Transparency…Does it Matter in Healthcare?

One of the reasons why people say that market forces don’t work in healthcare is because the consumer (patient) has poor access to data to judge the quality of the product. GBMC HealthCare has now had many of its quality data publicly available and updated monthly for over a year. Are people coming to our website www.gbmc.org/quality before they choose where to go for care? It is very hard to tell.

Our data show that we have made excellent progress in many areas. Hand hygiene is significantly improved over just a few years ago. Perhaps because of this and the hard work of our nurses, physicians, and other clinicians, our rates of hospital acquired infections- catheter associated urinary tract infections in particular, have decreased significantly as well. We have now gone seven months without a hospital acquired pressure ulcer. Do our patients care? Why have other local hospitals not followed us in making their data public? Do they know something that we don’t?

U.S. News and World Report continues to name “Best Hospitals” that the national data reporting system shows frequently as having average performances (see www.medicare.gov/hospitalcompare/search.html). The last round of awards did begin to generate some conversation among academics about the illogical nature of these awards but the public didn't seem to care. It appears that healthcare organizations keep their “brand” strong or otherwise independent of the evidence.

I believe however that the public is beginning to wake up and so called value-based healthcare will start to get some traction. We can no longer afford the 40% waste in the U.S. system. Please discuss this with your friends. Do you have ideas for helping patients make decisions about healthcare? Please share them.

Good Volume…Bad Volume?

GBMC HealthCare gets paid for the work that we do in serving patients in a number of ways. Physicians submit bills for their “professional” fees when they see a patient in the office, do a procedure, care for a patient in the hospital, or provide a consultation on a patient being managed by another physician.  The hospital and Gilchrist Hospice Care have always submitted bills to insurance companies, Medicare, Medicaid and individuals for services provided.  GBMC has always taken in more money if we see more patients. This is the so-called “fee-for-service” system.

The danger in fee-for-service is that people will provide unnecessary services due to the lure of making more money. In healthcare, there are very few examples of people knowingly providing unnecessary services (otherwise known as fraud.) In healthcare, most “unnecessary services” are delivered with good intentions with those providing the care believing that they are necessary. In the fee-for-service world, executives (like me) have no or little incentive to scrutinize whether care is truly necessary according to the evidence or if the patient could have been served as well in a more efficient, less costly setting. We executives have primarily been judged by the financial bottom line. Since we got more revenue for more services, we have been happy with full Emergency Departments and numbers of procedures over budget. I have often thought that it was sad that we would get upset if the Emergency Department was not packed. We were incentivized to make it full. But if your loved one was one of those waiting in the packed Emergency Department, you were wishing that the visit could have been prevented.

A New Direction

Well, this is now all changing. Maryland’s new contract with the Centers for Medicare and Medicaid Services (CMS), the so-called “new waiver,” sets us in a new direction. Since the State now needs to keep increases in hospital spending under the rate of increase of Maryland’s economy, projected to be 3.58 percent annually over the next 10 years, our hospital will be paid a fixed amount of money per year. If we bill more services, the hospital will not be paid more money unless the population grows significantly or something significant happens in the market, like a hospital closes and we must serve their patients. Gilchrist Hospice Care will still be paid for every individual service and our physicians will continue to be reimbursed fee-for-service.

Is this change in the payment system a good thing? I think it is because it begins to align incentives to keep people healthy and to create systems that serve their needs efficiently. Care coordination will now be critical. If we can serve someone more efficiently in their home or in the patient-centered medical home, then that is what we must do.

But now, our people are asking me, “Do we want to grow our programs? Because if we do, we may not be able to afford it.” My answer is simple: we want every person in our community who needs hospital care to get it at GBMC. Our vision is to be the healthcare system where everyone, every time gets the care we would want for our own loved one. This new payment system is better aligned with that vision. It gives us more room to do things that have not been paid for in the past, like coordinating care.

I have no illusion that this will be easy, but I have complete faith in our ability to do it. A major issue is that with physicians still paid fee-for-service, the major players’ incentives are not totally aligned. I am on a Health Services Cost Review Commission (HSCRC) committee that is studying how to bring physician payment in alignment with the new waiver. We will work on new solutions to solve this dilemma. The other obvious concern is that people will game the system and stop providing needed services; if the danger in fee-for-service is unnecessary care, in fixed revenue systems the danger is that patients won’t be able to get care that is necessary. We will not let this happen. We will stay focused on our vision and our 4 Aims: Better health and better care with less waste and more joy for those providing the care.

I want to thank all of my colleagues at GBMC HealthCare for all of your hard work as we enter this new phase in our transition to a more patient-centered and value-driven healthcare system in our State.

