Monday, January 22, 2018

What if it was your mother?

I have been reflecting this week about an incident that made it to the national news; a woman wearing a hospital gown was left by hospital personnel at a bus stop in our city. We don’t know all of the facts, but this has been reported not to be an isolated occurrence. Could this happen at GBMC?

Emergency departments are frequently under siege. I have been in healthcare for more than 30 years and through those years, I have seen how we frequently use the emergency department as the pathway of least resistance. Primary care office closed? Send the patient to the ED. Specialist unable or unwilling to deal with a problem in the moment? Send the patient to the ED. Hospital leaders not able to create a smooth system for admitting a stable patient to the hospital? Send the patient to the ED. No way to get an infusion done on the weekend? Send the patient to the ED. Mental health system is broken? Send the patient in crisis and his or her family to the ED. I have worked in the emergency department when it seemed that we were overwhelmed with many problems beyond our control. And of course when the emergency department is overcrowded, people wait and they get upset.

What if we assume for the sake of discussion that there is a patient for whom the emergency department has done its job of treating an acute problem? The staff believes it has done all it needs to do and the patient is not happy. The patient begins to act in a belligerent manner after being told that she is being discharged. Let’s also assume that the first reaction of the staff is to try and reason with the patient and calm her down. But what if the patient escalates her behavior and starts yelling and screaming and even threatening the staff? And what if this is the third angry patient of the evening who has gotten confrontational? Can you understand the urge of a physician, nurse, or security guard to have this patient leave the ED? Of course, you can.

And what if the patient in this not atypical situation was your mother? What should happen next? There is no perfect answer in this hypothetical situation, but of course, you want your mother treated with respect and kindness, even if she is out of control.

As the leader of the GBMC HealthCare System, it is my job to make sure that the ED staff members believe that we will not leave them on their own when they are confronted with problems beyond their ability to fix. They must also believe that people like me mean it when we say that everyone must be treated the way we want our own loved ones treated. But we can only hold people to this standard if we are ready to give them the help and support that they need to carry it out.

Could this happen at GBMC? It is my duty to assure that our incredibly hardworking physicians, nurses, advanced practitioners, other clinicians, and support staff teams have the equivalent of a safety button that they can push which will bring other leaders to help when they feel overwhelmed. I have shared this commentary with Dr. Jeff Sternlicht, medical director of our ED, and Monica Goetz, assistant nursing director, who oversee the emergency department, to have them assure our staff members that we will not leave them to deal with episodes like these on their own. What do you think?

Friday, January 12, 2018

What if it was Your Loved One in the Bed? The Absence of Alarm Fatigue in our MICU!

Back in July, I wrote a blog about “alarm fatigue.” In that blog I discussed my experience as a pediatric resident in a Neonatal Intensive Care Unit with alarms that constantly went off. We had become oblivious to them, unconsciously assuming that they were false alarms. In that blog I also commented that in highly reliable high-risk systems, like in an airplane cockpit, the alarms are minimized to those that are critical and that in those systems everyone responds immediately to them.

This morning I was on our Lean Daily Management walk in the MICU. Stacey Klingler, RN, the charge nurse, was presenting the Board accompanied by her manager, Rachel Ridgely, RN. Stacey was in mid-sentence explaining something to us when a patient alarm went off. Stacey immediately stopped and started to move to the patient’s room as did Rachel. I turned and looked towards the source of the alarm to see that other staff members were on the move as well. A staff member gave a thumb’s up “all clear” and everyone went back to what they were doing. Without missing a beat, Stacey finished her explanation. I was so proud of Stacey, Rachel and the entire team. If it is your loved one who is a patient in our ICU, you don’t have to worry about an alarm being ignored.

We thanked Stacey and Rachel for exhibiting the “preoccupation with failure” that all high reliability teams exhibit and for not assuming that the alarm was false or would be dealt with by someone else. Afterwards, I reflected on how quiet the unit had seemed before the alarm went off even though the unit was very full. We are making excellent progress in eliminating alarms that are not helpful and in presuming that all alarms are real until proven otherwise.

