Tuesday, April 22, 2014

The Cost of the Misuse of Prescription Drugs

The ever increasing cost of pharmaceuticals is a major driver of the American healthcare crisis. At GBMC, the cost of pharmaceuticals for our employees has gone up by 13% this year. We see drug expenses rising for many reasons. We are all willing to pay more for drugs that truly generate better health. But what about paying significant amounts of money for drugs that really don’t, or paying for drugs when they actually cause harm?

I am a pediatrician and a fellow of the American Academy of Pediatrics. Last week, I received an alert from the Academy that got my attention. The alert said that the majority of pediatric Clostridium difficile infections, which are bacterial infections that cause severe diarrhea and are potentially life-threatening, occur among children in the general community who recently took antibiotics prescribed in doctors’ offices for other conditions. This came from a new study by the Centers for Disease Control and Prevention (CDC).  The study showed that 71 percent of the cases of C. difficile infection identified among children aged 1 through 17 years were community-associated—that is, not associated with an overnight stay in a healthcare facility. By contrast, two-thirds of C. difficile infections in adults are associated with hospital stays. The CDC has data to show that many patients get prescriptions for antibiotics when the evidence shows that they are not necessary.

The FY 2015 Federal Budget requests funding for CDC for an initiative to reduce outpatient prescribing of antibiotics by up to 20 percent and healthcare-associated C. difficile infections by 50 percent in five years. A 50 percent reduction in healthcare-associated C. difficile infections could save 20,000 lives, prevent 150,000 hospitalizations, and cut more than $2 billion in healthcare costs.

After reading this, I was reflecting on people rushing to Urgent Care Centers and their doctor’s office to get antibiotics, frequently for viral illnesses where the antibiotics don’t actually help. I am curious about what would happen to business at Urgent Care Centers if the rate of antibiotic prescribing went down, as the CDC is trying to encourage. I also wonder if physicians in their offices would have more time to spend with their patients talking about what would actually improve their health if they were not writing so many prescriptions.

It is absolutely clear that antibiotics were a major breakthrough of the twentieth century and that antibiotics improve health and save many lives when they are used appropriately, but doctors, nurse practitioners, pharmacists and patients need to do a better job of making sure that the use of all drugs, but especially antibiotics, follows the evidence.

Tuesday, April 15, 2014

Beginning the Celebration: Almost 50 Years Old with a Bright Future

This week we kicked off GBMC’s big birthday celebration. Our Healthcare System is nearly 50 years old. Our hospital opened its doors on September 15, 1965 and a dedication ceremony was held on October 2, 1965.  Our HealthCare Board, under the leadership of our Chair, Harry Johnson, Esq., has created a 50th Anniversary Executive Planning Committee. Bonnie Stein, the incoming Board Chair, is the Chair of the Planning Committee.
(L-R): Harry Johnson, Bonnie Stein and Dr. John Chessare kick
off GBMC's 50th anniversary reception.
(Photo by: Maximilian Franz)

The Planning Committee decided to create a Founders Cabinet – a group of people important in the history of GBMC. This group includes community members who helped form GBMC, physicians, past and present GBMC Board members, long-term employees including many nurses, volunteers and donors. The group is inclusive of people from our hospital but also from Gilchrist Hospice Care, Greater Baltimore Medical Associates and private practicing doctors. The Founders Cabinet will guide the celebration and help us reflect on the many wonderful chapters of service to our community in the first 50 years. The Cabinet members will also be ambassadors to the community helping us continue to get the word out that all are welcome in the GBMC family.

So, to kick-off the 18 or so months of celebrating that will culminate on October 2, 2015 with a gala event, the Founders Cabinet gathered together for a reception. It was wonderful to see so many people who have given so much over the years to GBMC and our patients.

The event was organized masterfully by Jenny Coldiron our Vice President for Development and her staff from the Philanthropy Department. After a reception where people chatted and reminisced a bit, Harry opened the proceedings by thanking people for gathering and setting the stage for the evening. I then spoke about how GBMC has been an outstanding hospital and hospice with fantastic physicians, nurses, and other staff. I mentioned a few of our patient success stories and commented briefly on our work to make our care even better. Bonnie then spoke about the work of the Planning Committee and the role of the Cabinet in helping to make the celebrating and reflecting truly come alive in the community.

