Friday, January 20, 2017

Do we ask the patient: “What matters to you?”

Recently, I was having a conversation with a friend about the care of his elderly relative. My friend was a bit annoyed that his relative was not following all of the advice of his physicians. My friend obviously loved his family member and was really concerned about his health. He told me that he had had a frank conversation with this loved one and that if he did not follow all of the advice of the physicians, that he “was done.” By this, my friend meant that he would not be as attentive when his loved one called for help.

I asked my friend if he had asked his relative what mattered to him. My friend looked perplexed at my question. People are used to following their doctors’ recommendations, as they should be, but is following every well-intentioned recommendation really the “bottom line?” Shouldn’t we start any conversation about a plan for people with chronic disease, especially those towards the end of life, by asking “What matters to you?”

In my friend’s example, he was most annoyed by his loved ones’ dietary indiscretions. Well, the loved one was already frail and eating his favorite things was one of the few pleasures he had left. So eating what he liked, meant more to him than possibly shortening his life by a few days or hours.

Maureen Bisognano, the former president of the Institute for Healthcare Improvement (IHI), first began encouraging clinicians to change the question to the patient from “what is the matter with you?” to “what matters to you?” The ultimate decision about diagnostic tests or therapies lies with the patient, not the physician. The role of the physician, or advanced practitioner, is to lay out the choices along with the evidence as to their efficacy. Knowing matters most to the patient will help guide the dialogue between the provider and the patient and has a better chance of resulting in a plan that the patient will actually adhere to.

At GBMC we have learned a lot through our study of people who leave our hospital “against medical advice,” in other words leaving when we think they need to stay for some diagnostic procedure or therapy. We have met patients who leave rather than get fired from their job and patients who leave rather than miss a family celebration. Knowing what matters most to the patient may not change our primary recommendation, but it may get us to a common ground that ends up in a better plan.

So, let’s work to make the conversation about “What matters to you?” to be part of our standard work with people with chronic disease. What do you think about this? Please give me your thoughts.
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Helpful links to IHI and “what matters to you?”
http://www.ihi.org/Topics/WhatMatters/Pages/default.aspx

http://www.ihi.org/resources/Pages/AudioandVideo/WIHIWhatMatters.aspx

http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&ID=185&utm_campaign=tw&utm_source=hs_email&utm_medium=email&utm_content=29625149&_hsenc=p2ANqtz-8ua6m2Zfez7vKnAdeilcr7UOR4fLgWWfTZjEesoPO2aQ4DQQ6V_RB7EJwwiEu7oLy2FUEyoSPuALf-Owm6gOfHACls9B6uWQB6BhhuCDQAElnUjLQ&_hsmi=29625149

Friday, January 13, 2017

Remembering a Man of Peaceful Discourse, Learning and Reflection

Earlier today, GBMC hosted its 3rd annual Martin Luther King Jr. Day celebration which commemorated Dr. King’s life and vision. This year’s program, titled “Hear My Voice, Engage My Soul,” featured a keynote presentation by the Rev. Dr. Tim Tooten, who is also the education reporter at WBAL-TV, along with live music from the Cristo Rey Choir. I would like to begin my blog post with my introductory remarks from the celebration.

Have you watched television talk shows recently where the participants take turns shouting over each other? This is why they are called talk shows. Have you heard of television shows that are called “hear” shows or “listen” shows? I have not. We may only have talk shows because our society is full of people who “know” and want to “tell”.

I believe that our difficulty listening to and hearing others is one of the main reasons why we have such huge divides between groups of people today whether the line of demarcation is race, religion, income level, or rural vs urban habitat. Those who would divide us continue to talk without hearing.

Men and Women of good will must stop listening to their own voices and hear the voice of others. This is a message of Dr. King that we must take time to listen to what others are saying in order to understand and engage them to improve their lives and our own and improve our communities. We at GBMC must work hard to assure that all of our voices are heard, that we engage everyone and that everyone feels included.

I am grateful to Jennifer Marana, our new Director of Diversity and Inclusion and all of my colleagues on the Diversity and Inclusion Council for helping to drive us closer together. United, we can achieve our vision of being the healthcare system where everyone, every time is treated the way we want our own loved ones treated. If we don’t hear each other and engage each other we have no hope of achieving this lofty goal.

