Wednesday, November 26, 2014

If Your Mom had Diabetes Wouldn’t You Want Someone Reflecting on and Improving her Care?

One of the most enjoyable parts of my job is meeting with teams who are improving patient care. Last week I visited our patient-centered medical home (PCMH) at Hunt Manor. Drs. Robin Motter-Mast and Joe Connelly led a meeting focusing on improving the team’s diabetes composite score.  Also participating were Diana Mantell, the Administrator for Population Health of the Greater Baltimore Health Alliance (GBHA), Yvonne Latchaw, RN, the care manager at Hunt Manor, and Amanda Harris, one of the team’s medical assistants. The diabetes composite measure is made up of a number of evidence-based elements in the care of diabetes. The diabetes composite score is the first measure of population health on our system-wide scorecard.

The Hunt Manor team explained to me that it is not easy to get this diabetes composite score right. Either all of the elements are present for an individual patient or it is considered a miss. The five things that they must be achieved are:

•    blood pressure needs to be less than 140/90measured in the normal range
•    LDL cholesterol less than 100 in range
•    Hemoglobin A1c level less than 8
•    daily aspirin or anti-platelet medication in patients with diabetes and ischemic vascular
     disease (IVD)
•    and non-tobacco use 

Dr. Motter-Mast explained to me that the team has worked on engaging patients 18-75 years of age with diabetes that were missing lab values. Some of these patients were also seeing endocrinologists, so the Hunt Manor team worked with those offices to gather the values.  Other patients had not been seen recently so members of the team began contacting those patients to schedule visits.  The team also reviewed their Diabetes Disease Registry to find the patients who needed to be on aspirin, and contacted them to start if appropriate.

The GBMC data warehouse, built a few years ago, now gives us the ability to create reports like the Diabetes Disease Registry. These reports show performance at the level of the system, the practice and the individual provider and are used to find the patients who are deficient on one or more measures. PCMH teams then decide which metric to work on based upon the scores for their practice.

Most primary care offices in our country don’t have such reports and are not holding themselves accountable for helping the patient achieve measurable improvement with their chronic diseases. The GBHA, with the Hunt Manor office as an example, practices advanced primary care and is holding itself accountable for maximizing the health of each patient it serves. I am very proud of them and grateful for all of their hard work.

While at Hunt Manor the rate of success on individual metrics within the diabetes composite varies from 44 percent (LDL cholesterol) to 87 percent (aspirin use in IVD and non-use of tobacco), the overall rate of patients with all five measures met is currently 20.58 percent compared to 15.9 percent in late August of this year. Although it will be very difficult to get to 100 percent, the Hunt Manor team won’t quit until they get there!


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) at its annual meeting. The Humanitarian Award honors extraordinary and enduring humanitarian efforts by AAFP members, both within and beyond the borders of the United States.  As the medical director and chair of the Steering Committee for the Dominican Republic Medical Mission, Dr. Walsh has led annual medical missions to the Dominican Republic since 2003. Over the years, she has been instrumental in addressing the immense medical needs of the community and its lack of access to basic health care. In 2014, Walsh’s team held 13 clinics, treated more than 700 patients and initiated and oversaw the installation of a water purification system in Esperanza, a Haitian refugee village. Please join me in congratulating Dr. Walsh on her recent achievement and for her efforts to help the people of the Dominican Republic.

In my previous blog, I congratulated our Chairman of Radiation Oncology, Dr. Robert K. Brookland, for winning the Martin D. Abeloff Award for Excellence in Public Health
and Cancer Control.  This week I want to applaud him and his department for being 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).  Re-accreditation is given to health facilities that meet specific ACR-developed practice guidelines and technical standards, following a stringent peer-review evaluation by board-certified radiation oncologists and medical physicists who are experts in the field.  This designation is an honor and reflects GBMC’s ongoing commitment to excellence in cancer care. 

Finally, I want to wish everyone in our GBMC family a Happy Thanksgiving.   I have much to be thankful for.