We then watched a video that had been created by the GBMC Marketing and Communication team under the direction of Interim Director, Greg Shaffer. You have got to watch this video! It beautifully highlights what GBMC means to so many people using the stories of a few key individuals. What a great highlight of a wonderful evening to commence GBMC’s big 5-0 birthday party!

GBMC is made up of so many employees and volunteers who have been an integral part of GBMC’s past, and so many more staff members who are a part of our future. I thank all of our team members for playing a role in caring for our community for close to five decades. I look forward to reflecting on our past and celebrating our future with all of you.

Wednesday, April 9, 2014

Red is Not a Badge of Dishonor

Since we introduced Lean Daily Management (LDM) a little over a year ago, it has proven to be a very effective tool for generating focused problem solving and continual improvement led by the people doing the work. Lean daily management has been a great way to get people in action redesigning systems to work better. It’s also provided our senior leaders with the opportunity to visit our units and departments and learn about the many ways teams are working to improve patient care and to implement standard work. Through our daily rounding, we’ve also had the opportunity to get to know many of our frontline leaders and team members throughout the hospital who are studying problems and testing changes, allowing us to have open conversations with one another about how we can continue to move toward our vision. I remain truly excited about where LDM is taking us as we work toward continual improvement in our care.

Last week on LDM rounds, I had the chance to talk with Kate Devan, RN, BSN, CAPA, PACU Clinical Partner at Sherwood Surgical Center. Kate is a wonderful leader and she presented the LDM board for starting cases on-time at 7:30 a.m. under our aim of Least Waste. The LDM chart showed the metric in red for the previous day as they had two of the three cases starting on time, instead of all three. It was clear that seeing the red on the chart dismayed Kate and her team as they had been working hard toward achieving the goal of all cases being on-time, and they really care about what they do.

Pictured left to right: Holly Clevenger, RN, Clinical Partner,
Sherwood Surgical Center, Kate Devan and Laura Ghasseminia, RN.
“Sherwood has been working very hard to provide a safe and caring environment to our patients,” explains Kate.  “I felt extremely proud of our team in Sherwood for accomplishing two out of three cases on time, but also felt a sense of frustration that we were still not meeting our goals. I felt that maybe by setting our goal so high we were setting ourselves up for a goal that was not obtainable. It did not celebrate that we were successful in achieving over 60% on time starts, but rather showcased that we had 30% late starts and we were in the red.”

It became very clear that Kate was truly proud of what her team had accomplished already but that having to report that they still were in the “red” was a source of frustration for all of their efforts.

This caused me to reflect on the fact that many of our people see “red” as “bad,” and that I as a leader had done a poor job of explaining the nature of Lean Daily Management. It’s about finding process flaws and then testing changes to the process. If we don’t find the defects - and show the performance as “red” - we won’t know what to try to change. It seems that many of our people believe that LDM is about “catching people doing a bad job” and since we were children when red pens were used to find our mistakes…red is the color of negative judgment.

I am so excited about the great work that the Sherwood team is doing and it bothered me that they felt that the red on the LDM board was a badge of dishonor when nothing could be further from the truth. They have always done an excellent job but since LDM they have made dramatic improvements.

This opened up a candid conversation that provided us all with the opportunity to learn from our different perspectives. I pointed out to Kate and her team that in fact, identifying a defect in their process was actually great news and not something to be ashamed of!

After this conversation, Kate says, “It was reassuring to hear Dr. Chessare say the things that he did.  It felt as though he was in strong support of our efforts and our progress towards reaching our goals.”

When the engineers at Toyota find a defect, they actually celebrate this as an achievement because they know it’s an opportunity to make their product even better and generate problem solving.  Toyota has mastered the concept of daily improvement and at Toyota they know that if everything is green, nothing is being improved. Leaders in organizations that continually improve understand how to find the next opportunity, which requires people to think critically and not start from the presumption that everything is fine. As we discussed last week, we should start from the presumption that everything is NOT fine.

We must also move from the mindset of punishment to the mindset of curiosity. Red is not a badge of dishonor, but we are trained to think that it is. We are trained to believe that if you didn’t get it perfectly right the first time, you’ve failed. Not true!

