Thursday, October 9, 2014

A Lesson Learned from the First Ebola Death in the U.S.

It is with great sadness that I write about the Ebola patient case at a hospital in Dallas, Texas. The patient has now died. All healthcare providers would be well served by studying what happened in this case. In late September a man walked into a hospital with a fever, complaining of abdominal pain and a sharp headache.  When the patient was asked whether he had nausea, vomiting, or diarrhea, he said “No.”  At that time his symptoms, which were not severe, could have been associated with many infectious diseases, as well as many other types of illness.  He was also asked if he had been around anyone who had been ill, to which he said “No” and if he had traveled outside the United States within the last four weeks. He responded that he had been in Africa.  A nurse entered that information in the electronic medical record. From what we know it appears that he was sent home with antibiotics.  The patient returned two days later saying he was worse and this time he was admitted to the hospital and placed into isolation with possible Ebola.  Ultimately, the U.S. Centers for Disease Control released the information that this individual tested positive for Ebola and has now died of that disease.

Ebola scares us because it has a high mortality rate and its initial signs and symptoms are not unique. The current outbreak can and will be contained and extinguished but this will require a well-designed and executed international plan.

Is our current health care delivery system capable of creating and executing this plan? Well, everyone knows that we don’t have an international health care system. We have many national health systems of varying capabilities.  A country like Sierra Leone, for example, doesn’t have a well-developed public health infrastructure or primary care system. In our own country our healthcare system has more capacity, but, the events in Dallas show that you can have extensive financial resources deployed in a healthcare system, but, have it poorly designed to meet a need of the community it serves. 

In this case, the hospital in Dallas appears to have had a major “latent” error (hole in the Swiss Cheese) that was waiting to be part of a trajectory that would lead to the catastrophe of putting a patient with Ebola back out on the street. I am afraid that the very same latent error is present in many healthcare organizations throughout our country. That latent error is the absence of direct concise communication between members of the healthcare team. I should be cautious commenting on this case without all of the facts, but it appears that at least one team member knew that the patient had recently traveled from Africa and yet the patient was discharged from the emergency department only to be admitted later with Ebola, thereby having potentially spread the disease to multiple other individuals.

The knowledge of what happened in Dallas is a potential treasure for the rest of us in the US healthcare system. We must learn from this and redouble our efforts to operate as a high-functioning team with freely flowing information and people not afraid to speak up if they have a safety concern.

Physician Assistants WeekPlease join me in celebrating all GBMC physician assistants (PAs). This week is National PA week (Oct. 6-12) and is a time when PAs celebrate their profession and showcase the value they bring to today’s healthcare team.

A physician assistant (PA) is a nationally certified and state-licensed medical professional who begin their careers with rigorous education in a highly competitive field.  Upon completion of a bachelor’s degree, prospective students must then attend an intense three year PA program and complete at least 2,000 hours of supervised clinical practice.  They then must pass the Physician Assistant National Certifying Exam (PANCE), which is administered by the National Commission on Certification of Physician Assistants (NCCPA). 

The PA staff at GBMC practice in many areas from the outpatient offices to the inpatient units in a wide variety of specialties. Please join me in thanking our PA’s for their hard work and for their important role in caring for our patients.

Wednesday, October 1, 2014

Some Awards Mean Something

In previous blogs I have talked about certain “awards” or recognitions in health care that don’t have much merit. They are bestowed on individuals and organizations of beliefs that are not backed by data or they are based on the opinions of people with a vested interest in the outcome. There are other awards that are based on facts and the receivers of the recognition should be proud.

This week GBMC was officially presented with the 2014 Delmarva Foundation Excellence Award for Quality Improvement and we also celebrated our performance in the Centers for Medicare and Medicaid Services Partnership for Patients Initiative.  Both of these events demonstrate that we are on the right path towards our vision and in achieving our aims of  better heath and better care, with less waste and more joy for those providing the care in our health system.

The Delmarva Foundation for Medical Care (DFMC), the Medicare Quality Improvement Organization for Maryland, is an independent, not-for-profit health care quality improvement organization dedicated to monitoring and improving the quality and delivery of healthcare services in our state. To receive the Delmarva Foundation Excellence Award a hospital must meet specific performance improvement criteria on ten quality measures in two inpatient clinical areas:  medicine and surgery.  This is the second year we have received this award for outstanding performance against national standards.

