Monday, March 27, 2017

A Three Year Checkup for the Patient Centered Medical Home at GBMC

I am a pediatrician and all good pediatricians know the importance of checking the child’s development at regular intervals. So, you may remember that I interviewed a few patients on their perception of our advanced primary care patient-centered medical homes three years ago and included the interviews in the blog.

http://ahealthydialogue.blogspot.com/2014/03/what-do-our-patients-really-think-about.html   
Well, I think it’s time for another checkup.

The patient- centered medical home is our design for being accountable along with the patient for his or her health. We began building them when we created our transformational vision in 2011. At that time, we knew that we had to change our design of primary care if we wanted a different outcome. We wanted everyone to get what we wanted for our loved ones: the best health outcome with the best care experience at the lowest cost (with the least waste) and with the most joy for those providing the care.

So now in 2017, what do our patients think about our patient-centered medical homes?

Earlier this week, I interviewed Dale Cernik. For more than a year now, Dale has been a patient of Dr. Peter Burkill and his team’s nurse care manager, Anne R. Conrad, at Family Care Associates, our advanced primary care office in the North Pavilion on the GBMC campus. Dale, 66, came to us with symptoms of increased thirst and urination. He said that “basically I felt like my body was out of sync.” There was no history of diabetes in his family, but Dale did have a history of high blood pressure.

Dr. Burkill diagnosed Dale with diabetes and he prescribed medication and connected Dale with Anne. She began to check in with Dale by phone two times per week to make sure that the symptoms were improving and that Dale understood and was following his diet and exercise plan. Dale made lifestyle changes and followed the plan.Today, Dale’s blood sugar levels are normal, his high blood pressure is under control and he is now exercising six times a week!  Dale now feels that because of the care he has received from Anne and Dr. Burkill he’s been able to get his life back.

We had a nice conversation and Mr. Cernik made it a point of letting me know how happy he was to tell his story and how the “FCA staff is professional, kind and caring and how everybody is sincere in their actions.”

Click the video below to hear what else Dale had to say about his care from the team at Family Care Associates.





I am so proud of Dr. Burkill, Anne and the rest of the FCA team including the care coordinators, medical assistants, and patient service assistants. They are all willing to be held accountable to working with patients, like Dale, to help them improve their health.

I think our patient-centered medical home passed the checkup with flying colors!

I want to also express my gratitude to Mr. Cernik for sharing his experiences and story with me. The GBMC HealthCare System is moving closer to our vision of providing to every patient, every time, the care that we would want for our own loved ones.

Wednesday, March 15, 2017

Highlighting Our Work When It Comes To Patient Safety

This week is National Patient Safety Awareness Week and for this reason, I want to take the time to recognize the important achievements we as a healthcare system have made when it comes to the safety of our patients. I’ve asked Carolyn L. Candiello, Vice President for Quality and Patient Safety with GBMC HealthCare, to be a guest blogger this week. I hope the readers of this blog will find Carolyn’s observations on our patient safety work as illuminating as I did. 

Carolyn writes….

This Sunday, marked the beginning of National Patient Safety Awareness Week.  This year’s theme is “We are all Patients!” and if you think about it, it’s very much in line with our own vision – that we treat everyone the way we would want to be treated.

As I reflect on this week, I think it is a good time to pause and consider what we all (nurses, techs, providers, support staff, volunteers, and leaders) have accomplished so far and to recommit to following safe practices for patient safety. Earlier this month, The Joint Commission issued their 57th Sentinel Event Alert which discusses the essential role of leadership in patient safety. I am so proud to be part of an organization where safety starts at the highest level. In 2010, our Board of Directors made a commitment to improve patient safety and together we have all been working tirelessly to achieve highly reliable care for our patients! 

The results have been remarkable --in 2011, GBMC had 21 serious safety events. So far, in FY 2017 we have had one.  We have seen other improvements just as remarkable – reducing catheter-associated urinary tract infections from one every week to just under one every other month.  Having gone over a year without an event, I consider that we have virtually eliminated serious hospital-acquired pressure ulcers, ventilated associated complications, infections related to hip and knee replacements and are well on our way to achieving reliability in many other areas. This didn’t happen by “wishing and hoping” it happened as a result of several changes we made.