Drift

Rachel also told us that she was meeting with the leaders of our equipment hub. A few years ago we created the hub to remove clutter (and eliminate blocked corridors in the event of a fire) from our patient care units and also to have a system where we always knew where our equipment was. This way it could be moved quickly to where it was needed. At that time, we realized that hard-working, well-intentioned physicians and nurses were hoarding equipment because they were afraid that they would not get it back when they needed it…in other words, they knew that the system for removing equipment from and returning it to the units was unreliable.  Well, our system has worked pretty well since we created it but Rachel was seeing some drift away from our standard work. The physicians and nurses were beginning to hoard things again after one or two episodes where they had called for things that could not be found.

It is not a surprise that workers in unreliable systems begin to work around the system. They are not doing it for malicious reasons. They do it because they believe it will help them get their work done. But, as students of systems, we need to point out that when a system starts to fail and people stop following the design, it actually makes the system worse! Rachel is taking the correct step to meet with the hub leaders and ensure that we continue to follow our standard work to make sure that everything is in its place and moves according to need.

What do you think? Do you see other examples of drift away from standard work? Please comment below.

Friday, January 5, 2018

On Becoming a Learning Organization: 8 Employee Injuries

Today, I met with Simon Freyou, our new Director of Occupational Health, and discussed the GBMC HealthCare System’s progress in making our environment safer. Back in 2011, as we started becoming aware of the magnitude of this problem, we had as many as 40 injuries per month, many of which were lifting injuries, injuries due to slips on wet floors and sprains.


Last month we had “only” eight injuries. I use the quotes because if you are one of our eight colleagues who was injured, you deserve to be annoyed if the CEO says “only eight injuries.” I was telling Simon that the good news is that there were no sprains, strains, slips, and falls or chemical exposures this year.

How did this improvement occur? Was it by wishing and hoping? Or by paying better attention? I am sure that paying attention to wet floors or to how we lift patients did help; but most of the improvement came from studying the causes of the injuries, learning from them and making real changes. We now have “spill stations” throughout corridors where we often have spills or wet feet. We no longer place full trash bags on the floor, instead, we place them directly into carts because many contain liquid and may leak. We have placed lifting devices in most rooms or near where the care is delivered to aid in lifting patients.

With “only” eight injuries we still have work to do. All eight were in the category of potential blood-borne pathogen exposure- needle stick or other sharps injuries and splashes of body fluids. This category is probably the worst for our people. It is very unlikely that someone will get a serious pathogenic exposure from a sharps injury or a splash, but can you imagine going home after your work as a physician, nurse or other clinician and telling your spouse that you just converted to Hepatitis C positive because you stuck yourself with a needle? We owe it to our people to learn from every injury to make changes to eliminate injuries from our workplace. While we will never achieve perfection, we must always be working to reduce harm to our patients and our workforce. I am proud to report that we are becoming a learning organization and we are making progress. Let’s keep learning and testing changes on the basis of what we learn.

Thursday, December 28, 2017

2017: Another Great Year for Our System of Care

As we come to the end of 2017, I would like to highlight some accomplishments of the GBMC HealthCare System this year.

There’s no doubt that we continued to move towards our vision of becoming the community-based health care system where every patient, every time, gets the care we want for our own loved ones. 

I realize that the video below only mentions a small fraction of what the GBMC family did in 2017 to move us closer to our vision. What others do you want to mention? Please share your thoughts.

Best wishes to you and your loved ones for a Happy & Healthy 2018!