I was grateful to have had this conversation with Kate and her team because it was a learning experience for me about what our teams are getting out of these conversations at the LDM board during the daily presentation. If everything is good and all of the charts are green, then we should be worried that we’re not asking the right questions or studying the right processes. We must celebrate green and say thank you when green came as the result of a new change. And, if we’re going to assign bad performance to anyone it should be when we learn of a defect in our processes and fail to test changes to fix it.

The Sherwood PACU team certainly has a lot to be proud of in their care of our patients and in their actions to make the care even better.

Experts in improvement have a wonderful phrase – “Every defect, a treasure.”

When you identify the defect, it gives you the opportunity to get better. If you have defects that you don’t know about, you cannot fix them. So, we should always be looking for the defects so we can test changes to improve.

Red is not a badge of dishonor. The only dishonor is to allow poor systems to remain as they are and to not be in action testing changes.

Thursday, April 3, 2014

Preoccupation with Failure and the Prevention of Needle Stick Injuries

In the U.S. healthcare industry, most of us were trained to assume that if we worked hard and had good intentions, everything would go fine. In fact, everything usually does go fine when we provide care to patients. The problem is, when you work in a high risk industry like healthcare, a miss or lapse can lead to a catastrophic outcome.

Think about it this way: If you’re stocking cereal on a supermarket shelf and one box gets put in the wrong place, it’s not a big deal. But, if you’re working in a hospital, where thousands of needles are used every day, and one nurse or one physician gets stuck with a needle, it’s a huge deal. That one nurse or doctor can be exposed to diseases such as Hepatitis C or HIV. Working stocking shelves in a supermarket (which I have done) is not a high risk pursuit. Delivering health care is.

Other high risk industries like nuclear power, for example, teach their people to be mindful. They caution their people about becoming complacent and about ignoring little things that are wrong because they know that these little things can begin to add up.

“It’s okay to ignore the alarm…it’s probably that the lead has come off;” “It’s okay to let the patient leave before the Anesthesiologist has checked him…they frequently do and no patient has suffered before because of it;”  “It’s okay not to put on protective eye wear before I put this NG tube in that may make the patient cough…I've done it tons of times before with no ill effect.” 

The acceptance of these small deviations eventually add up to something bigger.

Nuclear power and commercial aviation have taught their people to be preoccupied with failure. They teach that the best way to avoid catastrophic failures is to look for them developing so as to head them off. They teach their people to follow the design and to be alert that even the best design may fail.

In health care, we often drift and allow failures in following the design because we assume that things will go ok. How many times do healthcare workers fail to use protective devices because they are usually not exposed without them. How often do surgical teams pass sharp instruments using incorrect technique because they have never been stuck before? Before pilots began using pre-flight checklists, most flights took off safely…but some didn’t and many people died because of this. Now, all pilots use the checklists every time and they are still mindful of things that may signal that something isn’t right.

Recently, we’ve had a couple of needle stick injuries where our people assumed that their colleague had disposed of a needle correctly. The colleague, however, did not. They became distracted and left a needle on a bed or on a stand and it became “hidden” in sheeting. Then, another staff member came in, and assuming everything was safe, grabbed for the sheet to throw it into the trash. But when they grabbed the sheet, there was a needle wrapped in its folds and this individual was stuck.

Telling people to always properly discard needles does help, but it cannot get us to higher levels of reliability and safety. We must also be mindful and have this preoccupation with failure and change the way we see our work. Rather than assuming all is well, we need to assume that danger is lurking nearby. If we are mindful that there may be a needle in the sheeting we’re about to throw away, we’ll deal with this sheeting differently and pick it up differently. This concept of preoccupation with failure is something we need to adopt at GBMC.  I welcome your thoughts and comments.

Tuesday, March 25, 2014

A Day to Reflect on the Great Commitment and Hard Work of Our Physicians

This year, National Doctor’s Day is March 30th. This is the one day of the year that we reflect on the many contributions made by our physicians and say thank you to them. The doctors of the GBMC medical staff work very hard to care for patients as they would want their own loved ones cared for. We have physicians throughout our healthcare system that are making a tremendous difference in the lives of patients every day.