The Passing of a Giant

Last week, GBMC lost a great friend. Mr. Willard Hackerman, the President of the Whiting-Turner Contracting Company (America’s fourth largest construction company and the builder of many edifices in our region) died at the age of 95. Mr. Hackerman was a great business leader and also a great philanthropist. Many, many organizations and individuals benefited from Mr. Hackerman’s gifts. In 2009, he gave GBMC $1 million dollars that allowed us to purchase a da Vinci robot for advanced surgical care.

When I first came to GBMC in the summer of 2010, I went to Mr. Hackerman’s office to thank him. He was so kind and generous with his time to me. He told me the story of the Whiting-Turner Company and his role in its development. He was so joyful in speaking of his mentor, Mr. Whiting, and he was so humble when asked of his own accomplishments. Mr. Hackerman invited me to visit his map collection…an invitation that I could not pass up even though I knew nothing about maps. I was fascinated not only by the maps but also by the depth of his knowledge of the topic.

Willard Hackerman worked very hard and accomplished much. He was the exemplar of someone who knew to give back to the community. GBMC and the entire Baltimore region benefited greatly from his presence and his actions. We will miss him dearly.

I Hate Snow!

My family and I moved here from New England so I am no stranger to cold and snow. But one of the reasons I was so excited to come to Baltimore was to get away from snow. I don’t enjoy winter and I enjoy it less each year. So this winter has been tough to take! Last Thursday, after shoveling the snow off of my street for about 50 yards, I got in the car and blasted through about 200 yards of snow to get to the first street in my neighborhood that was plowed. I drove to work and found what I always find….dedicated staff, most of who had been there since the previous day. Let me take this opportunity to thank everyone who worked so hard to get the job done for our patients and our community in that snow storm.

Special thanks must go to our beloved four man grounds team: George Dillon, Bob Marshall, Eduardo Rivera and Dave Mier. These guys worked just about around the clock with our snow removal vendors to make our campus safe and passable! Thank you, guys.

Thank You Team GBMC

Check out this video that shows some of our dedicated team members who helped keep GBMC fully operational to provide seamless care for our patients during the recent snow storm.

Coordinating Care for Patients

As I continue to explore how the patient-centered medical home benefits our patients, I’ve heard from practitioners who are on the front lines, working hand-in-hand with patients to effectively coordinate their care. The lack of coordination for those with chronic disease is the biggest problem with the U.S. healthcare system.

I heard from Vergie O’Garro, RN Care Manager at GBMC’s Texas Station and Owings Mills primary care practices, who has been a nurse for more than 20 years. She talks about how the care she delivers today is very different from the primary care of years ago.

Here, Vergie shares her perspectives as a healthcare provider on the patient-centered medical home model of care: 

“Before the medical home, some patients would get lost in the shuffle. For example, when patients were discharged from the hospital, we didn't have a good way to ensure they understood their condition and we didn't have a way to follow up with them to make sure they understood the plan and were following it. There’s so much information provided at discharge and many patients have trouble remembering everything they need to do for their health once they are out of the hospital. Now, however, we contact the patients and guide them in the transition from the hospital to home, help them find resources, help them understand their care plan, ensure they are receiving and taking their medications and just manage their care better overall.

As an RN Care Manager, when I have a patient discharged from the hospital, I call the patient once they are home, go through the list of medications they need to take and make sure they understand how to take the medications. Follow-up and creating a plan of care is important for long term management of a patient’s condition.”

What does it mean to coordinate care?

“I work closely with our care coordinators to provide patients with the resources they need to maintain their health and manage chronic conditions. Coordinating care not only means guiding a patient through a chronic health condition, but also helping patients find resources, financial or otherwise. For example, some patients need help finding transportation to and from doctor appointments. Our care coordinators work closely with patients to help them with things like this, which is another important part of coordination of care.”

Can you give an example of how you help manage a chronic disease like hypertension?

“As an RN care manager, if a physician refers a patient to me for hypertension, for example, I’ll look at factors like hereditary and other causes of the hypertension. Maybe it’s stress, so I’ll  find out about how the patient handles stress and help them manage it better. We’ll discuss things like diet and I’ll create a plan for modifying their diet to promote a healthier lifestyle. I’ll also talk to the patient about incorporating an exercise plan. It’s important that I really listen to the patient. I’ll let them tell me what their symptoms are and how we can manage the condition together. After we come up with a plan for managing their condition, I’ll call the patient on a monthly basis to make sure they are progressing in the care plan. This is a very comprehensive way to manage disease that also helps cuts back on hospital re-admissions.”

I thank the members of our healthcare team like Vergie for making the patient-centered medical home reach its potential as we generate our four aims of better health, and better care, at lower cost and with more joy for those providing the care. The patient-centered medical home is a fundamental building block of our transformation towards our vision of being the company where everyone, every time, gets the care that we want for our own loved ones.