2017 End-of-Year Recap

Tuesday, December 19, 2017

Meeting a Humble Leader


Last week, I was at the Institute for Healthcare Improvement (IHI) National Forum and I had the wonderful opportunity to hear General Stanley McChrystal give a plenary address on leadership. General McChrystal graduated from West Point in 1976, became an Army Ranger and rose through the ranks. In 1990, he became an action officer for Army Special Operations, working in Joint Special Operations Command (JSOC). In 1991, he saw action in the Desert Shield and Desert Storm tours. His last assignment was as Commander, International Security Assistance Force (ISAF) and Commander, U.S. Forces Afghanistan (USFOR-A). He previously served as Commander of JSOC from 2003 to 2008, where he was credited with the death of Abu Musab al-Zarqawi, leader of Al-Qaeda in Iraq.

General McChrystal spoke about the need to communicate quickly and up and down throughout the ranks in order to get the job done as leaders. He explained how JSOC was able to defeat Al-Qaeda in Iraq by changing the existing top-down communication system and getting the whole team involved in decision making. I reflected that we do not work under such a continually high pressure, high stakes environment, but to get to our vision, we could learn a lot from General McChrystal’s work.

HITTING A HOME RUN FOR THE HOUSE OF RUTH!!
As many of you know, this year GBMC has teamed up with WMAR-TV ABC2 to collect hundreds of needed items for the Fill the House initiative for the House of Ruth. Recently, we added a different twist. Instead of collecting parking fees, we handed out flyers asking visitors to "pay it forward" by donating much-needed items to the House of Ruth. Many visitors opted to “open their wallets” and gave money on the spot to help the cause. I am happy to announce that we collected over $4,000.00 for the House of Ruth. I want to thank all members of The GBMC leadership team who worked the parking booths along with the many people who helped with the campaign.

HOLIDAY SPIRIT
I know that you who attended this year’s annual Employee Holiday Meal enjoyed the good food and festivities. This is a system tradition that draws many GBMC HealthCare employees. Music filled the air at the meals as members of the GBMC Holiday Choir put on a wonderful lunch-time concert. Thanks to all who did their part to make sure this year’s event was a success and I wish you all Happy Holidays!




HAPPY HANUKKAH
Wishing all those who celebrate the Festival of Lights a very Happy Hanukkah.

Friday, December 8, 2017

“Brand” vs. “Evidence”

Recently, I’ve been thinking a lot about a big dilemma in the U.S. healthcare system. Patients are generally unaware of facts and rely instead on reputation when they choose a hospital or healthcare provider. They often don’t know if they’ve chosen a hospital of lesser value because they’ve assumed quality based on common wisdom or “brand.” Unfortunately, this can lead to patients receiving subpar treatment because they were unaware of facts when they were choosing their provider.

At their meeting this week, The GBMC HealthCare Board Quality Committee was reviewing the phenomenal performance of our orthopedics and spine surgical teams. Under the leadership of Joy Reynolds, RN, the Unit 58 nurse manager, Lee Schmidt, MD, the chief of orthopedics, and Bimal Rami, MD, the chief of neurosurgery, they’ve improved everything from evidence-based pre-op care in the physician offices, to outstanding performances in the operating rooms and phenomenal immediate post-op rehabilitation with GBMC’s sensational physical therapists. 

This improvement work has led to outstanding outcomes as evidenced by near-zero wound infection and readmission rates and the patient engagement scores for Unit 58 (where patients go from the operating room). These are among the highest in Maryland (with the best care experience). GBMC’s prices for the procedures are significantly lower than many, if not most, other hospitals in our region (with the least waste).



Our teams serve many patients but we would like to grow our programs. I would love to hear your ideas about how to get consumers to choose value over a brand.

In The Spirit of the Holidays, Please Donate ...
This year, we are a proud sponsor of the Fill the House for House of Ruth initiative to collect everyday necessities for this partner in care. This is the first year of the campaign and the items collected will help thousands of women and children to recover from abuse and to rebuild their lives. The work that the House of Ruth performs is closely aligned with our SAFE program.