Friday, November 21, 2014

Synchronizing to Start the Day on Time

Imagine if only 30 percent of BWI’s first flights of the day took off on time.  Commercial aviation is a large complex system. If 70% of flights from Baltimore arrived at their destinations late, it wouldn’t be long before the whole country was getting behind. Imagine how many upset travelers there would be. Imagine, also, the pressure on the air traffic controllers as they had to delay other flights to allow late flights to land.

We know that the hospital is also one large, complex system. If the operating room is sending cases out late, the PACU (Post Anesthesia Care Unit) will be delayed and cases will arrive to their inpatient beds (or outpatients to their homes) behind schedule. The downstream staff will be overwhelmed and people will have to stay longer than anticipated. The hospital will have to pay overtime to many or ask more staff to come in to handle the load. Subsequent operating room cases will start and end after their scheduled timeslots and some patients who have been fasting since the previous midnight will need to fast longer. No one is happy. 

It is not easy to make sure that everything is ready to go on time in all operating rooms in a surgical suite. Team members can arrive late, the patients can arrive late, there can be missing lab work that is required to assure that the surgery can be done safely, or the patient may be nervous and want to ask a few more last minute questions. But studying the reasons why cases are late and using problem solving to test changes will result in more on-time first cases. This is just what our Sherwood Outpatient Surgery Center Team has done under the leadership of its medical director, Dr. Aaron Wood, and its Clinical Unit Coordinators,  Holly Clevenger, RN and Kate Devan, RN3 BSN, CAPA.  This team selected first case on-time starts as one of their Least Waste metrics for Lean Daily Management and they have tested many changes and made great progress. You see from the run chart below that in March they had over 70% late first case starts and that number is now down to 34%. They have reduced the defect rate by more than 50% !


Team members understand that cases start late most frequently because of the system for getting ready, so they continue to study their system and ask the “why” questions when one does not start on time. I am so proud of them and I am very grateful for all of their hard work.

Congratulations to our Chairman of Radiation Oncology, Robert K. Brookland, M.D., who earlier this week was honored with the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control by the Maryland State Council on Cancer Control.  For those who don’t know, this award is given annually to a Marylander who has contributed to reducing the incidence, morbidity and mortality of cancer through research focused on cancer control. Dr. Brookland is a great leader at GBMC and we are proud of him for earning this prestigious honor. Please congratulate him the next time you see him!



While on the topic of significant recognitions,
I am so pleased to announce that our hospital was named Top Performer on Key Quality Measures® for 2013 by The Joint Commission, the leading accreditor of health care organizations in America. 

This is a big deal because less than one-third of U.S. hospitals earn this distinction. According to The Joint Commission, we were chosen for “our commitment to assuring that evidence-based intentions are delivered in the right way at the right time – because it’s the right thing to do for your patients.” I want to thank the following individuals and teams for helping us attain this major achievement:  Carolyn Candiello, Vice President of Quality and Patient Safety, the executive sponsor for the Core Measure reporting, Michele Cave, BSN, RN (Director of Clinical Quality Outcomes), Laura Hines, RN, Sara Helman, RN, and Laura Wieber.

The following nurse leaders also contributed: Lindsey Cromwell-Rims, RN (Nurse Manager of IR and the Kroh Center), Stephanie Topscher, RN (Clinical Director ED/UC), Charlene Mahoney, RN (Nurse Manager PACU), along with physician champions: Jeff Sternlicht, MD (Chairman, ED), Reed Riley, MD (Chief of Cardiology), Jack Flowers, MD (Chairman, Surgery), and all of our outstanding physicians, nurses and other clinicians.  Thank you for all you do for our patients.

I am truly proud of this recognition as it clearly demonstrates that we are moving toward our vision of treating everyone the way we want our own loved ones treated.  We are pleased that the Joint Commission has recognized us as one of their “top performers” on key quality measures. 

Tuesday, November 11, 2014

Again! GBMC Tops the List with More “Top Docs” and Thank-You to our Veterans

Again!  GBMC Tops the List with More “Top Docs”

Last week, we voted in the 2014 Maryland general election and on referendum questions. But recently there was another “election.”

Nearly 10,000 physicians in the region “voted” for the physicians, in a variety of specialties, that they would send a member of their own family to if they needed care. The Baltimore Magazine annual “Top Doctors” November issue was recently released and the votes are in.

