Thursday, September 11, 2014

Critical Care at GBMC: No Longer Relying on Hard Work and Good Intentions Alone

On January 1 of this year, GBMC began a new era in critical care. We have always had excellent physicians and nurses caring for our sickest patients in our ICU’s, but our care delivery model – the system our people worked in – was not state of the art. 

All of that is now in the past. Under the leadership of David Vitberg MD, all ICU patients are now covered by a new, high-intensity, hospital-based team.  From inception, this new team significantly increased the level of oversight and availability for our sickest patients by extending attending physician in-house coverage from 8-10 hours (on average) to sixteen hours per day.  Also from inception, the team took ownership of all surgical intensive care unit patients. Prior to this, the attending surgeon was responsible for the minute to minute changes often required in the SICU while continuing to do his or her other work in the office or in the operating room unless a consultation request was made.  Now, the GBMC surgeons that fill the SICU with patients and the dedicated nurses that staff this unit have an equally dedicated group of intensivist physicians that attend to this high acuity patient population around the clock. This is what you would want if the patient were your loved one.

During the past six months, six new physicians were recruited to the division – four of which split time between the intensive care units and the new pulmonary practice – Pulmonary Medicine at GBMC.  In addition, three supplemental attending physicians were recruited to provide extra coverage as needed.  Supporting these ten physicians, two physician assistants were hired and now provide coverage seven days per week between 0700 to 1900 hours.

The 7 full time members of the physician critical care/pulmonary group are:


As of September 1st, all of the members of this new team are on board. But much progress has already been made to improve the quality and safety of Critical Care Medicine at GBMC.  An overriding principle in developing this new division was to elevate the delivery of Critical Care Medicine and build an environment and group of clinicians that would deliver this care in a safe, efficient, evidence-based, and compassionate manner that would defy the ‘low intensity’ label typically attributed to a community intensive care unit.  The following key initiatives highlight the division’s dedication to rapidly creating a safer and more cutting edge critical care system at GBMC.

1. Therapeutic Hypothermia for heart attack patients
Therapeutic hypothermia after return of spontaneous circulation in survivors of cardiac arrest has been shown to improve neurologic outcomes.  Between 2002-2004 many local hospitals around the beltway developed and started using therapeutic hypothermia protocols.  GBMC created an order set for this therapy but did not design a robust system to use it.  Within weeks of launching our new Critical Care program in January, an updated therapeutic hypothermia protocol was written and equipment required to delivery this therapy was acquired (Arctic Sun Temperature Management System).  The policy and procedures for cooling patients was updated to reflect best evidence, and cutting edge technology like BIS monitoring (Bispectral Index continuous processed EEG) was incorporated into the protocol. to limit potential awareness under paralysis and improve patient safety, and the related Neuromuscular Blockade policy was overhauled and fully updated. This modality is now available for use on patients who will benefit from it.

2. Critical Care Infusions: Improving patient safety and standardizing care delivery
Realizing the risk associated with different physicians ordering the same titrateable medications in different ways (and the confusion this created for our nurses), Dr. Vitberg and his team identified every titrateable infusion commonly used in all critical care areas and standardized all five fields required to order these medications.  The ‘Medication Guideline – Critical Care Adult Titrateable Infusion’ policy was approved by the Medical Board in May.  Our MIS/IT staff is completing an update in Meditech which mirrors this paper policy.  This will undoubtedly lead to more appropriate utilization of these high-risk medications, increased standardization in our practice of critical care medicine, and provide a safer experience for our patients. 

3. The ICU Transfer Checklist: Ensuring no missed hand-offs and reinforcing direct attending to attending physician communication
One of the highest risk times during a patient’s hospitalization is the time at which they transfer out of the intensive care units to lower levels of care.  To ensure that the handoff to the receiving physician happens reliably, the new group created an ICU Transfer Checklist.  A patient cannot be moved out of the unit or transferred to another facility without the sending critical care attending talking to the receiving medical attending or surgeon, the residents giving sign-out to each other (when they are involved in patient care), and the nurses giving sign-out to each other.  Since the checklist was implemented, our Team has achieved a near 100% compliance with hand-offs over the past few months.
 
4. Creating standard work and  organizing critical care interventions to improve patient outcomes
Many interventions in critical care are time sensitive. Implementation of protocol-based care empowers nurse and respiratory therapists to begin therapy quickly for critically ill patients and engages all members of the critical care team.  Implementation of evidence-based protocols, many of which contain bundled care items recommended by organizations like the Institute for Healthcare Improvement, improve care reliability and patient outcomes.

