A Trip to Verona, Wisconsin in the winter?

Last week, I traveled to the Midwest with Dave Hynson, GBMC’s Chief Information Officer, Dr. Fred Chan, our Chief Medical Information Officer, Cindy Ellis, the Epic Project Director, and Mary Swarts, the Epic Nurse Champion. We went to Verona, Wisconsin, a suburb of Madison, the capital of Wisconsin, to visit the headquarters of Epic Systems Corporation. It was quite a trip.

Epic, the vendor of the new information system that we are about to begin building and implementing, has the reputation of being the company that is out in front of the others in the creation of a medical record that meets the needs of the patient, care providers, and those leading enterprises to deliver care. After meeting Judy Faulkner, principal owner of Epic and the person who started the company, I now can see how Epic got to the point of being the leader in this field. Judy described the origins of the company (1979) when she was helping create databases for clinical faculty members at the University of Wisconsin. People kept telling her that she should start a company. As a mathematician and computer scientist, she really didn’t know how to do this or even if it was a good idea. She took the advice and built a company with the motto: “Do good and have fun.” (Later she added “and make money”). Today, her company employs 8,000 people, 1,500 of the employees are programmers, on a sprawling 1,200 acre campus. 

The company moved to its present location in the early 2000’s and the buildings each have a Disney-esque feel and theme. Unlike most companies that use the conventional wisdom that individual offices for staff are not necessary and therefore build cubicles for their people, Epic has offices for just about everyone under the belief that a quiet space is necessary for people to maximize their productivity. 

We met with many people who explained to us the capabilities of the software and the importance of building it for GBMC in a way that will allow us to get the most out of it. We got a “test drive” of the software and we were all really impressed. When I last cared for patients I was using an electronic record but the capabilities of Epic are very advanced. Our colleagues demonstrated how easy it is to use telemedicine to communicate test results to a patient using their mobile app. They also showed us how notes can be created to maximize the discreet data that is captured for analysis later while allowing the provider to use voice recognition software to minimize typing.

Technology cannot create a vision or change a culture, but, it certainly can accelerate the rate of change toward a vision. I am very excited about implementing Epic so that each patient will only have one record at GBMC and it will make it easier to treat everyone the way we want our own loved ones treated. We have a lot to do between now and October, 2016 when we go live. Thanks to all who will help us get there and beyond!

Join the GBMC 50th Team for the Aids Walk & Run Baltimore on Sun. May 3rd

My good friend, Dr. Sam Ross, President of Bon Secours Hospital, asked me to support a cause that really needs help from the community. While some of us have not been focused on it, the AIDS/HIV epidemic has raged on, especially in the City of Baltimore. There are many undiagnosed cases of this terrible and treatable disease. On Sunday, May 3rd at 8AM there will be a walk and 5K run at the Maryland Zoo in Baltimore to raise money for AIDS awareness and testing.
   

I have started a team called GBMC 50th and I am asking all of my GBMC colleagues to consider coming out and walking or running with me as another fun way to celebrate our 50th Anniversary and give back to our community. If you want to get some exercise that morning or lend financial support (or both!) click on this link and follow the directions under “join a team”: https://www.kintera.org/faf/teams/registerTeam.asp?ievent=1112368&lis=1&kntae1112368=C5F4F766B96543009F1092421D8EC1D9&teamAction=join

Thanks!

Our People are Safer on the Job

The GBMC vision includes becoming the healthcare system where our team derives more joy from helping people. We have recognized that if our staff is not safe on the job, they clearly will not experience the joy in their work. For this reason, since fiscal 2013 we have had an annual goal to reduce employee injuries. In fiscal 2012 we had 370 injuries – more than 1 per day! In fiscal 2013 we had 327 and last fiscal year we had 231. This fiscal year, through January we have had 92. In the month of January, we had 7 employee injuries, the lowest since we started measuring!





We have not accomplished this by wishing or hoping or by lecturing our people. We did it by a thoughtful study of each individual injury. Mindy Beckwith, our Manager of Employee Health and our Employee Injuries Team have done a fabulous job in overseeing this system. When an employee is injured, his or her manager immediately studies the event and completes a form that includes a narrative about what happened. Every morning, the day’s injuries from 2 days prior (to allow adequate time for study) are reported on the Executive Lean Daily Management board. Our senior team looks for the learning from the injury and shares it at each of the LDM boards (we now have 30 of them) and later in the day, an email goes out to all that explains the nature of the injuries with suggestions for preventing them.  We have had major success in reducing employee strains and sprains especially from lifting. In addition, our learning from splash injuries and making the use of protective eyewear standard work, has almost eliminated blood borne pathogen exposures to the eyes.