This superior care is certainly evident in the 171 members of GBMC’s medical staff who were recognized in Baltimore magazine’s 2013 Top Doctor’s list, which also demonstrates just how good they are since the award comes from the votes of their peers.

And, last week we heard from patients who were very grateful for the coordination of care they received from their primary care physicians, Drs. Gregory Small and Nishi Das, and how the simple act of managing a person’s chronic health condition and providing them with a healthier, better quality of life, makes a world of difference. We are very fortunate to have a medical staff comprised of not only the best doctors in their fields, but doctors who dedicate their time, and their lives, to the care of people. So, in tribute to our physicians, I thought it fitting that we hear what our patients had to say, many of whom gave thanks throughout the year in our Foundation’s Gifts of Gratitude campaign for the care received from a GBMC physician:

“Dr. William McConnell is very kind, considerate and caring. He is always available when you need him.”
“Dr. Marshall Levine is so very special to me and my family.”
“I am fortunate to be in the care of Dr. Joseph Califano. He is a most caring and fine surgeon and a grand person.” 
“Drs. Lauren Schnaper and Sheri Slezak and their staff saved my life. They made me feel like I could make it and their skills made it true. I am forever grateful.”
“Dr. Geoffrey Neuner is a special doctor whose love of life and people shines through him in so many ways. I am here today because he cares.”
“Dr. Teresa Nguyen is fantastic! She takes the time to get to know the children and their families. We adore her!”
“I am 86 and walk pain free thanks to Dr. Victor Tritto.” 
“Dr. Thomas Guarnieri (cardiology)- For your care and wisdom, I thank you! Your referral last summer has resulted in a vast improvement in quality of life.” 
“I thank Dr. Kenneth Greene for his monthly medical updates and quick response to questions sent via email.”
“Thank you to Dr. Carter Freiburg, my vascular surgeon. He was so knowledgeable and caring and kind to me when I had my surgery. I rate him as a “10.”

From the surgeons and hospitalists to the ED physicians, primary care doctors and specialists all throughout GBMC, thank you for caring for patients and families from every walk of life, through all types of illnesses and injuries, and for helping GBMC move toward our vision: To every patient, every time, we will provide the care that we would want for our own loved ones.

In honor of Doctor’s Day and your physician, please share your thoughts and inspiring stories of patient care here…

Wednesday, March 19, 2014

What Do Our Patients Really Think About Our Care Management and the Patient-Centered Medical Home?

I've been discussing for a while the benefits of GBMC’s patient-centered medical home model and how we are working hard to ensure our patients receive coordinated care that focuses on the long-term management of chronic health conditions. We are building a system that delivers the care we would want for our own loved ones.

Over the past few months, I've talked about the new medical home office being designed and built for one of our primary care practices, Family Care Associates, and we've heard about coordination of care from one of our own RN care managers. But everyone knows how proud I am of GBMC and I am our chief salesperson. Readers of the blog expect me to say great things about our system and they should be curious about what our patients really think.  So, it was time I sat down and talked to some of them who are experiencing our care to hear what they really think about our system. Do they really believe that we are serving them better?

Last week, I met Alexis Watkins. Alexis has been a patient of Dr. Gregory Small, at our Texas Station primary care office, for several years and has worked closely with RN Care Manager Vergie O’Garro. Alexis, who is 65 years young, is being managed for type II diabetes, hypertension, and high cholesterol, among other conditions. She has seen significant improvement in her health because of the comprehensive coordination of her care. Vergie works with her to help her maintain proper diet and exercise as well as how to take her medications appropriately. She says, “When I first came in to the practice, Vergie took the time to really listen to me. She heard me and didn't overwhelm me. She took it one step at a time and that means everything. She and Dr. Small really know me and have helped me get my diabetes under control.”

As part of the coordination of care that has benefited Alexis, she tells me that the convenience has helped make staying on top of her health easier. “I use the GBMC patient portal to get my lab results, which really takes away some of my stress.”