5. CHARMS Committee: Taking a closer look at how we screen for and treat sepsis
The CHARMS Committee (Community Hospital Action plan to Reduce Mortality from Sepsis) was organized in June 2014.  The committee is made up of MICU and SICU nurses, ED physicians and nurses, intensivists, residents, and a faculty physician representative from the Department of Medicine charged with quality improvement.  The focus of the committee is to review every aspect of sepsis care at GBMC, decompartmentalize the delivery of sepsis care across all patient care areas (i.e. ED to ICU to floor), ensure evidence-based best practices are being utilized, and improve clinical outcomes for these patients.
  
Goals of the CHARMS committee include:

• Develop a house-wide screening tool for sepsis (build on the existing screening tool already utilized in our ED)
• Update all sepsis order sets to reflect best practice, evidence-based medicine
• Ensure sepsis treatments are ordered and delivered in consistent fashion across all patient care areas (decompartmentalization of care: EMS-ED-ICU-floor-discharge)
• Develop a standard approach to determining need for central venous access
• Meet regularly to monitor clinical outcomes via review of data from Crimson

6. Code / Rapid Response Committee (RRT): Improving our response to emergencies around the GBMC campus
The division has worked hand in hand with the Code / RRT Committee to improve our response to cardiac arrests and rapid responses on the GBMC campus.  A recurring problem at code responses has been overcrowding.  In July, code team huddles were launched.  Every day at 0745 hours, all members of the code team meet in Unit 57, hand-off badges which indicate pre-assigned roles in a code response, and receive 5-10 minutes of educational ‘pearls’ from the ICU attending physician regarding resuscitation.  The names of the code team members are recorded on a dedicated board in the center of Unit 57.  This board contains educational material which reminds team members of their responsibilities at a code response, the educational ‘pearls’ for the day are posted, and any important announcements like QA/QI initiatives or equipment issues can be posted.  As ‘badged’ code team members arrive at the patient’s side, they replace initial responders that have started the resuscitation.  Security personnel and the admission coordinators have been trained to limit responders at the bedside to only those that are wearing a code badge.

7. Limited Bedside Ultrasonography: a core feature of any cutting-edge ICU
Limited bedside ultrasonography has evolved into an extension of the physical examination for critically ill patients.  All critical care fellowships now teach this skill to improve patient assessment, for procedural guidance, and to help guide resuscitation.  Ultrasound is typically used to rapidly answer binary questions in the ICU setting: is a pneumothorax present or absent?  Is there cardiac activity?  Is there free fluid in the abdomen? Is the vena cava empty or full?  Ultrasound must be used whenever possible to guide needles during invasive procedures.
 
So, you can see what happens when a new leader grasps the concept that hard work and good intentions by themselves are not enough to move closer to flawless care. It takes a team to design better systems and then carry them out! I am absolutely amazed at what Dr. Vitberg and his Team have done in a very short period of time. I can’t wait to see the improved health outcomes and care experience along with the reduced waste and greater joy that adding them to our existing team of outstanding nurses and other clinicians will bring.

Wednesday, September 3, 2014

Assuming and Speculating vs. Observing and Learning


Throughout the GBMC HealthCare System, excellent improvement work is being done to move us closer to our four Aims and our Vision. Where our teams have made the most progress is in letting go of behavior that proud people like me have a hard time getting rid of. We “learned professionals” have studied hard and have been trained to voice our opinion when confronted with a problem. We hear a few facts and quickly give our belief on a cause without really knowing. We assume many factors and then speculate on how these have contributed to the problem.

Engineers, as a group, do things differently. They are trained to observe things in action, to take things apart and to see how things really work or don’t work. Engineers are taught how to investigate; to get as deep as possible an understanding of an element or a process before thinking that they have a solution. When they believe that they have thoroughly studied a process only then do they test changes, one at a time, so they can see if their change is responsible for an improvement.

Engineers know that the best incident investigation is done immediately after the event with the people actually involved so that the steps can be recreated with as much fidelity to the true story as possible. Getting as deep an understanding of what happened by asking a series of “why’s” is the best way to generate tests of change to prevent the incident from happening again.

On a bad day in healthcare when we ask someone how defective care occurred (like a nurse going to give a medicine to a patient only to find that the medicine is not available to give) we get responses that begin with “Well, usually….” or “Sometimes….” Beginning the response with these words shows that the speaker has not investigated the occurrence, but, is merely speculating on the basis of his or her personal assumptions.