1. We adopted a Just Culture – a firm belief that every system is perfectly designed to get the results it gets.  When errors happen, our focus is not on the individual, BUT on the system and how we can fix our processes.
2. We adopted a Reporting Culture– we believe that it is important for each of us to speak up when something isn’t right and to report incidents of harm.  One of our goals for a few years was to increase reporting into Quantros!  We went from receiving only a handful of incidents each month to receiving hundreds!  We encourage everyone, regardless of position, to report incidents of harm or potential harm.
3. We have adopted a Learning Culture - We are open and transparent about learning from our experiences. We openly share our data with our community on our website.  When there is learning from our LDM report, we share it in the daily email.  Each week we share deeper learning in the Tuesday Pearl of Wisdom. Three years ago, we started Great Save Wednesdays where not only do we share learning, we highlight safe behaviors by so many of our front line staff.  Each month we share learning in the form of a patient story – the story is told at leadership and board meetings and is available on the Infoweb.  Every manager is asked to share these stories at their staff meetings.

While all of these things help to build a culture of high reliability in order to provide the care to every patient every time as we would our own loved one, we are not there yet! I ask that each of you to join me in recommitting to taking the National Patient Safety pledge.  I pledge to strive to implement and follow practices that increase the safety of my patients and my team!  You can pledge on their website or enter your commitment below!
  
Thank you for all that you do every day to make care safer – to provide the care we would want for ourselves and for our loved ones!


THANK-YOU!!!
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.

Our environmental and food service workers were extraordinary in their ability to keep our facility clean along with feeding our patients, staff, and volunteers. Our grounds crew did their usual phenomenal job of snow removal to make our campus safe and passable and our facilities team made sure that everything remained in working order.

Most of the nurses and nursing techs, worked over 24 hours, and many of our physicians came in despite the inclement weather, I truly appreciate your commitment. You all clearly displayed your dedication to treating all of our patients the way we would want our own loved ones to be treated, every time.

I also want to point out that our leadership team also did a fantastic job, led by Stacey McGreevy, our incident commander, who did a remarkable job coordinating everyone’s actions. Cate O’Connor-Devlin helped to coordinate and address nurse staffing for over 200 patients and Michelle Tauson exhibited their expertise in disaster management for the duration of the snow event. I want to thank all the staff members who helped in the hospital’s command center, answering phones, coordinating accommodations for employees who stayed overnight and ensuring that all units had the proper coverage to care for our patients.

Again, my appreciation to all who worked so hard to get the job done for our patients and our community during the snow storm.

Tuesday, March 7, 2017

Strategic Planning in a Time of Uncertainty

Last Thursday and Friday, I spent most of the day with our senior team, nursing leaders along with our service line physician leaders and administrators. We were together to review the findings of our SWOT (strengths, weaknesses, opportunities and threats) analyses and to begin the creation of our one and three-year goals and next year’s strategic operating plan to get us there.

John Ellis, Senior Vice President for Strategy and Business Development, and Amber Taylor, Director of Planning and Business Development took us through their analysis of changes in the local health care market, the results of their interviews with health insurance leaders and patients, and the results of surveys answered by our leaders and members of the Board. Cathy Hamel, Vice President for Continuing Care and President of Gilchrist, presented the strategy over the next few years for Gilchrist, and Harold Tucker MD, President of GBMA and Ben Beres, Chief Operating Officer of GBMA, presented their thoughts on strategic moves within our physician company.

Our service line leaders (Medicine: Neal Friedlander MD and Jessica Heslop; Surgery: Jack Flowers MD and Michael Finegan; Women’s: Victor Khouzami, MD and Susan Bowen, RN; Geriatrics and Continuing Care: Tony Riley, MD, and Cathy Hamel; Cancer: Paul Celano, MD, and Michael Stein; and Primary Care: Robin Motter, DO and Danielle DaSilva) presented their thoughts as well. The group considered all of the information and began the work of creating one and three-year goals to move us closer to our vision under our four aims.

The next steps will be to choose the final initiatives to work on and then create the annual operating and capital budget. Keith Poisson, Executive Vice President and Chief Operating Officer, has done an excellent job overseeing this process and he was ably aided by Amber Taylor and Lisa Griffee, Director of Lean Operations, who kept us on schedule and even made the process fun at times.

I am very proud of all of the people who have participated so far and I am grateful for their hard work. Even though we don’t know the fate of all of the provisions of the Affordable Care Act and if the country will continue its march towards the triple aim of better health and better care at lower cost, we will persevere in serving our community and each patient as if he or she was our loved one.

THANK YOU TO OUR SOCIAL WORKERS!!!
March is Professional Social Work Month and I would like to thank the dedicated group of social workers who serve GBMC. We are fortunate to have such a talented and hard-working group of social workers on our team. 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 chronic and advanced illness receive the support they need. Please take the time to thank our social workers for all that they do to move us closer to our vision.

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.