Thursday, August 17, 2017

Are we following the standard work…the design?

Earlier this week, at the executive Lean Daily Management board, we learned of three cases of patient falls at GBMC where the individual sustained minor injuries. Our people, especially our nurses and nursing support technicians, have done a remarkable job at reducing falls within our system. I believe that frail elders are now safer at GBMC than they are in their homes. Let me make the statement that I don’t think we will ever get to zero falls because to do this we would have to rob patients of their freedom and we will not do that. But as smart, caring professionals we need to always be learning from falls and changing our systems to move closer to zero.

So when three falls get reported what should our first question be? Our first question should be “did we follow our standard falls prevention work?” That standard work includes assessing the patient’s falls risk, educating high falls risk patients about how we will act and how they should act to protect themselves, and then implementing measures, like red socks, to alert others to the high falls risk, and using the bed and chair alarms.

The Swiss Cheese Model of error informs us that we should not expect to find one cause of a fall. In large complex systems, it is usually a series of factors that result in the bad event. One category of “holes” in the Swiss Cheese is that leaders need to be aware of managerial failure. One type of managerial failure is knowing that the standard work (in the case of falls prevention it is standard safety work) is not being followed and not doing anything about it.

If you are a very busy nurse on a medicine unit caring for a number of sick elderly patients, you have a lot to do. Setting up the bed alarm and making sure that it is turned on is one of your tasks. It should come as no surprise that a very busy nurse will sometimes get called away to urgently help another patient and forget to turn on a bed alarm. At GBMC we have, as part of our every two-hour rounds, a safety checklist that is done in part to check that the appropriate safety measures are in place and turned on. But what if we are not doing the safety checks as designed? If we are not, then that is a hole in the Swiss Cheese that is waiting to line up with a busy nurse getting distracted and forgetting to turn it on that might then lead to a patient fall.

So, as leaders at GBMC, we owe it to our patients, our staff and ourselves to assure that those safety checks are being done correctly. As we work to improve our care and get to even higher levels of reliability, we accept the fact that people will make mistakes and we must be preoccupied in catching the mistakes before they might result in harm.  So, we set up audits or checklists, but if we don’t follow the standard work of the check itself we miss our opportunity to find the mistake and fix it.

All leaders at GBMC have to unite NOT on ‘re-educating’ our staff on the importance of not forgetting, but, unite on ways of making sure that the standard work is followed when we are doing the safety checklist.  Only after enrolling all of their team members in the standard work should leaders decide how to hold their people accountable.  Leaders must take ownership as well.  If we know that the standard work is not taking place, as leaders we can’t wait until there’s an event, we must immediately work to close the hole in the Swiss Cheese and prevent the event from happening.

Please share your thoughts with me. 

Thursday, August 10, 2017

The Affordable Care Act was not repealed. What next?

In light of the vote against repeal of the Affordable Care Act (aka Obamacare) two weeks ago in the Senate, it’s a good time to continue the dialogue about the successes of the Affordable Care Act, its problems, as well as reflect on what the future may hold.

While I won’t go into the politics of healthcare, I believe it is important that the public remain educated and informed on how we arrived at this major crossroads in the American healthcare system.

The Two Main Components of the Affordable Care Act
First, did you know that there are actually two major bodies of work within the Affordable Care Act? The first has to do with health insurance. By far, covering Americans with health insurance was the biggest draw of this healthcare bill. Before the ACA was enacted, roughly 50 million citizens were uninsured. Since the ACA was passed, that number has been cut roughly in half.

The other component of the ACA focuses on the actual health care delivery system. As you know, even though we don’t cover all of our citizens with health insurance, we still spend 40 percent more per capita on healthcare than every other advanced nation and we don’t have outcomes for chronic disease that are as good as those other countries. So the ACA began changing incentives to meet the triple aim of improved health outcomes, better care delivery, and lower cost. This part of the ACA has been successful. We’ve seen annual Medicare cost increases lower than ever before and new programs set in motion that incentivize hospitals, physicians, and nurses to drive better health care value that has also kept employer-based health insurance cost increases relatively low. We’ve been experiencing the success of the ACA and the incentive programs at GBMC.

Of course, no bill, no matter how well designed, is without its problems. Yes, the ACA significantly increased the number of low-income individuals and families who qualified for Medicaid coverage to the tune of about 20 million Americans. It also made it easier for middle-class Americans to buy individual policies when they did not receive employer sponsored insurance, accounting for about 15 million more Americans who could purchase and choose their own plans on the newly created healthcare exchanges.