The Centers for Medicare and Medicaid Services’ Partnership for Patients initiative, started in 2011, is a public-private partnership working to improve the quality, safety and affordability of health care for all Americans. The Partnership for Patients and its over 3,700 participating hospitals are focused on making hospital care safer, more reliable and less costly through the achievement of two goals: enhancing patient safety and Improving Care Transitions. At GBMC in an effort to meet this goal we assembled nine teams, each with accountability for an area of patient harm.  GBMC is achieving its goal in 12 of 14 measures. That means that if we continue at our current performance level we will meet the 40% reduction goal in 12 areas. Since January of 2014, these teams have eliminated 800 incidents of patient harm!!

Also, I am glad to announce that our Primary Stroke Center has once again been 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. Hospitals receiving the GWTG Gold plus Achievement Award have reached an aggressive goal of treating stroke patients with 85% or higher compliance to core standard levels of care as outlined by the AHA/ASA for 12 consecutive months. In addition, those hospitals have demonstrated 75% compliance in 5 out of 8 stroke quality measures during the 12-month period. Additionally we also achieved the Target: Stroke Honor Roll designation for meeting a specific GWTG achievement level and for improving stroke care. This designation means that at least 50 percent of eligible ischemic stroke patients have received IV rt-PA (TPA or “stroke buster” medication) within 60 minutes of arriving at the hospital (known as ‘door-to-needle’ time), assessed on a quarterly basis. This is the first year we have received the Target: Stroke Honor Roll highlighting the outstanding teamwork in our ED to identify and treat Acute Ischemic Stroke patients safely and rapidly.

All of these recognitions are for measurable improvements in care. I want to thank all of our clinicians for their hard work and dedication and for designing systems to get to this level of performance and for not relying on hard work and good intentions alone. Some awards definitely do mean something and we should be proud.

Wednesday, September 24, 2014

Pete’s Room is Now Clean and Neat

I have written before in this blog about the technique known as a 5S event. The main goal of a 5S is to organize and standardize an area 5S stands for Sort, Set in order, Shine, Standardize and Sustain. A 5S is at the foundation of performance improvement for an organization.  Clutter clogs up physical and mental flow of material and information.  After all, if members of our hospital staff are working in a cluttered   area how can we expect them to improve service to patients and others? Evidence shows that when a 5S is done well, the workplace will: “talk” to you, control itself, will be refreshing, safe, predictable and reliable. The results of a 5S will shorten training for new employees and be welcoming to everyone including our workers and our visitors.

5S GOR Team

Jody Porter, DNP, RN, our Sr. Vice President, Patient Care Services & Chief Nursing Officer was the executive sponsor for the event. The team also included Neil Crockett (Facilitator), Courtney Hendon (Team Leader), CJ Marbley, RN (Perioperative Nursing Administrative Director), Denis Albaladejo, RN (GOR Nurse Manager), Steve Adams, B.A., RN., CRCST (Sterile Processing/Anesthesia Manager),  John Bisker, RN (GOR Clinical Partner), Tracy Lamb, CRNP (Perioperative Nurse Specialist), Nick Dinatale, RN (OR Team Lead), Dan Schaefer, (Sterile Processing Supervisor), Frank McDonald, (Supply & Equipment Specialist), Charles Williams, (Supply & Equipment Technician), Will Boone, (OR Support Assistant), Kendrick Wiggins, (Stores Supervisor), Alyssa Natoli (Student Intern) and Celeste Demalo (Student Intern).  The team had representation from all areas that make the GOR run smoothly, which is critical for the last S, “sustain.”  Peter Whipple (Surgical Laser Coordinator), Stephanie Mayoryk, RN (Infection Control Manager), Michelle Tauson (Safety Specialist), our Environmental Services and Facilities team also played a key part in the success of the event.

The original scope of the event included hallways outside of the breakout room (pic below), central sterile and the locker room.  Other areas added were the “Breakout Room” (also known as the vendor equipment room) and “Pete’s Room” (storage area). Throughout the week the scope expanded to include the following supply rooms: the Equipment Room (pic. below), the Ramp Room, the Ortho Room (pic. below) and the Sub-Sterile (Emergency Cart) Room.