We should celebrate everyone’s hard work in making us all safer but we cannot stop until we get to zero employee injuries. Thanks to all and keep up the great work!

Follow-up on the Timely Reading of EKG’s

Last October, I wrote a blog about how Phil Komenda, our Director of Imaging and Cardiac Services, and his team were working to move our electrocardiogram (EKG) reading closer to 100% reliability and in turn moving us closer to our vision.
(http://ahealthydialogue.blogspot.com/2014/10/getting-to-level-3-mistake-proofing.html ).

Since that posting, Phil and a selection committee made up of nurses, biomed techs, cardiology techs, and IT, purchased 21 ELI 350 EKG carts that were distributed to the inpatient units, Emergency Department, and the Diagnostic Center.  Upon their arrival they were successfully configured and tested on the network. 

So, why is this important?

These new carts will offer significant enhancement for our staff and patients by improving operational efficiency and patient safety.  They will transmit the EKG tracing wirelessly by the push of a button; eliminating the previous wasteful steps where staff on our inpatient units had to find a wall jack, plug the cart into the jack, and then transmit electrocardiograms. These new machines transmit wirelessly once the study is completed thereby freeing up the staff member to do other work and eliminate waste in the system, as well as reduce transmission delays.

The second important enhancement is that all the demographic and clinical information is entered automatically through work list management. The nurse can either scan the patient’s bracelet with a barcode reader or type in a few letters of the patient’s last name to call up the patient from a list of orders on the EKG work list.  This process eliminates the time it takes to type in all the demographic and clinical information, as well as reduces error rates. When demographic information is typed incorrectly, the EKG cannot be matched to the order.

Training with the new carts is close to completion and will GO LIVE on Wed. Feb 18th. We expect that this enhancement will bring more joy to the areas providing care, and improve care by reducing transmission delays and the probability of the EKG not being read within 24 hours of the study.
 
I want to thank Phil and his colleagues for all their hard work and their commitment to our quadruple aim. 

Television Stars

Last week, Bonnie B. Stein, our HealthCare Board Chair, and I participated in a taped interview with our media partner, WMAR-TV, regarding the 50th anniversary celebration for GBMC HealthCare.  More on this at a later date.

What made me really proud was the touching story, on WMAR-TV, that highlighted the integral role GBMC played in meeting the healthcare needs and enhancing the quality of life for one family.  If you haven’t seen this clip, please watch it by clicking on the link below.  It will make you proud  to be part of a big team that delivers the care that one would want for their own loved ones!

http://www.abc2news.com/news/health/gbmc/lifesaving-to-life-changing-one-perry-hall-couples-love-affair-with-gbmc

Making It Easier (and Safer) to Get the Work Done on an Inpatient Unit

In August of 2012, I wrote a blog about the 6S process. (http://ahealthydialogue.blogspot.com/2012/08/5-or-6-s-having-prepared-work-space-to.html). Since then, we have used this Lean tool to improve the work environment in a number of areas from physician office practices to the operating room support areas.

Last week, a Team led by our new Lean facilitator, Ishmel Fulton, and the Nurse Manager, Cecelia Gayhardt,  made the workplace more organized and safer on Unit 48. To refresh your memory, 6S stands for:
1.    Sort: eliminating everything not required for the work being performed.
2.    Separate: efficiently placing and arranging equipment and material.
3.    Shine: tidying and cleaning.
4.    Standardize: standardizing and continually improving the previous three.
5.    Sustain: establishing discipline in sustaining workplace organization.
6.    Safety: creating a safe work environment.

The Team applied this methodology to the manager’s office (which became an equipment room), the supply room (which became the manager’s office), the med bays, the nursing station, and the break room….all in all 506 square feet of space. They filled 3 dumpsters with “stuff” that was outdated or no longer needed. The Team added 90 new storage solutions including bins and file holders and marked them with 190 labels. They managed 16 wires to make them less of a hazard and created 31 visual controls such as signs, standardized locations and color coding.

A neat and clean workspace where everything is in its place reduces inventory costs, frees up space for other uses, eliminates some types of error, reduces motion and time searching for things and can significantly improve morale. Just look at the before and after photos!

I am very grateful for the hard work of the Unit 48 6S team. They have made it easier to get the job done. The Team will now be creating the standard work to sustain their efforts. Team members include (from left to right): Ishmel Fulton; Lilian Isabor; Cecilia Gayhardt; Christine Collier; Rikki Pullet; Susan Stevens; Courtney Hendon; Rachel Olsen; Beverly Edwards and Teresa Schorr (not pictured).

