement Award from The Commission on Cancer (CoC), an official accreditation body of the American College of Surgeons and nationally recognized as the standard by which cancer programs are judged.  GBMC received a perfect score for all standards and was one of only 20 U.S. healthcare facilities with accredited cancer programs to receive this national honor.

--Teamed up for the first time with WMAR-TV and raised over $440 and collected hundreds of toys for the 17th annual “It’s Kindertime Toy Drive.”  Thank-you to all the hundreds of employees and their families along with the many donors who helped contribute to the toy drive.

--For the second year in a row, a GBMC physician was honored with the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control by the Maryland State Council on Cancer Control.  Dr. Gary Cohen, medical director of our Sandra & Malcolm Berman Cancer Institute, was presented with this year’s distinguished honor. This award is given annually to a Marylander who has contributed to reducing the incidence, morbidity and mortality of cancer through research focused on cancer control.

--The March of Dimes honored us for two significant milestones.  The first for reducing the number of elective inductions and Cesarean deliveries performed before 39 completed weeks of pregnancy and the second in recognition of Prematurity Awareness Month our NICU’s management was recognized for their hard work and dedication in caring for babies, mothers and their families.

--We were also recognized and accredited by the National Accreditation Program for Breast Centers (NAPBC), an official accreditation body of the American College of Surgeons, and nationally recognized as the standard by which breast centers are judged, upon the review of approximately 15 different standards limited to breast centers and breast programs and covering similar categories to the CoC accreditation.

--We appointed the first female physician as division chief within the Department of Surgery-when Dr. Alyson Wells was named the new Chief of Plastic Surgery.

--We were honored to help the Hewitt family with the birth of children -- spontaneous identical triplets.  This kind of birth was incredibly rare and newsworthy since they were conceived without any fertility treatments.

-- Becker’s Hospital Review magazine has listed the Greater Baltimore Medical Center among the nation’s “100 Hospitals and Health Systems with Great Oncology Programs” in its compilation of leading cancer care providers in the United States.

--A three-year, full accreditation with commendation designation recently was granted to our Sandra and Malcolm Berman Comprehensive Breast Care Center and its affiliated Advanced Radiology Breast Imaging Center by the National Accreditation Program for Breast Centers (NAPBC). This is GBMC’s third consecutive NAPBC designation since its first accreditation in 2009.

So I think you will agree that GBMC HealthCare made great progress towards our vision in 2015! 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 2015 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 2016. What other accomplishments would you like to highlight from 2015? Please share your thoughts below.

Best wishes to you and your loved one for a Happy & Healthy 2016!