These additional areas could be added because of the outstanding pre-work done before the event week. The objectives were to: train the team in 5S principles and implement those principles; target equipment areas to organize, standardize space for patient volume, staff workflow and the restocking process; determine the physical items and information needed in those areas; and to clear hallways to create a safer environment for both employees and patients.

Through this event the team “sorted,” “set in order,” “shined,” and “standardized” three hallways and six storage supply rooms. Results included the “crushing” and disposal of 100 unused items, the creation of 200 visual parking spots for equipment, the hanging of 120 visuals, the making of 400 parking spaces and equipment labels and the shining of 3,622 square feet in the GOR.  In addition six life safety violations were resolved.  The team also found obsolete equipment that was quoted for a resale of $12,550.

After the 5s event, the team plans to sustain the success of the event by using a 5S daily audit checklist, a follow-up newspaper and have a created a communication handout for stakeholders of the newly 5S’d areas.
What great work this Team did! Not only Pete’s Room, but many other spaces are now standardized and clean and will make it easier for our people to serve patients the way they want their own loved ones served. I am very grateful for the efforts of the GOR 5S Team. What do you think?

Thursday, September 11, 2014

Critical Care at GBMC: No Longer Relying on Hard Work and Good Intentions Alone

On January 1 of this year, GBMC began a new era in critical care. We have always had excellent physicians and nurses caring for our sickest patients in our ICU’s, but our care delivery model – the system our people worked in – was not state of the art. 

All of that is now in the past. Under the leadership of David Vitberg MD, all ICU patients are now covered by a new, high-intensity, hospital-based team.  From inception, this new team significantly increased the level of oversight and availability for our sickest patients by extending attending physician in-house coverage from 8-10 hours (on average) to sixteen hours per day.  Also from inception, the team took ownership of all surgical intensive care unit patients. Prior to this, the attending surgeon was responsible for the minute to minute changes often required in the SICU while continuing to do his or her other work in the office or in the operating room unless a consultation request was made.  Now, the GBMC surgeons that fill the SICU with patients and the dedicated nurses that staff this unit have an equally dedicated group of intensivist physicians that attend to this high acuity patient population around the clock. This is what you would want if the patient were your loved one.

During the past six months, six new physicians were recruited to the division – four of which split time between the intensive care units and the new pulmonary practice – Pulmonary Medicine at GBMC.  In addition, three supplemental attending physicians were recruited to provide extra coverage as needed.  Supporting these ten physicians, two physician assistants were hired and now provide coverage seven days per week between 0700 to 1900 hours.

The 7 full time members of the physician critical care/pulmonary group are:

As of September 1st, all of the members of this new team are on board. But much progress has already been made to improve the quality and safety of Critical Care Medicine at GBMC.  An overriding principle in developing this new division was to elevate the delivery of Critical Care Medicine and build an environment and group of clinicians that would deliver this care in a safe, efficient, evidence-based, and compassionate manner that would defy the ‘low intensity’ label typically attributed to a community intensive care unit.  The following key initiatives highlight the division’s dedication to rapidly creating a safer and more cutting edge critical care system at GBMC.

1. Therapeutic Hypothermia for heart attack patients
Therapeutic hypothermia after return of spontaneous circulation in survivors of cardiac arrest has been shown to improve neurologic outcomes.  Between 2002-2004 many local hospitals around the beltway developed and started using therapeutic hypothermia protocols.  GBMC created an order set for this therapy but did not design a robust system to use it.  Within weeks of launching our new Critical Care program in January, an updated therapeutic hypothermia protocol was written and equipment required to delivery this therapy was acquired (Arctic Sun Temperature Management System).  The policy and procedures for cooling patients was updated to reflect best evidence, and cutting edge technology like BIS monitoring (Bispectral Index continuous processed EEG) was incorporated into the protocol. to limit potential awareness under paralysis and improve patient safety, and the related Neuromuscular Blockade policy was overhauled and fully updated. This modality is now available for use on patients who will benefit from it.