Why was this a big deal? Because prior to the ACA, people could buy individual policies from insurance brokers – if they were healthy. Because only healthy people could qualify, the rates for these policies were relatively low. People who were sick or had a pre-existing condition (such as epilepsy, diabetes, or even cancer), however, were deemed uninsurable. The pre-existing condition clause in the ACA opened up health insurance to a whole new pool of individuals who were no longer discriminated against by the insurers. This was a great win for millions of people.

But, once you create a market for sick people to buy insurance, the healthy people must also be required to buy insurance to balance out the costs.

This is the part of the ACA that is not working.
The incentives for healthy people to buy coverage were just not enough for many. Every time a healthy person decides to forgo health insurance pays the penalty, and takes their chances that they won’t wind up with a major illness or accident, the cost of insurance goes up…and up, and up.  And every time the cost of healthcare insurance goes up, more and more young and healthy people decide to roll the dice, take the risk, and not buy insurance, leaving a yet higher percentage of sick individuals in the insurance pool which drives costs up further. In some states across the country, this is causing insurance companies to stop selling policies to individuals. In these states, the exchanges are at risk of failing.

Going forward, we need to figure out how to make these exchanges work. We need a bipartisan effort to fix this part of the ACA, whether that means steeper penalties for healthy people who don’t buy health insurance, or more significant incentives for the healthy to enroll in coverage to keep costs lower for everyone. I am hopeful that the bipartisan work that started in Congress last week will come up with some good ideas to help fix this. Remember, the goal is better health outcomes with better care experience at lower cost. I don’t know anyone…Republican, Democrat or Independent…who is against this. 

As a result of this turmoil, many people are now considering a single payer system for the first time in our healthcare history. This would eliminate the problem of pre-existing conditions and differing policy costs because every citizen would be covered in the same huge pool of people.

This doesn’t mean socialized medicine or total government control of our healthcare system. This is the misperception that is hindering our efforts to even discuss this as an option.

Think about this: There is a single payer system in Canada. In Canada, it’s like Medicare for all, where Canada (like Medicare), is just paying all the bills, not providing the care. Actually, it is the U.S. government that provides more care than the Canadian government. The Veterans’ Administration is government-delivered care (is the VA socialized medicine?). Because of the single payer system, Canada spends about five cents on the dollar on insurance administration. In the U.S., we spend about  18 cents on the dollar on administrative costs and profit (which is actually lower than the previous 22 cents on the dollar the U.S. spent before the ACA). The difference between that 18 percent and five percent is billions of dollars! Many Americans believe this is pure waste.

A single payer system does not mean government provided healthcare. In all of the debates and discussions about the future of our healthcare system, Americans need to stay calm and listen to the dialogue about what single payer actually means.

There are pros and cons of all of the healthcare systems in the world. There is no perfect system…our goal as a nation should be to make our system better. We can make great progress even without a single payer system but we must come together to truly explore the evidence and our options.

We have a long road ahead of us to get to where we need to be with our healthcare system in this country. Staying educated and informed is vital to keeping a smart dialogue moving forward.

Thursday, August 3, 2017

Studying Defects to Learn and Improve at GBMC

I and other members of the senior team have really been impressed with what Kendrick Wiggins and Kevin Edwards and the materials management team have done to improve their work and make sure that our nursing units always have everything that they need to care for our patients. They have significantly reduced calls from nursing units for all types of supplies. Our nurses are spending much less time looking for supplies and calling to get things that they need that should already be present on the floor. At the same time Kendrick, Kevin and their colleagues have reduced the waste of having too much supply on the unit that can then expire and have to be discarded or reprocessed. Kendrick and Kevin have made their processes much more reliable.

This Tuesday morning on LDM rounds, Kendrick presented the learning on calls for missing linen from the day before. Kendrick had received a call that Unit 36 needed more linen. After directing the delivery of the needed things, he began to investigate. He asked the first why: Why did the unit run out of linen? He learned that the daily cart that replenishes the supply according to the predicted usage had not been delivered to the unit. He then asked the second why: Why had the cart not been delivered? And he learned that the vendor had not delivered the cart for that unit to GBMC. He then asked the third why: Why had the vendor not delivered the cart to GBMC to be brought to that unit? Kendrick called the vendor and found that they had not followed their standard delivery work. He asked them to problem solve and to create a final check of their delivery and to alert materials management when they did not deliver what was needed. The process that Kendrick followed is called the 5 Why process because it frequently takes asking the why question 5 times before you get to the fixable cause of the defect. Kendrick got all of the information that he needed in this case by asking just 3 why’s.