I’m proud to say that many doctors agree on who is best! Once again, GBMC had more members of our medical staff cited as a “Top Doctor” than any other community health system or hospital. It is with a great deal of pride and pleasure to share with you that 138 GBMC physicians, covering 60 specialties, were recognized as a “Top Doctor.” Several of those medical staff members were recognized in more than one category, and some have been recognized many years in a row! 

Being recognized as a “Top Doctor” is an extraordinary honor, because it is a selection by peers. To all of the “Top Doctors” at GBMC, congratulations from all of us! The rest of us in the family are very proud of you.

To view a listing of our “Top Doctors” and to learn more about who they are, please visit GBMC's Top Doctors 2014 webpage.

Let me thank Dr. Alexa Faraday, one of our general internal medicine physicians practicing on our campus, who was one of the three survey advisers (and thus was ineligible to be selected as a "Top Doc" by her peers).

Thanking Our Veterans on Veterans Day and Every Day

Millions of American military veterans have honored us with their service. Today, we set aside a special day to honor them and thank them for all they have done. We enjoy our freedom because these individuals were ready to make the ultimate sacrifice. Without their service, our daily lives might be very different.

Veterans Day is a time to remember and pay tribute to the brave men and women of the U.S. armed forces who have served in the past and those who are serving today. As Americans, we owe a tremendous amount of gratitude to our veterans who, during peace and war, have demonstrated a steadfast commitment to safeguarding the principles upon which our nation was founded.

Everyone in the GBMC family should pause today and reflect on the gift of our fighting men and women and our veterans.

Thursday, October 30, 2014

Finding Truth and Taking the Appropriate Action

I received a call last week from a family member asking me, in the wake of the Ebola outbreak and media frenzy, if it was safe to fly on US commercial aviation. I told her that unless she was flying to West Africa and headed to one of the three Ebola-ridden countries, I did not see any reason why it would be unsafe.  This is a prime example of fear affecting people.  The fact that this family member called me was a good thing, but I am very concerned about well-intentioned people acting in ways that actually make a situation worse.

As we enter flu season, there is a great public health risk that people will take actions out of fear and ignorance and neglect actions that will actually protect them….like getting a flu shot. Because Ebola has a high mortality rate and the media has been talking about it for weeks now, we are all on heightened alert. But one must have direct contact with the body fluids of a patient with active Ebola to contract the disease. What has happened in Dallas should allay people’s fears about the communicability of Ebola.   The influenza virus is much more easily transmitted than Ebola. It is spread by respiratory droplet through coughing, sneezing, touching contaminated surfaces or shaking hands.

It is important to know the facts, to investigate the truth about something before making decisions, and this is particularly true about immunizations. I remember one day in 2005, when I was taking care of children on the inpatient unit at Boston Medical Center, a big inner-city trauma hospital, that we received a call from the Life Flight system.  We were getting a child from Nantucket. I immediately thought that the child must have been the victim of trauma, but I instead learned that the boy was suffering from invasive haemophilus influenza type B bacterial disease. The residents working with me had never seen a case of this disease.  This was because the Hib immunization came out in the mid 1980s, but when I was a resident in the early 1980’s, we had many cases and a significant number of children with serious complications and death.  Then the vaccine came out, and it was so effective that within a few years the disease became nearly eradicated in the States. Why, then, 20 years later, was this child being Life Flighted to Boston Medical Center from Nantucket, sick with a case of H-flu?  Because his parents did not believe in immunizations, and the child was on the verge of death from a preventable illness. The parents had never seen a child sick with the disease or heard about the devastation that it caused, so they minimized the risk. They also fell victim to misinformation and ignorance about the risks and benefits of the immunization. Luckily for them, the child survived the disease and did not have a significant complication.

We should be worried that people will drop their guard on influenza (the viral disease that we get annual immunizations to prevent) because they are scared about Ebola. Ebola has affected a mere handful of people in the United States, whereas influenza kills an average of 30,000 people per year.  If my family member had called me and said, “I’m going on a plane, what would you recommend?” I would have responded, “Get your influenza vaccine.”  Since influenza does not generally kill otherwise healthy people, many people ignore the evidence and don’t take the appropriate precautions.