2. Critical Care Infusions: Improving patient safety and standardizing care delivery
Realizing the risk associated with different physicians ordering the same titrateable medications in different ways (and the confusion this created for our nurses), Dr. Vitberg and his team identified every titrateable infusion commonly used in all critical care areas and standardized all five fields required to order these medications.  The ‘Medication Guideline – Critical Care Adult Titrateable Infusion’ policy was approved by the Medical Board in May.  Our MIS/IT staff is completing an update in Meditech which mirrors this paper policy.  This will undoubtedly lead to more appropriate utilization of these high-risk medications, increased standardization in our practice of critical care medicine, and provide a safer experience for our patients. 

3. The ICU Transfer Checklist: Ensuring no missed hand-offs and reinforcing direct attending to attending physician communication
One of the highest risk times during a patient’s hospitalization is the time at which they transfer out of the intensive care units to lower levels of care.  To ensure that the handoff to the receiving physician happens reliably, the new group created an ICU Transfer Checklist.  A patient cannot be moved out of the unit or transferred to another facility without the sending critical care attending talking to the receiving medical attending or surgeon, the residents giving sign-out to each other (when they are involved in patient care), and the nurses giving sign-out to each other.  Since the checklist was implemented, our Team has achieved a near 100% compliance with hand-offs over the past few months.
4. Creating standard work and  organizing critical care interventions to improve patient outcomes
Many interventions in critical care are time sensitive. Implementation of protocol-based care empowers nurse and respiratory therapists to begin therapy quickly for critically ill patients and engages all members of the critical care team.  Implementation of evidence-based protocols, many of which contain bundled care items recommended by organizations like the Institute for Healthcare Improvement, improve care reliability and patient outcomes.

5. CHARMS Committee: Taking a closer look at how we screen for and treat sepsis
The CHARMS Committee (Community Hospital Action plan to Reduce Mortality from Sepsis) was organized in June 2014.  The committee is made up of MICU and SICU nurses, ED physicians and nurses, intensivists, residents, and a faculty physician representative from the Department of Medicine charged with quality improvement.  The focus of the committee is to review every aspect of sepsis care at GBMC, decompartmentalize the delivery of sepsis care across all patient care areas (i.e. ED to ICU to floor), ensure evidence-based best practices are being utilized, and improve clinical outcomes for these patients.
Goals of the CHARMS committee include:

• Develop a house-wide screening tool for sepsis (build on the existing screening tool already utilized in our ED)
• Update all sepsis order sets to reflect best practice, evidence-based medicine
• Ensure sepsis treatments are ordered and delivered in consistent fashion across all patient care areas (decompartmentalization of care: EMS-ED-ICU-floor-discharge)
• Develop a standard approach to determining need for central venous access
• Meet regularly to monitor clinical outcomes via review of data from Crimson

6. Code / Rapid Response Committee (RRT): Improving our response to emergencies around the GBMC campus
The division has worked hand in hand with the Code / RRT Committee to improve our response to cardiac arrests and rapid responses on the GBMC campus.  A recurring problem at code responses has been overcrowding.  In July, code team huddles were launched.  Every day at 0745 hours, all members of the code team meet in Unit 57, hand-off badges which indicate pre-assigned roles in a code response, and receive 5-10 minutes of educational ‘pearls’ from the ICU attending physician regarding resuscitation.  The names of the code team members are recorded on a dedicated board in the center of Unit 57.  This board contains educational material which reminds team members of their responsibilities at a code response, the educational ‘pearls’ for the day are posted, and any important announcements like QA/QI initiatives or equipment issues can be posted.  As ‘badged’ code team members arrive at the patient’s side, they replace initial responders that have started the resuscitation.  Security personnel and the admission coordinators have been trained to limit responders at the bedside to only those that are wearing a code badge.

7. Limited Bedside Ultrasonography: a core feature of any cutting-edge ICU
Limited bedside ultrasonography has evolved into an extension of the physical examination for critically ill patients.  All critical care fellowships now teach this skill to improve patient assessment, for procedural guidance, and to help guide resuscitation.  Ultrasound is typically used to rapidly answer binary questions in the ICU setting: is a pneumothorax present or absent?  Is there cardiac activity?  Is there free fluid in the abdomen? Is the vena cava empty or full?  Ultrasound must be used whenever possible to guide needles during invasive procedures.
So, you can see what happens when a new leader grasps the concept that hard work and good intentions by themselves are not enough to move closer to flawless care. It takes a team to design better systems and then carry them out! I am absolutely amazed at what Dr. Vitberg and his Team have done in a very short period of time. I can’t wait to see the improved health outcomes and care experience along with the reduced waste and greater joy that adding them to our existing team of outstanding nurses and other clinicians will bring.