For LDM to be of value, the local leader must have a curiosity about how things are actually working. He or she must avoid the trap of assuming that they already “know” before going to study the actual event. On rounds when we hear people responding to the “what happened” question with “usually” or “sometimes” we know that the person has not actually investigated the event and done a 5 why’s. Tests of change that come from someone assuming what went wrong are not likely to be helpful. Engineers that are trying to improve something always start by going and watching the existing process. Only when they have observed and learned as much as they can about how a process fails do they test a change.

Another point that the leader must understand is to not stop the 5 why process too soon. On rounds we often hear “the chair alarm was not on.” The first ‘’Why was the chair alarm not on?” results in the answer, The nurse did not turn it on.” At this point we often hear that the leader has assumed education is the answer and that he or she is going to reeducate the nurse about the importance of turning on the chair alarm. If the leader had asked the second why, “Why didn’t the nurse turn on the chair alarm?” he or she may have gotten the answer that the nurse forgot. Very hard working and well trained people forget things from time to time, especially when they are under pressure and have many things to get done. Forgetfulness is better fixed by some kind of reminder in the moment (like a sign) or by some kind of constraint to make it impossible to get to the next step without completing the preceding step (you can’t order anything online until you have put in all of your credit card information) or by eliminating the step (like having the chair alarm reset itself). Leaders who stop the why process too soon don’t make as much improvement as those who learn as deeply as they can.

So the next time you see Kendrick, Kevin or anyone from the materials management team, thank them for being excellent learners and for helping us move closer to our vision faster!

Wednesday, July 26, 2017

Alarm Fatigue

I remember being a Pediatrics resident in a Neonatal Intensive Care Unit during my training and hearing many alarms going off simultaneously. Team members were frequently slow to respond to the alarms or they just didn’t respond at all. This was because they went off all the time and it was usually because the leads had become disconnected from the baby or the alarm was set to go off for something that we knew was not really an emergency…. like a momentary high heart rate because the baby was crying.  This concept, not reacting to an alarm because we have learned that they go off for reasons that do not require immediate action, has been termed alarm fatigue. Can you imagine being on a commercial jet where the pilot and the co-pilot were suffering from alarm fatigue?

“False” alarms breed contempt for the alarm system and teach people to ignore the alarm.  Do you always leave a building as soon as you hear a fire alarm? Probably not, because you have witnessed fire alarms going off when there was no fire. If this is the case, you have begun to assume that the alarm is false and the alarm is no longer serving its intended purpose. At GBMC, our standard work is to announce the testing of a fire alarm before we test so as to not create alarm fatigue and put our people at risk.

When I was a Pediatrics resident I received no training in complex systems, human factors or the Swiss Cheese Model of error. I did not know about the high-reliability concept of preoccupation with failure. No one taught me to be aware of the so-called “weak signals” that a catastrophe was brewing. No doctor or nurse told me that if I ignored cardiac monitors long enough eventually some baby might get hurt. Today, I know better but only because I have been involved in some cases and have read about many others where smart, well-trained and incredibly hard working clinicians got caught in the trap of alarm fatigue. Allowing devices on a hospital unit to alarm and ignoring the alarms is a hole in the Swiss cheese that is just waiting for a sick patient and hardworking and smart but human staff members to create a real problem.

So, I am asking all of my GBMC colleagues to not ignore alarms. If you hear an alarm respond to it. If the device is defective, then work with your manager to get it fixed or replaced. If devices are alarming because we don’t have good standard work (e.g. the leads are off the patient because they’ve gone for a test, but no one has shut off the device) then create the standard work. If devices are alarming because we have set the device to alarm at too low or too high a rate…reset the device.  If alarms are going off frequently for no good reason, we have to reduce the number of times this occurs.

I know how hard everyone works in our health care system. We should also want to reduce the number of alarms to reduce the stress on us and our patients as well.

Thanks for everyone’s help on this. Please tell me what you think.

New Executive Vice President for Medical Affairs and Chief Medical Officer
Congratulations to Harold Tucker, M.D. who was recently appointed as GBMC’s Executive Vice President for Medical Affairs and Chief Medical Officer. He is replacing the retired John Saunders, M.D. Dr. Tucker has been an active member of the GBMC's medical staff since 1984 and in that time has taken on several important roles. He was the Chief of the Medical Staff for six years and did an outstanding job of advocating for physicians and advanced practitioners and helping to improve patient care. Dr. Tucker will also continue to serve as the President of Greater Baltimore Medical Associates. Please join me in congratulating him as he takes on this important position.