I want to thank Dr. Tooten, members of the Cristo Rey Choir and our Black History Month committee that put together today’s magnificent celebration!

How much can anyone “know” if they are only listening to their own voice?  Dr. King was a well-read man who knew the importance of gathering information and reflecting on it prior to speaking and of the importance of hearing the voice of others. Let us all remember this as we move towards our vision at GBMC and we move into the next chapter in the leadership of our country.



Friday, January 6, 2017

A New Year’s Resolution

No reader of this blog will be surprised to hear that I have been a bit concerned lately about maintaining the gains that we, in the GBMC HealthCare System, and others across our nation have made towards the national triple aim of better health, better care, and lower costs.

Since the passage of the Affordable Care Act (ACA), also affectionately known as Obamacare, our nations’ hospitals, physicians, nurses and the rest of the healthcare team have generated significant improvements in our care. Medicare has seen the smallest annual cost increases in its history. Employers, like GBMC, have also seen annual health care cost increases barely above the rate of inflation in the overall economy. Much of this has been stimulated by the ACA and the agency it created: The Centers for Medicare and Medicaid Innovation. Millions of Americans who did not have insurance before passage of the ACA now do and people who have significant illness, so-called “pre-existing conditions” can now get insurance when before they could not. Adult children can stay on their parent’s insurance plans, until the age of 26, when before they could not be covered after the age of 22. Insurance companies must spend at least 85 cents of the premium dollar on care and limiting the administrative costs and profit to 15 percent when before there was no such requirement. Now, if they spend on administration or have as profit more than 15 percent, they must return the difference it to the purchaser of the insurance. The concern that the ACA would be a “job killer” has proven not to be true. The unemployment rate is now much lower than it was at the time of the passage of the ACA.

It is sad that the part of the ACA that is not working well, the sale of individual policies to people who don’t qualify for the government subsidies, is the only part that is getting much “air time.” The price of these policies has gone up significantly because the “individual mandate” is not working. Too many healthy people are not buying the coverage leaving only the sick people in the pool thereby driving the cost up and making it likely that more people will stop buying the coverage.

The wonderful thing about the triple aim is that it transcends politics. I have not met anyone, Republican, Democrat or Independent that does not want better health and better care at lower cost. So, we in the GBMC HealthCare System must put the rhetoric aside, ignore the distractions and redouble our efforts towards our vision phrase: to every patient, every time, we will provide the care we would want for our own loved ones. What we want for our own loved ones is: we want them to get better; we want them to have the best care experience; we don’t want their resources wasted and we want them to know that we get it that it is a gift to serve them and this is a joyful pursuit.

So please join me in a resolution for 2017: The GBMC HealthCare Family resolves, in the New Year, to rise above all distractions and bring more joy to each other and our patients as we move faster towards the national triple aim.

If you would like to share your personal new year’s resolution, or goal, that you’ve set aside for this year, please go to https://gbmc.formstack.com/forms/new_years_resolutions to share.

Thursday, December 29, 2016

2016: Another Year of Accomplishments for the GBMC HealthCare System

It’s hard to believe that another year is ending. As we get ready to make our resolutions for 2017, it’s good to take a moment and reflect on how well we moved closer to our vision in 2016.

Here are some of our accomplishments during 2016:

--2016 The Year of The Nurse…In 2016, we formally celebrated our incredible nurses and all that they give to GBMC and our patients. The culminating event was the spectacular Art of Nursing affair.  This was a festive occasion and a great opportunity to thank all of our nurses and to have some fun! A month later, thanks to the 30-minute TV special, “The Art of Nursing, which aired on ABC2 Baltimore, we got a glimpse into the lives of our nurses who make caring, comforting and providing kindness to their patients their life’s work. The special reconfirmed for me that our health system is truly blessed to have phenomenal nurses in our inpatient units, in our operating suites, in our outpatient areas, our physician practices, and in our hospice. Again, I am very proud of all of them and honored to call them my colleagues!

--The GBMC HealthCare System was honored with the inaugural American Society for Healthcare Risk Management (ASHRM) Patient Safety Award. We were selected from many applicants nationwide for our use of Lean Daily Management to improve health outcomes for patients and reduce preventable harm such as infections, falls with injury and hospital-acquired pressure ulcers. Receiving this recognition from an external authority, like ASHRM, is a substantial confirmation of the work we're doing to move us towards our quadruple aim.