Wednesday, September 3, 2014

Assuming and Speculating vs. Observing and Learning

Throughout the GBMC HealthCare System, excellent improvement work is being done to move us closer to our four Aims and our Vision. Where our teams have made the most progress is in letting go of behavior that proud people like me have a hard time getting rid of. We “learned professionals” have studied hard and have been trained to voice our opinion when confronted with a problem. We hear a few facts and quickly give our belief on a cause without really knowing. We assume many factors and then speculate on how these have contributed to the problem.

Engineers, as a group, do things differently. They are trained to observe things in action, to take things apart and to see how things really work or don’t work. Engineers are taught how to investigate; to get as deep as possible an understanding of an element or a process before thinking that they have a solution. When they believe that they have thoroughly studied a process only then do they test changes, one at a time, so they can see if their change is responsible for an improvement.

Engineers know that the best incident investigation is done immediately after the event with the people actually involved so that the steps can be recreated with as much fidelity to the true story as possible. Getting as deep an understanding of what happened by asking a series of “why’s” is the best way to generate tests of change to prevent the incident from happening again.

On a bad day in healthcare when we ask someone how defective care occurred (like a nurse going to give a medicine to a patient only to find that the medicine is not available to give) we get responses that begin with “Well, usually….” or “Sometimes….” Beginning the response with these words shows that the speaker has not investigated the occurrence, but, is merely speculating on the basis of his or her personal assumptions.

At GBMC, we are making great progress as our people work to investigate defects in close to real time to better come up with improvements. The learning from studying individual cases deeply is much more helpful than a perfunctory review of many cases. We leaders must give our people the time and resource to investigate defects as they occur. I look forward to hearing your thoughts on this.

I want to congratulate both Clair Francomano, M.D., Director of Adult Genetics at the Harvey Institute of Human Genetics and Janet S. Sunness, M.D., Medical Director of the Richard E. Hoover Low Vision Rehabilitation Services for their recent achievements.

Last month, we celebrated a monumental event, attended by Ehlers-Danlos Syndrome (EDS) patients and families from throughout the U.S., members of The Ehlers-Danlos National Foundation (EDNF) and GBMC leadership, to announce the official opening of The EDNF Center for Clinical Care and Research.  The major goals of the EDNF center are to expand treatment options for patients diagnosed with Ehlers-Danlos Syndrome (EDS), an inherited condition, which negatively affects the connective tissue that binds together skin, ligaments and bone.  EDS affects one in approximately 5,000 people in the US. Ours is the first center anywhere or at any time dedicated to helping EDS patients.  The center is being funded by EDNF which will give $250,000 a year over the next five years.  The funding will go toward providing comprehensive clinical care for patients, professional education , and cutting-edge research.  Dr.  Francomano will serve as the center’s Director.

Dr. Sunness has been selected to receive the 2014 Envision Award in Low Vision Research.  She is being 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.  The Envision Oculus Award is presented to individuals or organizations whose efforts in professional collaboration, advocacy, research or education have had a significant national or international impact on people who are blind or have low vision.  The Envision Award in Low Vision Research recipient is chosen by peers and selected from among nominations submitted by the Envision Research Peer Review Committee.

Wednesday, August 27, 2014

Caring for the Smallest of our Patients as if Every One was our Loved One

It has been many years since I cared for a sick premature infant, but, I can still remember looking into the eyes of anguished parents while caring for their baby. GBMC is known as a great hospital to have a baby. One of the reasons why this is true is because we have a great Neonatal Intensive Care Unit (NICU).

All health care leaders are proud about the work of their organizations, but my words here are more than bravado.  We can substantiate my claim with facts. Last week, Dr. Howard Birenbaum (pic. rt.), the medical director of our NICU, shared with me the 2013 Vermont Oxford Network (VON) Annual Report. The VON ( is a nonprofit voluntary collaboration of health care professionals established in 1988. Today, the Network is comprised of nearly 1,000 NICUs around the world. The units share data to find the best performers so that they can learn from each other. GBMC’s participation in this network is one measure of our commitment to quality of care.