Thursday, July 13, 2017

Summertime Fun and a Celebration of Our People

Yesterday, we held our annual employee and volunteer BBQ, titled Camp GBMC HealthCare. This event was a great opportunity for all of the GBMC family to come together and celebrate what we have accomplished, while also having some fun! It is no secret that healthcare requires self-sacrifice and dedication and that the work is truly hard. We spend so much time working to achieve our vision, to provide the care to every patient, every time that we would want for our own loved ones, that at times we need to take a step back, reflect and celebrate what we have achieved, together as the GBMC team!

Everyone seemed to enjoy the music, the good food, camp-themed games, and having a relaxing time with friends and colleagues. I also noticed that there were several magnificent karaoke performers! Many enjoyed participating in or watching tug-of-war, Bingo, and the three-legged, potato sack, and egg and spoon races. It was a great opportunity to celebrate together and leave our work behind, even if only for an hour or so.

Our Philanthropy Team, led by Jenny Coldiron, our Human Resources Team, led by Anna-Maria Palmer, and our Marketing and Communications Team, led by Greg Shaffer, put on a fabulous BBQ! Special thanks to Kim Davenport from Marketing and Shannon Baumler from Philanthropy for their hard work on this event, beginning early in the morning and stretching all the way through the night shift. Lunches were delivered to offsite GBMA practices and Gilchrist homecare staff were given food coupons that they could use at their convenience. At 11 a.m., the barbecue began. Hamburgers, hot dogs, veggie burgers, BBQ chicken, watermelon, salads, and s'mores pops were served by Rouge Catering. The Kona Ice truck was on site providing shaved ice for a cool treat. We assembled again from 10 p.m. until midnight to BBQ and do some karaoke with the night shift staff.

This year, we hosted a fundraising tent called “Camp Hope,” where different departments hosted fundraising activities to benefit our Oncology program. The winners are announced in this week’s Pulse.

We also hosted a horse decorating contest, in which departments decorated papier-mâché horses to show support for Legacy Chase and the Oncology department. A huge thank you to all the departments, units, and practices who participated in the Camp Hope Legacy Chase Horse Decorating Contest! There were 34 horses submitted, and BBQ attendees voted on their favorites! Here are the winners in each category, pictured below clockwise: 

Legacy Chase Theme – Epic Team

Cancer Awareness Theme WINNER  – Oncology Clinical Trials

Cancer Awareness Theme RUNNER UP – (There were so many submissions and a close number of votes) – Inpatient Rehabilitation

Overall Theme – Oncology Support Services

All winners will receive a pizza party celebration.  Please contact Kim Davenport at to schedule.

All in all, we had a great day celebrating our employees! Check out the photos.

What do you think?

Friday, July 7, 2017


I have had the good fortune of being away this week with my family. I have enjoyed seeing extended family members, celebrating Independence day and having fun. But everyone knows that the email does not stop coming.

I am very lucky to be the President of GBMC because the positive news hugely outweighs the negative. Among the messages I received this week was one from a GBMC colleague who had been admitted to the hospital after a holiday visit to her patient centered medical home. She was effusive in her praise of those who had served her.

Among the other messages was the notice that next week, July 9-15, is GBMC Spirit Week. This got me wondering about spirit. My first reaction was just how wonderful our marketing, human resources and philanthropy groups are. They are clever and tireless in their efforts to make the hard work of patient care and its associated tasks more rewarding and at times actually fun. I was then wondering which socks I would wear for ‘Crazy Sock Day’. (I don’t think that many who know me would be surprised by this. It is amazing how many comments I get at work if I am not wearing a dark suit, white shirt and a tie.) I also thought about karaoke at the barbecue this Wednesday….

But then my thoughts returned to my GBMC colleague who had been admitted to the hospital for July 4th. Her story awakened me to what spirit really is. Spirit is a rallying cry. It is what joins us together in our mission. Outside of work we have so many differences in our daily lives. But in the hospital, our physician offices or in a Gilchrist setting we are one Team. Teams are all imperfect because they are made up of humans who are imperfect. But spirit brings us together and makes us stronger together. Spirit helps us rejoice in our inherent differences and helps us see them as assets to make the Team richer and better. Spirit helps us look out for each other, celebrate together in good times and console each other and be resilient together in bad times.

So as I return to work I want to wish each and every one of my GBMC colleagues a Happy Spirit Week!

Tuesday, June 27, 2017

A Titan Moves from Management to Governance

This coming Thursday (June 29), Dr. John Saunders will retire as the chief medical officer (CMO) of the GBMC HealthCare System.