At GBMC, we are making great progress as our people work to investigate defects in close to real time to better come up with improvements. The learning from studying individual cases deeply is much more helpful than a perfunctory review of many cases. We leaders must give our people the time and resource to investigate defects as they occur. I look forward to hearing your thoughts on this.

I want to congratulate both Clair Francomano, M.D., Director of Adult Genetics at the Harvey Institute of Human Genetics and Janet S. Sunness, M.D., Medical Director of the Richard E. Hoover Low Vision Rehabilitation Services for their recent achievements.

Last month, we celebrated a monumental event, attended by Ehlers-Danlos Syndrome (EDS) patients and families from throughout the U.S., members of The Ehlers-Danlos National Foundation (EDNF) and GBMC leadership, to announce the official opening of The EDNF Center for Clinical Care and Research.  The major goals of the EDNF center are to expand treatment options for patients diagnosed with Ehlers-Danlos Syndrome (EDS), an inherited condition, which negatively affects the connective tissue that binds together skin, ligaments and bone.  EDS affects one in approximately 5,000 people in the US. Ours is the first center anywhere or at any time dedicated to helping EDS patients.  The center is being funded by EDNF which will give $250,000 a year over the next five years.  The funding will go toward providing comprehensive clinical care for patients, professional education , and cutting-edge research.  Dr.  Francomano will serve as the center’s Director.

Dr. Sunness has been selected to receive the 2014 Envision Award in Low Vision Research.  She is being 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.  The Envision Oculus Award is presented to individuals or organizations whose efforts in professional collaboration, advocacy, research or education have had a significant national or international impact on people who are blind or have low vision.  The Envision Award in Low Vision Research recipient is chosen by peers and selected from among nominations submitted by the Envision Research Peer Review Committee.

Wednesday, August 27, 2014

Caring for the Smallest of our Patients as if Every One was our Loved One

It has been many years since I cared for a sick premature infant, but, I can still remember looking into the eyes of anguished parents while caring for their baby. GBMC is known as a great hospital to have a baby. One of the reasons why this is true is because we have a great Neonatal Intensive Care Unit (NICU).

All health care leaders are proud about the work of their organizations, but my words here are more than bravado.  We can substantiate my claim with facts. Last week, Dr. Howard Birenbaum (pic. rt.), the medical director of our NICU, shared with me the 2013 Vermont Oxford Network (VON) Annual Report. The VON (https://public.vtoxford.org/) is a nonprofit voluntary collaboration of health care professionals established in 1988. Today, the Network is comprised of nearly 1,000 NICUs around the world. The units share data to find the best performers so that they can learn from each other. GBMC’s participation in this network is one measure of our commitment to quality of care.


Some GBMC highlights of the VON report:

- Our mortality for infants 501-1500 grams was 7.4% compared with 12% for the Network.  We have had a declining trend in mortality from 2009-2013.

- Our use of surfactant, a drug to help expand immature lungs, was 27.8% compared with 59.3% in the Network.  We were in the lowest quartile for use since we began using early nasal continuous positive airway pressure (CPAP) and avoiding mechanical ventilation as an approach of minimizing lung injury and chronic lung disease.

- Our use of any mechanical ventilation was 45.3% compared with 59.8% in the Network, also in the lowest quartile.

- Our incidence of chronic lung disease in infants < 33 weeks of gestation (full term is 40 weeks) was 17.8% compared with 25.7% for the Network.

- We had no cases of severe intraventricular (brain) hemorrhage compared with 7.9% for the Network.

- We had 5 cases of late infection (9.4%) compared with 12% for the Network. This trend continues to improve.

- Our incidence of severe retinopathy of prematurity was 2.2% compared with the Network's 5.8%.

- 80% of our babies were discharged feeding human milk versus 55.8% in the Network. We were in the top quartile!

- No infant above 750 grams or 26 weeks gestation was discharged home on oxygen. 

Together with Eva Stone, RN, the NICU nurse manager, Dr. Birenbaum leads a very talented, dedicated, and extremely hard working team of physicians, nurses, respiratory therapists, pharmacists, nursing support technicians, nutritionists, and other technicians, therapists and support personnel. We and our patients and their families are blessed to have such an outstanding team and the data prove it! So when you see any member of this team, please thank them for all that they do in moving us closer to our vision.

Tuesday, August 19, 2014

How can patients compare one hospital or system of care to another?