Some GBMC highlights of the VON report:

- Our mortality for infants 501-1500 grams was 7.4% compared with 12% for the Network.  We have had a declining trend in mortality from 2009-2013.

- Our use of surfactant, a drug to help expand immature lungs, was 27.8% compared with 59.3% in the Network.  We were in the lowest quartile for use since we began using early nasal continuous positive airway pressure (CPAP) and avoiding mechanical ventilation as an approach of minimizing lung injury and chronic lung disease.

- Our use of any mechanical ventilation was 45.3% compared with 59.8% in the Network, also in the lowest quartile.

- Our incidence of chronic lung disease in infants < 33 weeks of gestation (full term is 40 weeks) was 17.8% compared with 25.7% for the Network.

- We had no cases of severe intraventricular (brain) hemorrhage compared with 7.9% for the Network.

- We had 5 cases of late infection (9.4%) compared with 12% for the Network. This trend continues to improve.

- Our incidence of severe retinopathy of prematurity was 2.2% compared with the Network's 5.8%.

- 80% of our babies were discharged feeding human milk versus 55.8% in the Network. We were in the top quartile!

- No infant above 750 grams or 26 weeks gestation was discharged home on oxygen. 

Together with Eva Stone, RN, the NICU nurse manager, Dr. Birenbaum leads a very talented, dedicated, and extremely hard working team of physicians, nurses, respiratory therapists, pharmacists, nursing support technicians, nutritionists, and other technicians, therapists and support personnel. We and our patients and their families are blessed to have such an outstanding team and the data prove it! So when you see any member of this team, please thank them for all that they do in moving us closer to our vision.

Tuesday, August 19, 2014

How can patients compare one hospital or system of care to another?

Much has been made of the need for “consumerism” in health care.  Many people believe that a big reason why the U.S. spends so much more than other countries on healthcare without better outcomes than countries that spend far less is because the consumer has been taken out of the equation.  Certain people believe that if the patient only had good information about the quality and cost of their care that the cost would go down. 

Recently, the annual hospital rankings of U.S. News and World Report were released. One should ask himself or herself what the rankings are based on. Do the rankings show that the highest rated hospitals provide the best value for the money spent? Or at least do the highest ranked organizations provide the best health outcomes and the best patient experience even if the price is much higher? If you take the hospitals mentioned in the rankings and examine their actual clinical outcomes and patient satisfaction scores and divide that by the prices that these hospitals charge for those services, you could come up with a value that an educated consumer could use in deciding where to receive their care. 

As has been mentioned before in this blog, The Department of Health and Human Services has created a website where patients can compare the performance of hospitals on many parameters. The website is  At this site, a consumer can find comparative hospital data on clinical outcomes such as mortality rates after certain procedures, patient satisfaction scores, and many process measures of care and some outcome data beyond mortality rates for certain disease states.  What you will find, surprisingly is that hospitals that are ranked high, in various high profile national assessments, do not perform any better than hospitals that are ranked lower in the same mass media evaluations. You will also find that many of the highly ranked organizations are among the nation’s most expensive hospitals even if their outcomes are not any better than many less costly institutions. 

What our citizen’s should be desperate for is true and meaningful comparative data so that a patient can rationally choose where they would want to go for elective care.  That is why since early 2013, the GBMC Healthcare System has displayed many of our quality parameters at and updated them monthly. Currently, we are the only local community health system doing this and very few others do it nationally. Maryland consumers also know that our rates are set by an independent agency and that agency’s website lists the hospital rates and although the data are somewhat cumbersome to navigate, an educated consumer could use the data to compare value between providers. 

When more of our citizens truly examine outcomes and cost data this will further incentivize healthcare leaders to improve care and drive the waste out of the system and care will be better, faster. Patients will then truly be able to see which hospital or community health system is the best because the rankings were based on the facts.

If it were your loved one seeking the answer to the “who is the best?” question, you would want him or her to be able to find the data to reach the correct conclusion.  Have you had an experience in trying to decide who was the best provider for a loved one?