--GBMC Goes Epic…On Oct. 1, we flipped the switch and Epic went live. While things are not perfect, Epic is running smoothly and patients now have only one record at GBMC. No longer do patients have multiple allergy lists with the inherent danger of this. So many people worked so hard to make this happen. It is now easier to have all of the patient’s information present when we are serving them.

We implemented simultaneously more modules than all of the other local hospitals, and there is clearly more work to be done. Stay tuned as we optimize the system over the months and years to come!

--Breaking A World Record… GBMC Healthcare set the Guinness World Record for the longest cancer awareness ribbon measuring 7,593 feet and 1 inch – more than 1.5 miles – during the 16th annual running of the Legacy Chase steeplechase event. The lavender ribbon is a symbol of GBMC’s commitment to continually reduce the scourge of cancer. Beyond breaking the record, this year’s event was a huge success. The annual event benefited GBMC’s oncology support services at the Sandra and Malcolm Berman Cancer Institute. The event would not have been successful without the support of our loyal volunteers. I thank all those who attended and all those who donated time or treasure.

Some of our other achievements in 2016 included:

--TOP DOCS 2016!..Dr. Melissa Sparrow, our first female chief of staff, was the physician on the cover of this year’s Baltimore Magazine Top Docs issue. I would also like to commend Dr. Neal Friedlander, chairman of the Department of Medicine, who was selected to be one of only seven doctors profiled in the issue, chosen from more than 680 doctors who were nominated for the honor. More than 120 Greater Baltimore Medical Center (GBMC) physicians, in 74 unique specialties, were also named in the issue. Once again, we had more physicians recognized than any other community health system in the region! We are so fortunate to have outstanding surgeons, internists, pediatricians, family physicians, and other wonderful specialists.  Congratulations to both Dr. Sparrow and Dr. Friedlander for their achievements as well as all others who were named 2016 Top Docs.

--Baltimore Magazine released a second list of exceptional medical providers, recognizing 50 of the region’s top nurses for their extraordinary contributions to healthcare. The 2016 “Excellence in Nursing” issue featured SIX GBMC HealthCare nurses among the 50 awardees! Having our nurses represented on this list is evidence of what we already knew – our HealthCare system has the best nurses!

--GBMC HealthCare added three new Physician Titans of Care: Rudiger Breitenecker, MD; John E. Savage, MD; Claire Weitz, MD.  Their outstanding skills, service, commitment, and instrumental roles have helped expand GBMC HealthCare’s reputation in our community and beyond.

--Our maternity care staff received the Blue Distinction Center+ for Maternity Care designation, a new designation under the Blue Distinction Specialty Care program.  Blue Distinction Centers+ for Maternity Care, an expansion of the national Blue Distinction Specialty Care program, is awarded to hospitals recognized for delivering quality, cost-effective specialty care safely and effectively, based on objective measures developed with input from the medical community.

--Our SAFE program received its share of accolades in 2016.  Colleen Moore, our Domestic Violence Coordinator, recently won a Governor’s Award for Excellent Victim Services, Laura Clary, RN, FNE-A/P, SANE-A, CFN, CPEN, clinical manager of our SAFE program, was recently awarded the Henry Gleim Memorial Award by the Governor’s Maryland State Board of Victim Services. The award recognizes her outstanding contribution to the field of victim services and for her work in the area of victim advocacy, and our program was also awarded a Citation from the Maryland General Assembly for excellent services provided to the citizens of Baltimore County.

--I was so pleased that in 2016 GBMC hosted our first Walk a Mile in Her Shoes®:  The International Men’s March to Stop Rape, Sexual Assault & Gender Violence. The one-mile event, in which men (wearing heels) and women (wearing tennis shoes) walked together, was a way to educate the community and support our SAFE and domestic violence programs. I was so grateful for the more than 300 participants who helped us raise over $30,000 and allowed GBMC to continue providing necessary services to women across the community.

--Our Comprehensive Obesity Management Program (COMP) achieved certification for weight loss surgery under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) which sets standards for safe, high-quality bariatric patient care.  To earn the MBSAQIP designation, GBMC’s COMP program met essential criteria for staffing, training and facility infrastructure and protocols for care, ensuring its ability to support patients with severe obesity. Currently, there are more than 700 centers in the country that hold this accreditation. Congrats again to COMP for this great accomplishment!