Much has been made of the need for “consumerism” in health care.  Many people believe that a big reason why the U.S. spends so much more than other countries on healthcare without better outcomes than countries that spend far less is because the consumer has been taken out of the equation.  Certain people believe that if the patient only had good information about the quality and cost of their care that the cost would go down. 

Recently, the annual hospital rankings of U.S. News and World Report were released. One should ask himself or herself what the rankings are based on. Do the rankings show that the highest rated hospitals provide the best value for the money spent? Or at least do the highest ranked organizations provide the best health outcomes and the best patient experience even if the price is much higher? If you take the hospitals mentioned in the rankings and examine their actual clinical outcomes and patient satisfaction scores and divide that by the prices that these hospitals charge for those services, you could come up with a value that an educated consumer could use in deciding where to receive their care. 

As has been mentioned before in this blog, The Department of Health and Human Services has created a website where patients can compare the performance of hospitals on many parameters. The website is www.medicare.gov/hospitalcompare.  At this site, a consumer can find comparative hospital data on clinical outcomes such as mortality rates after certain procedures, patient satisfaction scores, and many process measures of care and some outcome data beyond mortality rates for certain disease states.  What you will find, surprisingly is that hospitals that are ranked high, in various high profile national assessments, do not perform any better than hospitals that are ranked lower in the same mass media evaluations. You will also find that many of the highly ranked organizations are among the nation’s most expensive hospitals even if their outcomes are not any better than many less costly institutions. 

What our citizen’s should be desperate for is true and meaningful comparative data so that a patient can rationally choose where they would want to go for elective care.  That is why since early 2013, the GBMC Healthcare System has displayed many of our quality parameters at www.gbmc.org/quality and updated them monthly. Currently, we are the only local community health system doing this and very few others do it nationally. Maryland consumers also know that our rates are set by an independent agency and that agency’s website lists the hospital rates and although the data are somewhat cumbersome to navigate, an educated consumer could use the data to compare value between providers. 

When more of our citizens truly examine outcomes and cost data this will further incentivize healthcare leaders to improve care and drive the waste out of the system and care will be better, faster. Patients will then truly be able to see which hospital or community health system is the best because the rankings were based on the facts.

If it were your loved one seeking the answer to the “who is the best?” question, you would want him or her to be able to find the data to reach the correct conclusion.  Have you had an experience in trying to decide who was the best provider for a loved one?

Tuesday, August 5, 2014

Smaller is Often Better

Every couple of weeks someone will ask me when we are going to be acquired by or merge with a larger company. This question always frustrates me. That’s because I think we have communicated often that our Board would prefer that we maintain our “independence” (no healthcare provider is really independent) so that we can fulfill our mission and move toward our vision as a true community based system of care through the eyes of the patient.

However, I know that this question is a very honest one and is almost always coming from someone who accepts that bigger is better. While it is true that bigger companies often have more assets and can weather storms better than smaller organizations, in healthcare in our local market some of the companies actually have less flexibility because they have such high debt relative to their assets. 

But finances aside, is bigger always better? I have recently finished reading Small Giants: Companies that Choose to be Great Instead of Big by Bo Burlingham. Mr. Burlingham studied 14 companies who decided that rather than getting as big as possible as fast as possible that they would focus on becoming the best at what they do. The group did not include a lot of household names but did include companies like Clif Bar and Company, a leading maker of energy bars and other foods; Anchor Brewing, the original American microbrewery; and Zingerman’s Community of Businesses, the company that includes the world-famous Zingerman’s Delicatessen in Ann Arbor, Michigan. All 14 companies have had many opportunities to be bought out, to merge, to expand quickly or to otherwise grow fast. Instead, they decided to stay focused on their mission. Their collective vision was to continually make their products better and delight those they were serving. 

Mr. Burlingham found seven threads that ran across all 14 companies. First, the leaders of these companies recognized the full range of choices they had about the types of companies they could create. They hadn't just accepted the belief that they had to get big to survive. Second, they had overcome the pressure to take paths they had not chosen and did not necessarily want to follow. Third, the companies had an extraordinarily intimate relationship with the local community in which it did business. Fourth, the companies built exceptionally intimate relationships with customers and suppliers. Fifth, the companies had unusually intimate workplaces that were little societies that addressed a broad range of their employees needs as human beings. Sixth, they had developed a variety of corporate structures that gave them the freedom to develop their own management systems and practices. And seventh, their leaders had a passion for what their company did. 