Please don’t forget to donate items at various drop-off locations on the GBMC campus, including Family Care Associates and at each of our 10 off-site primary care locations. Some of the House of Ruth's greatest needs include diapers, women's and children's undergarments, pillows, twin-sized sheets, comforters, and blankets. The drive will run through Friday, December 15. All items must be new and unopened. An additional way to donate is through our Amazon Wishlist. All items purchased through this link will be shipped directly to GBMC Marketing so you don’t have to worry about dropping anything off.

Thursday, November 30, 2017

Waste

When experts talk about our country’s health care delivery system they usually begin by stating that the U.S. spends 40 percent more on health care per capita than any other country in the world. This is usually followed by the claim that a large amount of this spend is wasted on things that don’t actually benefit patients’ health.

This is a big statement, so let’s try to bring it down to the level of someone actually working in health care. What does waste look like to them? This morning I learned of a situation in our medical center. One of our employees collected information about a patient, loaded it into the electronic health record, and then printed out some of the information. This paper later reached a co-worker who scanned the information back into the very electronic system that it was originally printed from! (I suspect that this occurred because no one redesigned the work during the Epic implementation and it used to be going from one computer system to another). In the language of Lean production, this is called overprocessing and is one of the seven key wastes. The others are:
  • Overproduction (making more of something than necessary or before it is needed)
  • Production defects 
  • Movement or transportation (taking a material farther away from the process and requiring it to be moved back)
  • Inventory (the storage of overproduction)
  • Waiting
  • Unnecessary motion
The efforts of our colleagues who printed from a computer and then scanned the same information back into the computer were wasted. It added no value to the patient or to GBMC. I am sure that these colleagues were well-intentioned, but it raises the question of how many other tasks are being done that do not add value to the patient. Our people have so much to do that actually does add to the patient, but how much of their energy is spent on wasteful steps?

Our leadership system requires that our managers teach their employees about these wastes and empower them to test changes to our processes to get rid of waste. Lean Daily Management is just one tool to help eliminate waste. Value stream mapping and kaizen events are other tools that can be used. In the example of scanning information into the computer when the information is already there, we should just stop doing it!

I have a challenge for everyone in the GBMC HealthCare System. There are things that are scanned that do add value in healthcare, like outside medical information brought to us on paper or insurance cards, but are there things that we are scanning that don’t actually add value? Are we overprocessing this information? Please study all scanning and let me know what you find by commenting on this blog. Thanks! 

Holiday Decorations
Don’t the holiday decorations on our campus look beautiful?  I wanted to say thank you to Stacey McGreevy and her team for transforming our hospital into an eye-catching winter wonderland.

Let’s Fill Up The House!
This year, we are teaming up with WMAR-TV (ABC 2 – Baltimore) as a proud sponsor of the Fill the House for House of Ruth initiative to collect everyday necessities for this important non-profit organization. I am hoping that I can count on your help!

The House of Ruth provides services to nearly 9,000 women annually who are victims of intimate partner violence. Donations are needed to help women and children recover and rebuild their lives. The work that House of Ruth performs is aligned with our SAFE program. 

Earlier this week, various drop-off boxes (see picture) were set up throughout the GBMC campus including the GBMC Pediatric Group, Human Resources, Oncology Support, Spiritual Support, Volunteer Services, Family Care Associates and at each of our 10 off-site primary care locations.

All items donated must be new and unopened. The items of greatest need are:
--Diapers (all sizes) – House of Ruth uses 1,000 diapers each month
--Women’s and children’s undergarments – Underwear, bras, and undershirts (all sizes)
--Pillows, twin-sized sheets, comforters, and blankets

Other needed items include:

--Air mattresses
--Washcloths
--Gender neutral infant clothing
--Socks (all sizes)
--Children's coats
--Children's shoes

Another way to donate is through our Amazon Wishlist, where the most-needed items can be purchased straight from your computer. All items purchased through this Amazon link will be shipped directly to GBMC and then will be delivered with all the other items to ABC2 for distribution. 

Please don’t forget to donate at any GBMC drop-off location.You have until Friday, Dec. 15th! Thank you in advance for your generosity and Happy Holidays!