Watch what else Alexis had to say about the care she receives from the team at GBMA’s Texas Station patient-centered medical home in this video:

I also had the privilege to meet with patient Eddie Bostic.  Eddie, age 40, was diagnosed with type II diabetes several years ago with an initial blood sugar level of more than 900. He soon landed in the ED with a blood sugar over 1,000. (He tells me he shouldn't be here, but he's a hard man to kill!). He sees Dr. Nishi Das and Vergie at our GBMA Texas Station primary care practice and says they have worked with him to get his diabetes under control through the use of appropriate medication as well as lifestyle changes such as diet. He has learned to use a Smartphone app to monitor his blood sugar and during his follow up visits, he provides the information from the app to Dr. Das to make sure everything stays in check.

Eddie explains, “They've helped me find a better way to manage my diabetes. I can share information through the GBMC patient portal and know I will always get a response from my doctor, which is very helpful. I feel like I’m talking to friends when I come in for an appointment.”

We had a nice conversation and Eddie ended it by telling me, “GBMC has always been amazing, for me and my family.”

Watch what Eddie had to say about the care he receives and how GBMC is making a difference in his life:

I sincerely thank Alexis and Eddie for sharing their experiences and stories of patient care with me. It’s heartening to hear how our system of care is working for our patients and helping us move toward our vision - To every patient, every time, we will provide the care that we would want for our own loved ones.

Wednesday, March 12, 2014

Mistake Proofing in the PACU

Everyone knows it – GBMC has outstanding anesthesia care. We have great anesthesiologists and nurse anesthetists. Our OR staff is second to none and we have excellent, dedicated nurses in our Post Anesthesia Care Unit. I have now been at GBMC for almost four years and I can’t remember a complaint about this team.

The system that they have been working in is not perfect, however.

High Reliability means “what should happen, happens and what should never happen, doesn't.” The Joint Commission has been concerned that there are infrequent events around the country where patients who have received anesthesia have suffered a bad outcome because they were not truly ready to leave the care of the anesthesia team after a procedure, but left anyway. So, to prevent against these rare events, the Joint Commission has a rule that a licensed independent practitioner must evaluate the patient before the patient can go to a lower level of care (the inpatient unit if an inpatient, home if an outpatient). Well, GBMC has not had untoward events that I am aware of, but we have had a significant problem with getting the documentation that the anesthesiologist has evaluated the patient.

Two weeks ago, the PACU joined the units participating in LDM (Lean Daily Management). Charlene Mahoney, the Nurse Manager of the GOR PACU decided with her team to measure daily completion of the Post Anesthesia Evaluation Note as one of their metrics. Earlier this week on LDM rounds, I was stupefied at how fast they had driven their performance to 100% completion of the form! On rounds, Charlene explained that the Team had implemented two process changes to meet their goal. First, she had met with Dr. Lewis Hogge from our Anesthesia group to discuss the charge anesthesiologist rounding on an hourly basis. This helped their compliance but did not get them to 100%. Charlene, CJ Marbley, our Director of Perioperative Services, and Dr. Hogge then decided to put a hard stop in the PACU. No patient would be allowed to leave the PACU without the form being completed. This is a huge culture change for our staff who are trained to keep the unit open for incoming patients from the OR. They have accepted this challenge with the support of Jennifer Trunk, the PACU’s clinical partner and our PACU charge RN's. And, the Team has gotten to perfection in this measure without slowing down the operating room.

Experts in mistake proofing identify three levels of this. The first level is when people remind others of the possibility of an error and ask them to be vigilant. This has a positive effect but since the operators are human, sooner or later someone will get distracted and forget. In healthcare we frequently turn to education of the staff as a level one mistake proofing action.

In level two mistake proofing, we make a process change that improves performance but does not fully stop the error from occurring. In the PACU example, Charlene, Dr. Hogge and their Team did this when they instituted hourly rounding of the anesthesiologists.

Level 3 mistake proofing is when a constraint or “hard stop” is created that totally prevents the bad outcome. An example of this from my daily life is that I cannot start my car without having my foot on the brake to assure that the car doesn't start moving before I intend it to. The PACU Team turned to this successful level 3 action when they stopped anyone from leaving without a signed form.

I am very proud of the PACU Team and grateful for their speedy problem solving to fix this hole in the Swiss cheese and make our patients safer!