Unless someone is less than 6 months of age, has a true chicken egg allergy or has had Guillain Barre syndrome after a previous immunization, there is no contraindication to the influenza immunization.  In our society, we have a tendency to fall into the trap of fads and pseudoscience, believing in ideas that are contrary to the actual facts.

GBMC must work hard to help people get the care that will cure them or keep them healthy. Let’s work to maximize the rate of influenza vaccine this season, and help get the facts out about Ebola to minimize fear and the nonsensical actions that fear can trigger.

Tuesday, October 21, 2014

Getting to Level 3 Mistake Proofing

Lean Daily Management (LDM) has been a very valuable tool in moving us closer to our vision, creating many more focused problem solvers than we’ve ever had. Phil Komenda, our Director of Imaging and Cardiac Services, and his team have been working to move our electrocardiogram (EKG) reading closer to 100% reliability. Their standard for success is that every EKG will be officially read by a cardiologist within 24 hours of the completion of the study.

Phil’s team of nurses, technicians, cardiologists and other managers has significantly improved the percentage of EKGs read within 24 hours.

Some of the changes that Phil’s team has adopted include:

a.      Placing written instructions and reminders on each EKG cart.
b.      Having the nursing units transmit EKGs instead of waiting for the cardiology tech.
c.      Assigning cardiology techs on each unit to help with staff training.
d.      Sorting the EKGs to be read from the oldest to most current.
e.      Increasing the stream of communication to inform cardiologists when there is an EKG to be read.

When they began their improvement efforts, roughly 9 out of 10 EKGs were read within 24 hours. Now, roughly 97 out of 100 are read on time. This is great improvement, increased reliability by almost a factor of 10!

So now the challenge is how to get rid of the 3 errors per 100. One of the most common reasons why the study is read more than 24 hours after it was completed is because it was not transmitted to the cardiologists in time. Phil’s team has tried educating staff members of the importance of transmitting the study as soon as it is done, citing getting it read quickly so as not to miss a possible heart attack or arrhythmia as critical. This is called level 1 mistake proofing. Education is a powerful tool if the staff members are not aware of the importance of the official read.

The written instructions and the reminder on the cart itself to transmit the EKG as soon as it completed is an example of level 2 mistake proofing.  This is a more powerful strategy than simply reeducating staff members because it the text is actually present on the cart in front of the person doing the study when he or she has completed it. As you can see from Phil’s team’s results, this has helped. However, you can imagine a nurse or nursing tech who has just done an EKG and showed the strip to a Hospitalist then getting interrupted and forgetting to push the TRANSMIT button. The reminder on the cart is helpful but imperfect.

This week I had a discussion with Phil about meeting with the suppliers of EKG machines to see if any of them have a device that automatically sends the study when it is done, thereby taking operator forgetfulness out of the mix. This is an example of level 3 mistake proofing and it is what all good engineers, especially those working in high-risk industries, strive for. If it was your child who was being checked for a potentially life-threatening but uncommon arrhythmia, 3 errors in 100 is just not good enough. Let’s see what Phil learns…..stay tuned.

I want to thank those that posted comments on my recent blog that focused on the first Ebola Virus Disease (EVD) case in the U.S.

While it is still very unlikely that we will see a case of Ebola at GBMC, we must prepare for that possibility. Our ED has responded a few times over the last few weeks when patients presented with positive responses to the screening questions but were later found to not be at risk for Ebola.  I am very grateful for our staff’s hard work and for the fact that they were prepared, using the appropriate personal protective equipment until they found that the patient was not at risk.

We have a team, led by our Chief Operating Officer, Keith Poisson, that is following this situation very closely and is assuring GBMC’s readiness according to the directives from the Centers for Disease Control. Our work in Ebola preparedness can be found on the Infoweb. There you will find a schedule for training our people in the use of personal protective equipment. We are starting with those most likely to need to use the equipment.

GBMC must be ready to serve our community if a patient with Ebola ever presents. We must communicate well and remain calm. We must avoid contributing to misinformation and doing things that are not indicated by the evidence, for these responses only make people more fearful. My thanks to the entire GBMC team for their professionalism and their commitment to evidence-based care.

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.