John came to GBMC in 1979, as a fellow in head and neck surgery from Walter Reed Army Medical Center, to work with Drs. Robert Chambers and Darrell Jacques. He joined the medical staff and after 10 years in private practice, Dr. Saunders became the medical director of the Milton J. Dance, Jr. Head & Neck Center. Under John’s direction, the Dance Center became the premiere community-based program for head and neck cancer surgery and rehabilitation, and voice disorders.

John retired as an active surgeon in 2012. He served as GBMC's chief of staff from 2004 to 2010 and as interim Chief Executive Officer in 2010.

I was most fortunate when John agreed to take on the role of CMO in 2010 and has served in that capacity until this day. In his role as CMO, John has been responsible for the clinical quality of our healthcare system and has served as the designated institutional official (DIO) at GBMC for the Accreditation Council of Graduate Medical Education, overseeing all of our residency programs and working closely with the Graduate Medical Education Committee.

We all know that John is an icon at GBMC. There is no more respected individual in our system than John Saunders. Patients know John Saunders as a great doctor with an outstanding bedside manner. Clinicians know him as an extremely talented surgeon, who was very calm in the most difficult situations. Residents and medical students knew him as an outstanding teacher who was always kind but firm. Members of the senior team know John for his wisdom, his insightful guidance, his wonderful sense of humor and his outstanding storytelling capabilities.

John and Carolyn Candiello, GBMC’s vice president for Quality and Patient Safety built an excellent structure that is second to none and both have overseen the cultural and performance change that has put GBMC in the quality limelight locally and nationally. John has presented patient stories monthly for seven years. These stories have educated many about the complexities of caring for patients and about a model to make things better.

Everyone knows John for his humility and self-deprecating humor. I have come to know John as an outstanding family man, who along with his wonderful wife, Betsy, have raised three great children and is now helping to raise his grandchildren. John plays the piano and at his retirement event I asked him to play a few numbers but he refused when I told him he had to play at least one Steely Dan song.

All kidding aside, John has become a dear friend and I will miss him on our senior team. I don’t know anyone who can imagine the GBMC HealthCare System without John Saunders. The good news is that John is not leaving us as he has agreed to continue to serve as a director on the GBMC HealthCare Board. Congratulations, John and thank you for everything you have done through the years for GBMC and our patients!

Cause For Celebration
Earlier this month, more than 300 cancer survivors, their caregivers, friends and family members celebrated life at our annual Cancer Survivorship Celebration.

Over the last 26 years, we’ve held this event for GBMC cancer patients and their caregivers as an opportunity for cancer survivors, loved ones and staff to join together, renew acquaintances and celebrate both survivors and their caregivers. It provides us the opportunity to commemorate our patients’ courage and our caregivers' commitment to their treatment. More than 2,000 individuals annually turn to the experts at The Sandra and Malcolm Berman Cancer Institute at GBMC when faced with potentially life-changing medical diagnoses. Our Berman Cancer Institute is not only locally recognized, but nationally as well and is fully accredited by the American College of Surgeons Commission on Cancer.

The number of people who attend this event continues to grow. Congratulations to our survivors, their families, and our caregivers!

Happy 100th Anniversary! 

This year The American Occupational Therapy Association (AOTA) is celebrating its 100th Anniversary.

The AOTA, originally called the National Society for the Promotion of Occupational Therapy, was created in 1917 by a small group of pioneers in the profession.Today, there are more than 213,000 occupational therapy practitioners nationwide that help people of all ages gain or maintain capabilities that help them live life to the fullest.

Our therapists and therapy assistants provide functionally oriented treatment that helps individuals of all ages after an injury, illness or medical procedure. Their work promotes healing, increases strength and endurance and teaches patients how to prevent further pain or injury. Their specialty care can help their patients achieve a higher level of independence.

I want to sincerely thank all the OTs and OTAs for their incredible work and for their unwavering dedication to our patients!

Remember to…
Don’t forget to RSVP for this year’s Employee & Volunteer Appreciation BBQ titled “CAMP GBMC Healthcare.” This year’s event, slated for Wednesday, July 12, will be a great opportunity for our staff and volunteers to come together to celebrate what we have accomplished, while also having some fun! Please join us! You have until Wednesday, July 5 to RSVP and can do so by clicking here. I look forward to seeing you there!

Happy Birthday to Us! 
Finally, I want to wish everyone in our GBMC family a safe and happy Independence Day. July 4th marks the birthday of our great country…the land of the free and the home of the brave. Let's take some time to reflect on what we can each do to make our country even better than it is today.