 


Internal Medicine Residents Demonstrate Their Knowledge
This weekend, a team from our Internal Medicine Residency Program won second place in the Doctors' dilemma contest at the Maryland Chapter of the American College of Physicians (ACP) meeting. Our Team will now be moving on to the competition at the National ACP meeting at Boston in April.

While other teams consisted of 3rd and 2nd year residents, the GBMC team consisted of three 1st year and one 2nd year resident. Our team included: Dr. In kyu Yoo (2nd year), Dr. Azharuddin Soudagar (1st Year), Dr. Faizan Babar(1st year), and Dr. Laurel Cummings (Preliminary year, Dermatology).

Please join me in congratulating our team and in wishing them luck in Boston!

Delivering on a Promise to the Community

Last Thursday, I traveled to Annapolis to address the Senate Finance and Budget and Taxation Committees. I was part of a panel from the Maryland Hospital Association (MHA) that was asked to give the Senators an update on how hospitals are transforming themselves in order to meet the four requirements of the new waiver: to keep hospital cost increases no higher than the rate of increase in the general economy, to improve the quality of inpatient care, to reduce re-admissions and to save money for Medicare.

At the hearing, there were two panels. In the first panel, the Senators heard from John Colmers, the Chairman of the Health Services Cost Review Commission, the body that sets hospital rates and must assure that the State complies with the waiver mandates, and Donna Kinzer, the Executive Director of the Commission. These two leaders did an excellent job of educating the lawmakers on the basic tenets of the waiver and how the State was performing so far.

The Committees then heard from David Horrocks, the Executive Director of CRISP (Chesapeake Regional Information Sharing for our Patients network), our regional health information sharing network. Mr. Horrocks told them of the work of CRISP in sharing patient information across hospitals.

The Chairman of the Finance Committee, Senator Mac Middleton, then invited the hospital panel to address the senators. Carmela Coyle, the President of the MHA, told them that the hospitals had embraced the notion of global revenue budgets as a means to begin converting towards higher value health care and that significant progress had been made in a short period of time. Carmela referenced the waiver “dashboard” ( http://www.mhaonline.org/finance/hospital-2-0-waiver-watch/waiver-watch) that the MHA was updating monthly.

Then it was my turn. I had been invited because of all of our accomplishments to date in building a system of care through the eyes of the patient – a system that can achieve our four aims of the best health outcome with the best care experience with the least waste of resources and the most joy for those providing the care, in other words, the care that you would want for your own loved one. I told the senators a bit about our hospital, our hospice, our excellent physicians and nurses, and our outstanding acute care capability, especially in surgery. I then told them of our vision, our 100+ primary care providers practicing in the patient-centered medical home working with embedded care managers, our extended hours of operation, and our daily use of CRISP to assure that our teams were not missing important information about our patients. I concluded with a few examples of our results so far and I informed them that GBMC has the lowest readmission rate in the State among non-rural hospitals. I had a huge sense of pride as I was speaking. We are delivering on our promise to the community. While I knew that the legislators did not understand everything that I was saying, I also knew that they were grateful for the work of the GBMC family. We were not asking for more money or lamenting our lot in life and telling them how hard our work was (even though it is!) – We were transforming into a company that can deliver better outcomes at lower cost and we had data to prove it. I want to thank all of my GBMC HealthCare System colleagues for being in action on change for the better!

Improvement Across Departments Requires “Boundary Spanners”

The GBMC HealthCare System is making great progress in improving care. Every morning on Lean Daily Management rounds I hear of tests of change that have led to better outcomes under our four aims. We are making performance improvement the way we run our organization.

Dr. Deming taught us the importance of deep process knowledge. Without knowing how the work is actually happening, we have no hope of generating better designs. We must go to the workplace, or as the Japanese call it the “gemba” and observe the process to find the opportunities to make it better.  It is clear to me that when the work is totally within the control of a given unit or department, we make progress quickly. There are many examples of this at in our system of care, but one that I spoke about in this blog is the work of Charlene Mahoney, RN, Lewis Hogge, MD, and their team in the GOR PACU. They quickly identified a design change and got to 100% completion of the final check by the Anesthesiologist before the patient leaves the PACU.

