A Conversation With GBMC HealthCare’s Director of Diversity and Inclusion

The GBMC HealthCare System is committed to having a workforce that mirrors our community. In order to achieve our vision, we need to be welcoming to all. We need to celebrate our racial, cultural, and other differences to help us become more unified as a team. GBMC recognizes the need for it to be more deliberate in its actions to achieve inclusivity. Towards this end last year, we hired a new Director of Diversity and Inclusion, Jennifer Marana, MS, PhD. Jennifer has been leading our Diversity and Inclusion Council and I asked her to guest author this blog.

Jennifer has over 15 years of experience in diversity. Her primary responsibilities, in her previous places of employment, have included diversity and intercultural communication training, facilitating focus group discussions and data analysis that help to develop diversity initiatives and strategies. I believe that Jennifer’s skills and experience are just what we need to help us become even more inclusive. Jennifer believes our commitment to providing a Just Culture and developing an inclusive community resonates with her personally and professionally.

Please join me in welcoming Jennifer if you haven’t already!

Can you tell me a little more about your background?
I have worked as a diversity and inclusion professional for more than 15 years, directing strategic diversity initiatives at institutions of higher education such as McDaniel College, Claremont McKenna College, and Bard College. One of my most poignant experiences related to diversity and inclusion has been raising a child with special needs. My 13-year-old son has cerebral palsy among other health-related challenges. While I was already steeped in diversity work before he was born, my experience with him brought a new meaning to my work. My empathy for those who are different from myself has deepened and I have become more fervent about teaching and training to assist others with expanding their understanding and connection across difference as well.

What brought you to GBMC?
I was interested in bringing my knowledge, skill, and experience with diversity and inclusion into a new environment.  When I learned more about GBMC’s needs related to diversity and inclusion, I knew I could make a difference.

As the director of Diversity and Inclusion, what is your role and primary focus?
The diversity and inclusion mission of the GBMC HealthCare System is to create a more diverse workforce and foster an inclusive workplace. This will allow us to better achieve our vision by providing culturally competent care. This mission guides my work as I develop training, multicultural programming, dialogue facilitation, and provide overall leadership and support for GBMC’s strategic diversity goals.

Diversity is a very broad subject. Do you have a simplified definition of diversity?
Diversity is the combination, inclusion, and acceptance of the identities, experiences, and knowledge that make us who we are.

What is the most common mistake in our thinking about diversity?
I believe that some people think too narrowly about diversity.  They see it solely about the numbers – the racial/ethnic demographics.  As a diversity practitioner, I am intentional about coupling the word diversity with inclusion so that we address diversity in terms of race/ethnicity, sexual orientation, religion, and other aspects of our identity while creating spaces for mutual respect, learning, and understanding that comes with bridging the divides that may result from these differences.  

What does the role Director of Diversity mean at GBMC Healthcare and how do you see your role enhancing the GBMC community?
The role of Director of Diversity & Inclusion is a testament to GBMC’s commitment to its diversity and inclusion mission.  In some organizations, diversity and inclusion work is assigned as an additional task for the Learning & Organizational Development Director or other professional.  In these cases, diversity and inclusion work is not given the attention it deserves.  There is great value in having someone spearhead diversity and inclusion efforts.  This requires dedication and work from all employees, it requires a leader to guide the way.

Last month, your department facilitated an “Inclusivity Learning Forum” that you were particularly excited about, can you tell us who showed up to your forum and what the outcome was?
I have actually been excited about every single one of the Inclusivity Learning Forums (ILF) that the Diversity & Inclusion Council has hosted.  The Inclusivity and Learning Forums (ILF) are monthly educational seminars on topics that foster, promote and facilitate dialogue about diversity and inclusion.  Up to this point, we have addressed topics related to our Muslim, Jewish, LGBTQ (lesbian, gay, bisexual, transgender, queer) communities and even hosted a discussion on how to “Teach a Child about Diversity.” They provide a vehicle for learning about the diverse cultures, religions, and experiences that make up the GBMC employee and patient population.

The August Inclusivity Learning Forum was on the topic of “Judaism and GBMC.” panelists shared what it means to them to be Jewish and practice the Sabbath (if they do so), how their faith influences their work, and what we can do to make GBMC a more inclusive place to work.  Their responses illustrated the commonalities they shared in their faith as well as the diversity of their practices. We discussed what resources employees can access on the Sabbath and/or Jewish holidays if serving a Jewish patient who may refuse specific care.  Because many of our Jewish friends and colleagues may not be accessible on these days, Dr. Frankel shared a related story and taught attendees the term “Vechai Bohem,” words from the old testament that basically mean "to live by them."  Therefore, if someone comes to the hospital on the Sabbath or on a Jewish holiday and they refuse specific care, all we need to tell them is..."Vechai Bohem,” conveying that life is of utmost importance.