--In 2016, GBMC was again recognized as a leader in Lesbian, Gay, Bisexual, Transgender (LGBT) healthcare equality by the Healthcare Equality Index (HEI). This acknowledgment reinforces GBMC’s strides in HEI’s stringent core four leader criteria: Patient Non-Discrimination; Equal Visitation; Employment Non-Discrimination; Training in LGBT Patient-Centered Care. We are proud to have met the criteria and sub-criteria in all four categories!

--Our care management team in the hospital, at Gilchrist Hospice, and in our patient-centered medical homes won a few awards at Decision Health’s 8th Annual Care Coordination Summit.  The summit showcases new models of care and innovative processes that are transforming the healthcare system leading to improved patient outcomes and appropriate use of healthcare resources.

--In June, the hospital started using the Patient¬-Centered Care Team (PaCT) model of care. This is a collaborative model between physicians, nurses and other clinicians that makes it easier for us to stay focused on the patient. We have made telemetry available on most units to eliminate unnecessary patient transfers; physicians and case managers are now located on a single unit; multidisciplinary rounds include all members of the care team, and medical directors and their partner nurse managers are now accountable for the care on each unit and for achieving our four aims.

--Gilchrist Hospice received their CHAP (Community Healthcare Accreditation Partner) accreditation. Gilchrist is the best hospice anywhere, period. Cathy Hamel and her team are exemplars in healthcare management.

--Dr. Albert Blumberg and his wife, Beth, in a magnanimous gesture of gratitude, established the Beth and Albert Blumberg Radiation Oncology Staff Development Fund. For over 30 years, Dr. Blumberg has cared for patients at GBMC.  This wonderful gift is one way that the Blumbergs have decided to say, “Thank you!” to the Radiation Oncology staff who have made possible the department’s and Dr. Blumberg’s success in delivering life-saving treatment.

--This year, unfortunately, we said goodbye to Darin Lerner, MD, our former Chair of Psychiatry. Darin’s hard work and marvelous devotion to his patients made him such a trusted healer, friend, colleague, and teacher.  We also felt the loss of our good friend Joseph Keelty. Joe gave so much to the GBMC community and was a force in giving of his time, talent and treasure to both Gilchrist Services and our hospital. There is no doubt that we lost someone who was very special and a great friend to GBMC. We will always be thankful for what Joe did for GBMC and we are truly going to miss him.

--Approximately 900 participants spent part of their Father’s Day with GBMC and helped raise approximately $140,000 at the Father’s Day 5K. In 28 years, the 5K has raised close to $2 million for critically ill and premature babies.  More than 100 weight loss patients from our Comprehensive Obesity Management Program completed their first Father's Day 5K.  We had twins and 2007 NICU grads, Cody and Selena Staab, raise money for the NICU by selling their bracelets during the Father’s Day 5K.

--During this year’s Baltimore Running Festival approximately 100 runners joined team #RunGBMC to raise funds in support of Gilchrist Center Baltimore – the Joseph Richey House. The 19-bed inpatient center has been serving patients in Baltimore City for more than 30 years by providing residential, acute and respite care. We raised more than our $50,000 goal. I’m very grateful to all of the employees, volunteers, patients and supporters of GBMC Healthcare who helped us raise money and awareness of the outstanding work at the Joseph Richey House.

--Our Night at “The Yard"..Many of our employees attended our first GBMC Employee Night at Camden Yards.  It was nice to see so many of our people come out and have fun with their colleagues. And yes, the Orioles victory that night added more joy to an already festive event.

--For the first time ever, GBMC celebrated "Random Acts of Kindness Week.” These actions were spearheaded by the BeKind Brigade, comprised of GBMC staff from various departments, who randomly chose a certain hour on a selected date, to walk around the medical center and conduct random acts of goodwill.  In addition, GBMC delivered over 1,200 lbs. of non-perishable food to the Bea Gaddy Family Center for families in need. Thanks again to everyone who helped with this endeavor.

--GBMC Teamed up again with WMAR-TV to collect hundreds of toys for the 18th annual “It’s Kindertime Toy Drive.” Thank-you to all the hundreds of employees and their families along with the many donors who helped contribute to the toy drive.