Have you had experience working with a care manager? Has it helped you coordinate your care?

What Happens When No One is There to Coordinate Your Care?

We often don’t realize how important something is until we need it and we don’t have it. It is very helpful to have someone, or even better some team, to coordinate your care when you have a medical problem and multiple care providers who may have differing opinions of what you should do. I was reminded of how important having a primary care physician and his or her team (like the patient-centered medical home) can be for patients when I recently went to visit a woman who is a close friend of a friend when she was admitted to the hospital.

This individual had an acute medical problem but did not have a primary care physician. So, when she found herself acutely ill, she decided to visit an urgent care center. Since she did not have a problem for which she could get a quick prescription for an antibiotic (the forte of urgent care centers), she was told to go to the Emergency Department. Once in the ED, she was assessed quickly and had a number of tests, but her diagnosis was not clear and she was in significant pain. She was admitted to the hospital for observation and more consultations. She was discharged feeling better and with the belief that she didn’t have a life threatening problem. But she was discharged clearly in need of someone to manage her ongoing care which included appointments with a number of specialists.

Who will now reconcile the varying opinions of specialists that she will see? Who will serve as her guide? Who will filter the specialist opinions through the lens of other things going on in her life?

Oftentimes, people don’t understand the importance of being connected to good primary care until they need it most. Urgent care centers fill the need for getting in and out. They exist because the economic model makes sense to insurance companies - the companies pay Urgent Care Centers less than they pay Emergency Departments. It is also true that they pay Urgent Care more than they pay your doctor for the same visit (which is one of the reasons why primary care offices have not historically stayed open late). But the Urgent Care Center doesn't have your records and they have no ongoing relationship with you. They don’t know you. 

Primary care physicians practicing in the patient-centered medical home now have more resources to actively manage the health of their patients. They have teammates including nurse care managers and care coordinators who can help connect things and make it easier for the patient to make the best decision. The team is available into the evening and via the patient portal also during the night. They have all of the patient’s medical information and can make sure others have it when they need it. (Had the patient that I visited been a patient of one of our medical homes the GBMC ED physician would have been able to see her history). The physician is the captain of the team but the other team members play important roles by coordinating patient appointments, ensuring patients stay on their diets or on course with a medical regimen to optimize chronic conditions; and others help with prescription refills, referrals, and more. A recent article in the New England Journal of Medicine calls the patient-centered medical home “advanced primary care.”

Had the patient that I visited been in one of our medical homes she may have still needed the hospitalization but it would have progressed more smoothly. And, although she still would have been in pain, she would not have had the added anxiety of navigating through the maze on her own.  On discharge, it would have been clear who was going to be there for her.

So, the case of my friend’s friend is a prime example of why it’s beneficial to have a primary care physician who practices in a well-designed system to coordinate your care. You never know when you will need it.

In the coming weeks, I’ll be talking to patients, care managers, physicians and care coordinators at some of GBMC’s patient-centered medical home practices to see just how this system is working to treat everyone the way we want our own loved ones treated.

Have you had experience with this system of “advanced primary care?”

Meeting With a Man on a Mission

Last week I had the pleasure of spending some time with Dr. Samuel Ross, the CEO of Bon Secours Hospital in West Baltimore. Sam and I have been comparing notes about necessary changes in our national healthcare system. He visited GBMC a few weeks ago and I made a trip to see his operation.

Bon Secours serves a community with a very high unemployment rate and a median household income of $23,070. While the infant mortality rate in Maryland is 7.9 per 1,000 live births, it is 18 per 1,000 births for the population served by Bon Secours. The mortality rate for cancer is 50% higher than in the rest of Maryland and the mortality rate for heart disease is almost double what it is in the rest of the State.

Dr. Ross took me on a tour of Bon Secours. Every member of his team that I met, from the guard at the entrance to the nurses in the ICU, were upbeat. It looked to me like they were all following their leader and they were on a mission. They appeared ignorant of the fact that the odds were stacked against them – they were determined to beat those odds and lessen the burden of disease in their community. No one lamented the age of the facility…but they were very proud of their robot that allows them to use telemedicine to improve care in the intensive care unit. Dr. Ross showed me the “COWS”- computers on wheels -  that are connected to the new single database electronic record that they are about to roll out. He explained to me that they would not have been able to purchase this system without the help of the Bon Secours system.

I reflected on how lucky I was to not have the same burden of poverty and rate of chronic illness in the community served by GBMC. Sam and I spent some time thinking about how we could learn from each other and we committed to looking for areas in which we could collaborate – I think it would be fantastic if we could help Dr. Ross bring advanced primary care to the Bon Secours neighborhood. There are many hurdles to get over but we will look for ways to make this happen. Sam and his team are on a mission, and I am betting on them.  