What is the WISER movement?
WISER is Working In Sync to Enhance Resiliency at GBMC.  Resiliency is the ability of employees to recover and remain engaged even in challenging work environments.  It is the opposite of burnout. The WISER team is made up of a group of GBMC colleagues who care for others while caring for themselves.  The team develops resiliency initiatives to support GBMC employees’ ability to engage patients and others as individuals and derive intrinsic value form work (at work) and disconnect and “recharge” (outside of work).  

What are some other programs or workshops your department has started and how can GBMC Healthcare employees get more information?
In addition to the monthly Inclusivity Learning Forums and WISER program, you will find the “Diversity & Inclusion Corner” of monthly cultural and religious observances and holidays on the Infoweb.  We have expanded the annual Black History Month celebration to include weekly activities throughout the month of February.  For more information, email diversity@gbmc.org

What would you like people to know about the council and future initiatives for employees?
The Diversity & Inclusion Council is committed to creating a framework that reflects our vision of creating an organization that attracts, retains, and leverages the diversity of our staff to meet the needs of our workplace and the populations we serve.  Future initiatives include religious and cultural celebrations, holidays, and upcoming GBMC diversity and inclusion events, a talk Line that employees can call if they feel as though an event, interaction, or encounter has left them feeling uneasy, disrespected or excluded from a diversity and inclusion standpoint.  Professional development opportunities related to developing inclusive work environments and engaging in bold conversations about diversity and inclusion.

Lights! Camera!....

On Thursday morning, you might have seen a video crew following our teams during the daily Lean Daily Management (LDM) walk. They were here filming LDM because of our national patient safety award, from the American Society for Healthcare Risk Management and Datix, that we received last year.

We were honored with the inaugural ASHRM Patient Safety Award for our use of LDM to improve health outcomes for patients and reduce 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 the Best Health Outcome and the Best Care Experience with the Least Waste of resources and the Most Joy for those providing the care.



In winning the award, we demonstrated how LDM principles, applied in a health care setting, improved patient safety. Some examples of the improvements through LDM included a reduction in catheter associated urinary tract infection (CAUTI) of 92 percent, surgical site infections (SSI) by 85 percent along with a reduction in readmissions rates for patients, fewer instances of missing medications, fewer employee injuries, better hand hygiene and an overall improved patient experience as measured by HCAHPS.

The ASHRM Patient Safety Award recognized our organizational excellence in patient safety and celebrated our efforts in risk management and in promoting patient safety across our health care system. Receiving this recognition from an external authority, like ASHRM, is a confirmation of the work we're doing to move us towards our quadruple aim.

This award was the result of the hard work and dedication of the entire GBMC family. I am so grateful that the crew was here to document LDM so it can be shared during this year’s ASHRM annual meeting next month in Seattle. We will also receive a video that we can use to teach new employees about our process.

We should all be very proud of our achievements in moving closer towards our vision.

The Summer is Ending

I hate the winter. When I tell people this they often point out to me that I moved to Baltimore from Boston where it is much colder. I am very grateful that I now live in a warmer place but I still wish that summer lasted all year long. I guess I just have to get over it.

But the change of seasons is a good time to reflect. I’ve been thinking recently about how much we have changed over the past seven years. I was reminded this morning on Lean Daily Management Rounds of one big change that we have made. When we were at the LDM Board in Family Care Associates, I asked the team if everyone had plans for the weekend and Dr. JoAnne Wills said: “I’m working”. Why will Dr. Wills be working as a primary care physician this weekend? Well, what if your daughter was sick and needed to be seen for something that wasn’t an emergency? Wouldn’t you want her to be seen in a timely way by a team that knows her and has her medical record, will treat her with kindness and won’t generate a very large bill? This is why Joanne will be working and it shows that we have changed and become truly more patient-centered in our advanced primary care offices. Thank you Dr. Wills!

We all know that just about every clinical outcome that we measure has improved over the last seven years because of our adoption of continuous performance improvement as the way we do our work. We are not perfect, but we get better at getting better every day. So maybe it’s good that the summer is ending and I will be spending less time outside…I’ll have more time to work on helping our healthcare system move faster towards our vision.

Labor Day
As our country celebrates the hard work of the American people, this Labor Day holiday, many of us will enjoy a three-day weekend.  But, many of my colleagues (like Dr. Wills) will be working. Please let me thank all of the phenomenal people of the GBMC HealthCare System for their labor towards our vision. Let me thank all of them for what they will do this weekend and every day to serve our community. Let me give a special shout-out to everyone who works in the Emergency Department for all that they do especially dealing with the opioid and mental health crises in the face of a nursing shortage. What makes a healthcare system truly outstanding is not the technology or the facilities, but the people.  I want to thank all of you who make our health system strong because you go to work every day and work hard serving others. Thank-You!