I am sure that Mr. Burlingham would be the first to say that very big companies could also do a lot of these things but it would be (and is) much harder. 

Reading Small Giants caused me to reflect on how GBMC HealthCare is doing across these seven elements. I think our Board and our senior team clearly recognize what our choices are and have consciously chosen to stay focused on continually improving our healthcare product. We are frequently “courted” and have resisted the temptation to merge. This does not mean that we don’t understand that we can’t do it all alone and that we don’t value the gift of working with outstanding partners - we do. 

GBMC has an excellent relationship with the community and we are working to grow it even stronger as we reach out during our 50th Anniversary celebration. We have good relationships with our patients (see the Alexis Watkins video in this blog for an example) and we are working to make them better one at a time. We do well with our suppliers, although I am sure that we have room for improvement in this area. We are consciously working to make GBMC a better place for our employees and our private practicing physicians, although again, we can do better. Lean Daily Management is an example of a management practice that we have committed a large amount of our time to that would not necessarily be possible if we were just one hospital in a large company. And lastly, I think that most GBMC leaders are showing the passion for achieving our vision. 

I would love to hear your thoughts. Do you agree that smaller can be better?

P.S. In case you think that I only read management books, I just finished reading Tatiana, the most recent in Martin Smith Cruz’s Arkady Renko series. Renko is a detective in post-Soviet Russia. For those of you who like suspense and intrigue, Tatiana (and the rest of the series for that matter) is a page-turner.   
 
 

Monday, July 28, 2014

Excitement about Change and Improved Outcomes

I started my day on Friday at the Partnership for Patients leadership team meeting. Cathy Hamel, our Vice President for Post Acute Care and Cate O’Connor Devlin, our Administrative Director for Nursing Patient Safety and Bed Flow lead this team and they have done phenomenal things! Partnership for Patients is a collaborative effort sponsored by the Centers for Medicare and Medicaid Services to get hospitals to learn from each other to improve care. Our P for P team has overseen the creation of more reliable care that has significantly reduced pressure ulcers, patient falls, catheter associated urinary tract infections, and surgical site infections, among other things. I sat at this meeting so proud to be involved with this outstanding group of leaders who are delighted to be in action and moving us toward our vision.

I asked the Team what I could do to make their work go even faster and they really struggled to come up with anything. They did say that they want my support as they are studying adding hand wipes for patients to help us reduce our hospital acquired infection rates even further. These wipes will add an expense to the budget and they are searching for the best, most cost-effective product. Otherwise, they didn’t need my help…and that is the way that it should be!

Sometimes things don’t go as well. I had a couple of interactions last week where local leaders were struggling to get something “fixed” when it involved more than one department. I encountered a couple of very frustrated individuals who were pushing problems up the chain of command and were accepting answers from colleagues that, in my mind, were unacceptable instead of calmly and respectfully working on the solution.

Hierarchy Vs. Bureaucracy

The larger an organization is, the greater the tendency to have multiple levels of authority. Everyone gets it that someone has to be ultimately responsible for the organization. These multiple levels of accountability are called hierarchy. The Merriam Webster dictionary defines this as Hierarchy (noun): A system in which people are placed in a series of levels with different importance or status.

A hierarchy becomes part of the problem when the levels require non-value added communication or when it leaves people lower in the hierarchy with the impression that they have no power to change or fix things. They then wait for someone above them to fix problems for them. Or even worse, hierarchies can leave the option for silos to be obstructive to change, waiting for the leader above multiple silos to step in and get through an impasse.

When the hierarchy becomes an impediment, it is then a bureaucracy.  The Merriam Webster dictionary defines this term as: Bureaucracy (noun): A system of government or business that has many complicated rules and ways of doing things; a system of administration marked by officialism and red tape.
 
The leaders of the P for P Team are working beautifully across boundaries. They are making offers to and requests of each other continually and they are creating meaningful change. They are never going to their bosses unless there is a barrier that they cannot overcome. We need more of this. The larger an organization becomes, the more managers it needs (hierarchy), the harder it is to keep everyone on the same page and have all line managers feeling like they have the power to generate change.

And, in large, complex organizations with many departments often spread over vast areas, there is a temptation to not work manager to manager and push problems up the hierarchy. (Yesterday, a manager thanked me for getting a problem fixed when he had been given a silly answer as to why the problem couldn't be fixed. I felt really bad that I had to intervene.)