I Like Swiss Cheese…But Not in My Work

I remember being a 22-year old in Italy and not worldly-wise. I was trying to buy “Swiss cheese” and was asking a friend to help me find it in a supermarket and translated it literally. My friend pointed out to me that Switzerland was known for its cheeses and there were many kinds of “Swiss cheese.” I explained to him that it was the one “with the holes in it,” and he then told me that the cheese was called Emmental.  

Many years later, when I was learning about safety, human error, and complex systems, I got introduced to the “Swiss Cheese Model of Error,” the work of Professor James Reason of Manchester University, in England. Professor Reason created the model to help his students understand the relationship between the thoughts and actions of humans in a complex system and how these thoughts and actions can either contribute to the creation of bad outcomes and in some cases, catastrophes, or help prevent them.

Reason knew that humans understand at some level that they are fallible, so that they build protective walls to “block” errors from resulting in bad outcomes. An example of this is in the system for protecting patients from medication ordering errors.  Physicians can and do occasionally make errors of ordering the wrong drug, the wrong dose, or the wrong route. The first wall of defense to block one of these errors is called pharmacist verification. Every time a doctor orders a medication on a patient in the hospital, the pharmacist checks it to make sure that it is safe for the patient. But pharmacists also occasionally make mistakes. So the pharmacy verification wall has holes in it, too. The next wall of defense is called nurse check. Nurses also make mistakes so this wall is also imperfect. If you line up all of the walls what does it look like? You guessed it…Swiss cheese.

                                                                                                                                                                   
Reason calls the holes in the cheese latent failures. Latent means hidden or present in an unexpressed form. These latent failures can be grouped into a number of categories. One of the categories is failures at the managerial level. This occurs when a manager knows that a design is not being followed that could cause a bad outcome but the manager allows the design to not be followed. An example would be if a manager knew that the doctors and nurses were not doing the timeout correctly before a procedure but let the procedure go on anyway.

A second type of latent failure is called a psychological precursor. Psychological precursors can be thought of as beliefs held by those involved in a complex system that lead to people not following the design. An example of this would be if doctors and nurses did not do the timeout properly because they believed the timeout was “stupid” and “not necessary and a waste of time.” A psychological precursor that is rampant in healthcare is: “I do it whatever way I have to, to get whatever my patient needs.” This psychological precursor is the end result of clinicians working in broken systems. They come to believe that they don’t have to do it the way it is designed because the design never works anyway. This psychological precursor is the opposite of what people in other high risk industries like commercial aviation or nuclear power believe: “I follow the design because it is not safe to do otherwise.”

Other holes in the walls may be due to less pervasive problems or one- time events. These latent errors are called: local triggers, intrinsic defects, or atypical conditions. An example of an atypical condition is when a clinician is dealing with a patient that does not speak his or her language. We know that the opportunity for error increases when our patients can’t participate fully in their care or in protecting themselves from harm.

Bad outcomes may start with an unsafe act where an individual does not follow a procedure as designed or does not follow the standard work.  

Let me tell a story about an employee injury at GBMC using the Swiss cheese model. 

Our colleague falls and injures her arm.
An employee took an office grade bag of trash that had a lot of liquid in it out of a break room garbage can. The employee placed it on the floor in the hallway where it leaked onto the floor. (The designed procedure is to place the bag immediately in a cart.) The employee then realized that the bag had leaked, and retrieved a mop and cleaned it up. The employee did not put a wet floor sign down and a nurse turned the corner and slipped, falling to the floor and injuring her wrist.

So applying the model we see that one latent error in our system is that we use trash bags that are not designed for liquid in trash cans that may receive liquid. Although it is not absolutely clear it appears that at least someone may have the psychological precursor of “any trash bag will do” in using the bag that is not designed for liquid.  A second psychological precursor may have been, “I don’t need to follow the rule, it won’t leak, I’ll just put it on the floor.” The actual unsafe act was putting the bag on the floor. A last unsafe act was not putting the wet floor sign up.

Notice that if any one of these latent errors had been “fixed,” the hole would have been blocked and our colleague would not have been injured. If the correct bag was used, or if the person emptying the trash had put it directly in a cart or if he or she had put up the wet floor sign, our colleague would not have been injured. But, if only one had been fixed, the other latent errors would still have been present waiting to align for the next bad outcome or catastrophe.

We cannot wait until the holes in the Swiss cheese align to create a catastrophe; we must fix the holes when we find them. This is what our near miss (Quantros) reporting system helps us to do.

What latent errors have you found and are working to fix in our healthcare system?