In a complex system, like a hospital, it is much more difficult to improve performance when the process involves more than one unit or group. This is because no one “sees” the whole process. People know the part of the process that they are involved in and are quick to assume what is happening in the rest of the process. An example of this is in our process for medication delivery from the pharmacy to inpatient units. I remember in April 2013, at the Unit 38 LDM board, it was reported that there had been over 30 missing doses of medication the day before. This means that when a nurse went to give a patient a prescribed medication, it was not there at the time it was due. Through the hard work of our nurses, technicians and pharmacists, the rate of missing medications is much lower but we are still not at perfection. It is hard to fix the remaining defects because it requires direct study of each defect across the departments and units involved.

In this blog, I have been talking about mindfulness and the tenets of high reliability and referring to the work of Drs. Karl Weick and Kathleen Sutcliffe. Last week, I commented on the commitment to resilience, or the enhanced ability of high reliability organizations to deal with and overcome the unexpected. Another tenet of mindfulness is the reluctance to simplify.  Weick and Sutcliffe point out that high reliability organizations do not jump to conclusions and they do not allow people who haven’t seen and studied the entire process to suggest changes to the process. They suggest that organizations have “boundary spanners” or people that go from one department to see the part of the process that they don’t know in another department. This is the same concept as going to the “gemba” in Lean terms.

Boundary spanning is hard because we generally don’t have people who have created time in their schedule to do it. Instead, they are put in the position of spending their time fixing the same problem every day like in the movie Groundhog Day. In the medication delivery example, we need to do the hard work of studying the few remaining missing doses to come up with the improvements required to eliminate them. We need boundary spanning and we need to be reluctant to simplify and assume why things are not going well to avoid making the situation worse.

Do you have an example of boundary spanning or going to see the work in another department that has resulted in better care?

Resiliency

In the GBMC HealthCare System, we are students of high reliability. We have to be if we are working towards our vision of patient-centeredness and treating everyone, every time, the way we want our own loved ones treated. The defining characteristic of high reliability organizations, according to Dr. Karl Weick, the internationally recognized expert in this field, is “mindfulness.” You can think of mindfulness as a heightened awareness of what is going on around you coupled with an unwillingness to believe that since everything is going along smoothly, things will continue to progress smoothly. Highly reliable organizations have robust processes (standard work) that can be relied upon, but they also anticipate and become aware of the unexpected faster so that they can deal with it.

In previous blogs I have discussed one of the fundamental underlying concepts of mindfulness - preoccupation with failure. This week, because of the outstanding work that our people have done in dealing with the influenza epidemic, it occurs to me that I should write about another of the concepts – a commitment to resilience. Dr. Weick points out that highly reliable organizations develop better capabilities to detect, contain, and bounce back from unexpected events. They learn from things that don’t go well and refine their processes. They try and plan to be ready for whatever might come their way, but still they can get caught unprepared for a rare event or for the magnitude of a less rare event. Such is the case with our current influenza epidemic.

Over the last 3 winters, we have not had huge increases in demand due to the flu.  One day last week, our emergency department saw 238 patients in a 24 hour period. Our normal average number of patients is around 150 per day. Imagine any business that needs to serve over 50% more customers than the usual! The ED nurses, physicians, nurse practitioners and physician assistants came in early, stayed late, and came in on their days off in order to serve those in need.  

And clearly all of the extra work has not been limited to the Emergency Department. Our hospitalists have also had huge increases in workload. Our hospitalists normally cover around 70 patients per day and they peaked earlier this week at 98. Our inpatient nurses and nursing technicians have also been tirelessly caring for a higher number of patients than usual. We opened Unit 37 to care for more acutely ill patients, and the intensivists and critical care nurses made it work.  All of our other clinicians, from therapists and phlebotomists to lab and radiology technicians, have all dealt admirably with the influx of patients. Of course our environmental services and food services teams have also had to rise to the occasion and cover the increased demand. Every member of the GBMC team has pitched in at some level to get the job done.   

I am very grateful to all of my colleagues for their expertise, hard work, and resiliency. Our patients and our community are so much better off because of their efforts.

2014 – Another Year of Great Accomplishments Moving Towards Our Vision

2014 was a year of tremendous accomplishments for the GBMC HealthCare System.  The end of the calendar year is a good time to reflect on our work towards our vision. How much have we progressed in becoming truly patient-centered? What have we done to make it more likely that  every patient, every time, gets the care we want for our own loved ones?