--Our fantastic volunteer auxiliary again contributed thousands of hours of service and tremendous success in fundraising through our Nearly New sales.

The evidence is clear. GBMC HealthCare made great progress towards our vision in 2016! We have many, many people to thank for this. Our doctors, our nurses, other clinicians, and all of our non-clinical employees have done a fabulous job. And lastly, we must thank our patients – you are the reason we do what we do. We are honored and grateful that you have chosen GBMC for your care.

I realize that these things only represent a small fraction of what the GBMC family did in 2016 to move us closer to our vision. What others do you want to mention? Please share your thoughts below.

Best wishes to you and your loved ones for a Happy & Healthy 2017!

THANK YOU…Today we experienced a critical power failure to our data center in the North Pavilion that then caused our computer systems to shut down for hours.  We will take steps to assure that this cannot happen again. I want to thank all of our people who worked so hard under downtime procedures to care for our patients. I also want to thank Dave Hynson, GBMC’s Chief Information Officer, and his team, for all their hard work in addressing the issues and getting us back to normal operations as quickly as possible. I also want to express my gratitude to all members of our Incident Command Team.

Friday, December 23, 2016

Peace on Earth – Good Will to Men

It is very impressive how at the holiday season there are a few more smiles in the corridors of GBMC. We still deal with pain and the sadness that comes with illness and loss, but people’s spirits are raised as they focus on celebrating and gift –giving. In the executive office, we had our annual visit from Santa Dr. Gary Cohen and his elves from the Cancer Center and they brought joy to our day. Well wishes abound from staff members to other staff members and to patients and families.

With all of the meanness and evil that is evident in our world, we must make this time of year, especially this year, an opportunity to exhibit good will to all men and women and to have the spirit of giving lessen each other’s burden.

On behalf of the organization, I want to extend best wishes for a safe, healthy and happy holiday season for those celebrating Christmas, Kwanzaa or Hanukkah.  Enjoy your time with family members and think about the things that are important in your lives.  For those staff members working during the holidays, a special “thank you” for taking care of those who aren’t able to be at home during the holiday season. I am blessed to work with all in the GBMC family and I am very grateful for this.

THANK YOU!
This year GBMC had the privilege of teaming up with WMAR Baltimore to collect toys and donations for the 18th annual “It’s Kindertime Toy Drive.” 

Over the last three weeks, many of you have donated gifts at various drop-off boxes in our main GBMC Hospital campus and at each of our 10 primary care offices. To help promote the toy drive, people who donated towards the cause were entered into a raffle to win either two (2) pre-screening tickets to Star Wars; Rogue One, a BB-8 Talking Figure or a Star Wars Legendary Jedi Master Yoda Figure.

I just want to thank the hundreds of employees and their families along with the many donors who helped contribute to the toy drive. The toys were distributed, by ABC2, to children and families living on the Eastern Shore, Baltimore City, Baltimore, Carroll, Cecil, Harford, Howard and Anne Arundel Counties, and at the Ronald McDonald House and Kennedy Krieger.

Again, I am very grateful to Nick Travelstead, committee chair for our Father’s Day 5K, who provided us with a group of his employees to load one of his vehicles to transport all the toys to WMAR-TV, and our Marketing Department who ran the drive for us. It is outstanding to see so many people give back during the holidays.


Thursday, December 15, 2016

A Letter from a Patient



December 9, 2016

Dear Dr. Chessare:
From Dec. 1 to Dec. 4, I was a patient in Unit 38 – Telemetry. This was not my first experience with GBMC, but it was a most pleasant experience at a stressful time because of the caring and attentive service provided by the nursing and tech staff.

I apologize to anyone I omit but these are the names I remember: 
NURSES: John, Kathleen, Shu, Brittni, and Rebecca (student nurse from Stevenson U).
TECHS: David, Tamika, Sade, Andrea and Amy. 

Not once did I have to wait more than a minute for someone to come assist me to and from the bathroom. Believe me when I say I have waited longer in other hospitals and units for someone to even answer the “bell.”

Most of all, I am extremely impressed with Hospitalist Dr. Carolyn O’Connor. What an asset to GBMC! Besides being competent, Dr. O’Connor offered clear, understandable explanations as to the findings of tests given. She had a caring attitude, didn’t rush and always followed through with whatever she said or advised. 