Here is a great example of managers working together across departments to identify a problem, create a plan for a solution and obtain great results:


  • When U45 went through an expansion in December 2012, it created two sides – Unit 45A and 45B. The staff quickly realized that the new U45B was not a mirror of 45A including the supply set-up. They quickly found that U45B did not have the general supplies readily available to them and staff was continually going back and forth from one side to the other just to find supplies and equipment needed to provide patient care. Nurse manager Eileen Skaarer recognized that the staff was becoming increasingly frustrated and decided to put metrics in place that provided incredible data – U45B had up to 30 missing pieces of supplies and equipment every day, causing staff to constantly have to search for the tools needed to provide care.

    Armed with this significant information Eileen and her team, along with Jim Duerr, Director of Materials Management, and his team, developed a solution to the supply problem on her unit. An Omni Cell and bulk cart storage that mirrored the existing supply storage on U45A was put into place on 45B. The result? According to Eileen, her team is now only searching for one or maybe two missing pieces of equipment/supplies per day compared to close to 30 missing items per day before the two department leaders took action to find the right solution. 


"It's Your Right to Fix What's Not Working..."

As managers and leaders in the organization, it is your right to question decisions or answers that don’t make sense; it’s your right and obligation to work together with other department managers in a calm, respectful yet direct way to fix things that aren't working for the benefit of our patients.

Do not accept what doesn't make sense. Get in action, work together, and cut across silos. Find appropriate solutions to work across departmental lines to fix what is not working and improve things.

Communicate openly and directly. Like the process owners on the P for P Team and Eileen and Jim, take ownership and get in action testing change. And only when the plan isn't being worked by both managers should you escalate it up the chain of command.

I am very grateful for everything that our leaders are doing to get the outstanding improvement that we are seeing. Please keep it up!

Friday, July 18, 2014

Summer Heat and Storms, an Unreliable Electric Grid, and Resilience

GBMC has once again shown its ability to rise above adversity and meet its mission over the last few weeks. The summer has brought high temperatures, thunderstorms and our local electric grid has not been able to supply GBMC with a reliable flow of electricity. We had three significant events where our campus had power interruptions.  During the most recent event with the added dilemma of an electrical storm, lightning struck one of our main feeders causing a power interruption.   Approximately one hour later, the second feeder on to our campus was incapacitated.  Power was then restored 45 minutes later. St. Joseph’s was also affected by this event.

The good news is, over the past few years GBMC has installed three new emergency generators so that we do not go without power. The bad news is these generators do not backup everything.  Our priorities for emergency power include: life support devices, emergency lighting, fire protection systems, patient communications devices, critical computer systems and clinical equipment. Our chilling system, which among other things cools the air in our buildings, is not connected to emergency power. So, when the power goes down, the chillers shut off. The fans continue to run as they must for ventilation and pressurization, but they are then pulling high humidity air from the outside into the building, thereby increasing the internal humidity.

Our operating rooms and our surgical instruments must stay within a narrow band of humidity to keep them sterile. During the summer, with high external humidity, the chillers keep the internal air within acceptable temperature and humidity levels. But when the chillers go down, the humidity can quickly get too high, and the rooms need to be re-cleaned and the surgical instruments need to be re-sterilized. There is a renewed emphasis on humidity and temperature control by CMS/Joint Commission to prevent healthcare acquired infections.  We can clean the operating rooms fairly quickly but it takes many hours to re-sterilize all surgical instruments.  For this reason, GBMC has had to delay or cancel many operations during these events.

I want to thank all of our staff who have risen to the occasion over the past few weeks to help us get things back in order. Our operating room nurses, technicians, central sterile staff, anesthesiologists, administrators and environmental service workers have done an outstanding job under very difficult conditions. I want to also thank our surgeons for understanding the problem and for having done everything to get their patients what they need.

Our management team has realized that we did not have the emergency designs in place to communicate well with our patients, our surgeons, and the rest of the GBMC team. I apologize to all for this. Over the past few weeks we have learned from each event and we have developed better systems of communication, but we need to do even better - and we will.

As for preventing future events, we are working with vendors to see if we can install emergency air conditioners that we can connect to the generators to better protect our sterile supplies.  We are also exploring back-up systems and emergency power connections for our Sterilizers. The long range fix is to connect the chillers to the emergency power. This is a very expensive proposition and will take a significant amount of time, but we are presently studying this with our engineers.

GBMC is an excellent healthcare system and we will grow stronger as we learn from these events and make the required changes. Thanks to everyone who is helping us.