Here are some of our accomplishments in 2014:

•    Lean Daily Management (LDM) continues to be a success story.  LDM has generated many, many improvements throughout our system. We have reduced blood-borne pathogen exposures to our workforce and nearly eliminated splash injuries to the eye because we are now reliably wearing protective eyewear when we should. The average ED patient now waits 90 fewer minutes to get to an inpatient bed.  We beat our goal of having 10 serious safety events in FY14 and had only six. We have only had one in the first 5 months of this fiscal year! We won’t stop until we get to zero, but we are on our way! You may remember the “not so good old days” in fiscal 2012 when we had 20 serious safety events.
•    Our fantastic volunteer auxiliary again contributed thousands of hours of service and  high success in fundraising through our Nearly New sales. Our Foundation ran a spectacular Legacy Chase steeplechase event that showcased our HealthCare system to the community.
•    Gilchrist Hospice Care celebrated its 20th Anniversary and along with Gilchrist Greater Living continued their spectacular work and truly led the region in compassionate, evidence-based care to seniors and those at the end of life. Their year culminated in an outstanding outpouring of support from the community at the 2014 Holly Ball.
•    138 members of GBMC’s medical staff in 60 different specialty areas were recognized in the annual Baltimore Magazine Top Docs 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.
•    We celebrated the opening of the new office of Family Care Associates.  Many are  talking about patient-centeredness but GBMC is delivering it NOW!  I am pleased to see a team of doctors, nurses, and technicians really design care that is less wasteful, delivers better outcomes, and is more fun to be involved in.
•    GBMC is now embarking on its 50th Anniversary and we’re excited to tell the world about our history and where we’re going in the future as we deliver on our vision.

Some of our other accomplishments in 2014 included:
•    GBMC HealthCare was selected again as winners of Practice Greenhealth’s 2014 Emerald Partner for Change Award and with the organization’s first Circle of Excellence Award for environmentally preferable purchasing.
•    In June, over 400 employees, patients and volunteers participated in our Pink Glove Dance. Because of their efforts WE WON the national Pink Glove Dance competition. As a result, our community partner, The Red Devils, received $10,000 to support their work helping breast cancer patients and families.
•    Bonnie B. Stein, a member of the Board of Directors since 2009, was appointed as the Chair of the Board of Directors replacing Harry S. Johnson following the completion of his three-year term.
•    We celebrated the official opening of the Ehlers-Danlos National Foundation Center for Clinical Care and Research.  Under the leadership of Dr. Clair Francomano, the Center will provide comprehensive clinical care for patients, professional education and cutting-edge research.
•    For a second time, we received the Delmarva Foundation Excellence Award for outstanding performance in inpatient care.  To achieve this recognition a hospital must meet specific performance improvement criteria on ten quality measures in two clinical services: medicine and surgery. 
•    Dr. Janet Sunness received the 2014 Envision Award in Low Vision Research and was recognized for her expert work and as a prolific clinician-researcher in the area of maculopathy and for her significant contributions, most specifically in the understanding of and defining the parameters in clinical trials for the “dry” form of advanced age related macular degeneration.
•    Greater Baltimore Medical Center (GBMC) was designated as a Center of Excellence in Minimally Invasive Gynecologic (COEMIG) Surgery by the American Association of Gynecologic Laparoscopists (AAGL), the leading association of minimally invasive gynecologic surgeons, and Surgical Review Corporation (SRC).
•    Our Primary Stroke Center was once again recognized by the American Heart Association/American Stroke Association’s (AHA/ASA) Get With The Guidelines® (GWTG) program for our commitment to quality patient care.  Additionally, we achieved the Target: Stroke Honor Roll designation for meeting specific achievement levels and for improving stroke care.  This is the first year we have received this award for outstanding teamwork in our ED to identify and treat Acute Ischemic Stroke patients safely and rapidly.
•    GBMC was named Top Performer on Key Quality Measures® for 2013 by The Joint Commission, the leading accreditor of health care organizations in America.  Less than one-third of U.S. hospitals earn this distinction.
•    Chairman of Radiation Oncology, Dr. Robert K. Brookland, was awarded the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control and his department was also awarded a three-year term of re-accreditation in radiation oncology as the result of a recent review by the American College of Radiology (ACR).
•    Linda A. Walsh, MD, a GBHA board member and family physician at Jarrettsville Family Care, was recently awarded the 2014 Humanitarian Award by the American Academy of Family Physicians (AAFP).

So I think the evidence is clear. GBMC HealthCare made great progress towards our vision in 2014! 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 2014 to move us closer to our vision. All I can say is thank you! I look forward to all of our accomplishments to come in 2015. What others do you want to mention? Please share your thoughts below.

Influenza A Outbreak
Let me also thank everyone who has been resilient through our recent increase in the number of patients served during the Influenza A outbreak. Special thanks go out to everyone that works in the ED and on inpatient medical units.

Best wishes to you and your loved ones for a Happy and Healthy 2015!!