Please commend these caregivers and thank them for me. 

--Signed by a grateful patient. 

Does this sound like the care that you would want for your loved one? Expert, timely, caring and considerate. Always there when the patient needed help. Explained things in a way that the patient could understand. This is clearly what I would want for my loved one!

I am in awe of Dr. O’Connor, John Livingston RN, Kathleen Meade RN, Shu Zhang RN, Brittni Riemer RN, Tamika Parker NST, Sade Hunter NST, Andrea Sylvester NST and Amy Meiser NST.

I know how hard their work is and I am very, very grateful to them for not forgetting why they do what they do. The Unit 38 team is moving us closer to our vision.

Speaking of teamwork, it’s important that we share the stories of our success.

In September, GBMC HealthCare was honored with the inaugural American Society for Healthcare Risk Management (ASHRM) Patient Safety Award for our organizational efforts to improve care by utilizing Lean Daily Management (LDM). We were selected from many applicants nationwide for making care safer by reducing preventable harm such as infections, falls with injury and hospital-acquired pressure ulcers.

Since we started LDM, we have seen a significant reduction in not only patient harm but employee injuries as well. We have also used this technique to reduce waste and improve patient satisfaction. We measure our progress towards achieving our vision by our results in each of our four aims of Better Health, Better Care, Least Waste and Most Joy for those providing care. Receiving this recognition from a national organization, like ASHRM, is a validation of the work of our dedicated staff members.

So, earlier this week during hospital LDM rounds, members of leadership presented each unit and department with an ASHRM certificate as a way to highlight our accomplishment and to thank everyone for making this possible. We should all be very proud of our achievements in improving care.

Please Donate A Toy For The Holidays
Again this year, we are a proud sponsor of the Kindertime Toy Drive! Annually, toys collected for the Kindertime Toy Drive are given to children at the Ronald McDonald House and Kennedy Krieger as well as children in need in the Baltimore area. Please don’t forget to donate a new, unwrapped toy at any GBMC drop-off location.You have until 5 PM on MONDAY, DEC. 19! Remember, that if you donate a toy you can enter for a chance to win either two (2) tickets to Star Wars; Rogue One, a BB-8 Talking Figure or a Star Wars Legendary Jedi Master Yoda Figure. To be entered into the raffle after donating a toy, visit:
https://gbmc.formstack.com/forms/toydrive_2016. If you’ve already donated a toy, you're also eligible to enter into the raffle via the same link!

The prize drawing will be held on TUESDAY, DEC. 20. For more information, please visit www.gbmc.org/toydrive

Holiday Spirit
I hope that many of you enjoyed the food and company at yesterday’s annual Employee Holiday Meal. This is a hospital tradition that draws a big crowd every year and I was happy to see many of you enjoy the event. Music also filled the air at the holiday meals as members of the GBMC Holiday Choir put on a wonderful lunch-time concert as usual.Thanks to all who did their part to make sure this year’s event was a success and I wish you all Happy Holidays!

Monday, December 12, 2016

Let’s Stop Doing Some Things

On a bad day, it appears that some people think that improvement always requires more steps. If we didn’t ask the nurse to add this click or that phone call then we couldn’t have possibly made it better. GBMC has phenomenal people who work very hard and are very well intentioned, but leaders need to be sure that the standard work is all necessary to help us get to our vision. If not, we will just overwhelm and frustrate our people.

So this week, when I learned of some tasks that we have not eliminated, like faxing reports to people who are already getting them through our new electronic medical record, I realized that we still have work to do in driving waste out of our system.

I watched the Art of Nursing television show this week. What a marvelous tribute to our nurses and their commitment to our patients! As I heard of all the things that our nurses were doing that really do help our patients, I realized that it is my job to make sure that we unburden them of tasks that don’t really help.



The Institute of Healthcare Improvement (IHI) National Forum

Some members of the GBMC Team attended the IHI National Forum this week. Lisa Griffee and Caroline Candiello presented some of our work in Lean Daily Management and in “breaking rules” that don’t really add value to our patients and their families. It made me very proud of all that we have done to improve care and move towards our vision. All of our attendees, including myself, learned a lot from other organizations as well.