Tragedy in Texas
Our thoughts and prayers are with all those that have been affected by Hurricane Harvey. Watching the news, you can’t help but feel sorry for all the people who were harmed by the storm, lost loved ones or who had devastating property damage.  It is very sad to see so many homes destroyed. We Americans, the descendants of people who built this country often under adversity, are a resilient lot. I have no doubt that all the cities affected by Hurricane Harvey will rise up again.

Please join me in donating online using this link. You can also text “HARVEY” to 90999 to make a donation of $10. The GBMC HealthCare System is very good at helping those in need…let’s show the people of Houston and the other affected areas that we stand with them now! Thank you.

GBMC: the only healthcare system in Maryland to reach HIMSS 7 for both Inpatient and Ambulatory Care

Back in early June, we had representatives from the Healthcare Information and Management Systems Society (HIMSS) evaluating our healthcare system on the use of electronic health records. As you know, GBMC has been utilizing the Epic system since this past October.

I am very pleased to announce that GBMC HealthCare has achieved Stage 7 on the HIMSS Analytics Electronic Medical Record Adoption Model (EMRAM) for our inpatient care and ambulatory care! This award represents a lot of hard work to eliminate paper records and get all of our patients' information in one electronic file.

EMRAM is a methodology for evaluating the progress and impact of electronic record systems and includes eight stages (0-7) that measure a hospital’s implementation and utilization of IT to optimize the care that patients receive. Stage 7 represents the most advanced patient record environment. HIMSS Analytics developed the EMRAM as a tool to compare information technology maturity in health care organizations. Less than 5 percent of hospitals in the United States have achieved Stage 7 certification.

This accomplishment is due to the commitment and effort of the GBMC staff which includes our highly-skilled team of physicians, nurses, other clinicians and IT professionals. I want to thank all of my GBMC colleagues for this achievement especially Dr. Fred Chan, our Chief Medical Information Officer, Cindy Ellis, Epic Project Director, Dave Hynson, GBMC’s Chief Information Officer, Chase Roberts, Finance/Operational Efficiencies Manager and Mary Swarts, the Epic Nurse Champion, who all played an integral role in getting us to this point.

Achieving this recognition is something we all should be proud of.  It exemplifies our true commitment to ‘one patient, one record.’ Without this, we cannot reach our vision of being the community-based health system where every patient gets the care that we would want for our own loved ones.

Congratulations Dr. Kline!
Recently, I learned that Dr. Antonie “Tonie” Kline, the director of our Pediatric Genetics at the Harvey Institute for Human Genetics, will receive the RARE Champions of Hope in Medical Care and Treatment Award for her development of the Multidisciplinary Cornelia de Lange Syndrome (CdLS) Clinic Program. This award honors physicians for their notable efforts in rare disease advocacy, science, collaborative medical care, and treatment.

CdLS is a developmental disorder that affects many parts of the body. The features of this disorder vary widely among affected individuals and range from relatively mild to severe. An estimated 20,000 people in the U.S. have CdLS but remain undiagnosed and without support services.

Dr. Kline has coordinated free bi-annual Multidisciplinary CdLS Clinics for Adolescents and Adults at GBMC. During these small clinics, patients meet with Dr. Kline and a group of volunteer specialists. Patients and families are provided with behavioral plans, treatment protocols and valuable information on expectations for the individual’s current stage of life. This service helps families in knowing what to expect as their loved one with CdLS ages, and they are able to bring these protocols back to their personal physicians, educators, and caretakers.

As the medical director for the CdLS Foundation, Dr. Kline is also involved in both national and international research related to the condition. Over the years, she has established other clinics throughout the country; provided consults to roughly 300 children at biennial CdLS National Family Conferences; raised approximately $85,000 and has organized the Foundation's running group, Team CdLS Baltimore.

Please join me in congratulating Dr. Kline on her recent achievement and for her efforts to help people with CdLS.

Baltimore City Fire Department Gives To GBMC

Last Friday, Baltimore City Fire Department Chief Niles R. Ford and members of the Local Unions 964 and 734, visited our Sandra and Malcolm Berman Comprehensive Breast Cancer Center and kindly presented us with a generous monetary donation.

From the sales of a few hundred pink Baltimore City Fire Department t-shirts, they were able to raise $8,500 which will be used by our breast cancer center in providing holistic breast cancer support; such as breast surgery aftercare kits, therapy, and other recovery options.

We are truly honored that these men and women of valor chose us to be the recipients of their efforts to bring awareness and aid in our fight against breast cancer. I want to thank all the firefighters, not only for their generosity and caring but, for what they are doing for our community.

Are we following the standard work…the design?

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

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

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

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

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

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

Please share your thoughts with me. 

The Affordable Care Act was not repealed. What next?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Studying Defects to Learn and Improve at GBMC

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

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

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

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

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