Working Together For Safety

Dr. Chessare is on vacation this week.  Guest blogging is Carolyn Candiello, GBMC's Vice President, Quality and Patient Safety.

As I approach my one-year anniversary this fall of joining GBMC HealthCare as Vice President, Quality and Patient Safety, I find myself continually impressed with the strength and commitment of my colleagues. 

For example, soon after I started, the mother of one of our patients sent me a letter sharing some thoughts about how care might be improved in the Neonatal Intensive Care Unit (NICU). She and I met to discuss her ideas, and GBMC’s Chairman of Pediatrics, Dr. Timothy Doran, took time out of his busy administrative and clinical schedule to attend and hear the parent’s thoughts first-hand. At a lot of hospitals you wouldn’t find a clinical leader who takes the time out of their day to do that. We listened to the mom’s feedback from her experience and she offered some good suggestions about ways we could improve our care. Dr. Doran and I subsequently met with the rest of the clinical team and they implemented changes to improve and enhance the patient care experience in the NICU.

I also reflect back on the leadership off-site in March.  My colleagues and I spent time learning about how errors occur and how to design our processes and strengthen our behaviors to prevent them.  When looking at an error it is easy to focus on “the sharp end” or the person closest to the error.  This might be the nurse administering the medication or the tech assisting a patient out of bed who falls.  However, knowing that “every system is perfectly designed to get the results it gets” we recognize that failures in our system occur anywhere along the continuum of the process.  Strengthening our processes can make care safer for patients and provide more joy for those at the bedside. 

The best example for understanding errors is Reason’s Swiss Cheese Model.  Looking at this model, we can see that errors occur when failures in our process line up.  We also can see that errors can be prevented when we block the holes through safe system design and using safe behaviors. 

Safe system design can be anything from a simple checklist to redesigning our information system for safe medication ordering.  Safe behaviors such as “having a questioning attitude” can also help prevent errors.  Not long ago, I learned about a situation where a nurse saw that a physician had ordered a medication for a patient that didn’t make sense for that individual’s treatment.  Using a “questioning attitude” the nurse appropriately questioned the physician and it turned out that she had intended to order that medication for another patient.  In turn, the physician’s response and gratitude for the nurse’s “good catch” demonstrates another safe behavior of “working together with your team”.  While this error never reached the patient, we are grateful that she reported this to us as it helped to understand some holes in process which have been fixed.

Learning about incidents such as these is a gift to those of us who work in quality and patient safety here at GBMC. It may seem counter-intuitive that we’d want to hear reports about times when something goes wrong or “almost” happens, but every incident report we get is a treasure because it gives us a chance to see where there may be holes in our process and allows us the opportunity to make care safer.

Recently we became aware of some instances where our process for patient identification wasn’t followed as designed. While we have a great system for medication administration using bar code technology, there are other times when this technology is not available to assist us—for example identifying patients for treatment, transport, nutrition and outpatient medication.  At GBMC we ask the patient to state their name and date of birth.  We then compare that to the patient's name and date of birth on the order or requisition.  Finally, we look at the patient's identification bracelet to confirm the correct name and date of birth.  But add in other complexities and interruptions and it’s easy to get ourselves into “auto pilot” and miss one of these important steps—we’re human after all.  A good tool to help is “S-T-A-R”!

• Stop, pause for 1-2 seconds and focus on what you are about to do
• Think, think about what you are doing– is it the right thing?
• Act, concentrate and take action to perform the task
• Review, do a self check to review if the task was done correctly

“S-T-A-R” is not just designed for clinicians, it’s a good tool for all of us to use in situations where the potential consequences might involve high risk or will require a lot of re-work if not done correctly.  For example, it is a great tool to use before sending an important email; or at home, it might be helpful to use the tool before locking the door (with the keys on the other side!) or paying a bill electronically (did I get the decimal in the right place?).

I am looking forward to sharing and learning from each of you over the coming months as we work together to improve our system of care.   I am both pleased and proud to be a part of GBMC and thank you all for what you do every day to keep our patients safe. 

If you have any stories you would like to share about safe behaviors or redesigning systems please comment below.  Also for GBMC employees, please follow the Patient Safety group on Yammer (GBMC’s Social Network).  Go to www.Yammer.com--sign up using GBMC email and join the conversation!

Change Agents To Be Proud Of: Gilchrist Greater Living and Gilchrist Hospice Care

On Monday, I was proud to accompany several GBMC HealthCare colleagues to San Diego where GBMC’s geriatric and palliative medicine practice Gilchrist Greater Living and Gilchrist Hospice Care were recognized with the prestigious 2011 Circle of Life Award from the American Hospital Association (AHA). The Circle of Life Awards, given to only three organizations in the country, were created in 2000 to recognize programs that have found innovative ways to deliver the best and most timely palliative and end of life care possible. Circle of Life Award winners are considered role models for other communities.

In choosing Gilchrist for the national honor, the AHA selection committee noted the organization’s unique role in creating the Gilchrist Greater Living (GGL) geriatric and palliative medicine practice, which follows its mostly elderly patients throughout the healthcare continuum – from office visits, to the hospital, to nursing homes, assisted living and rehabilitation facilities and ultimately, to hospice. GGL is overseen by Cathy Hamel, Gilchrist’s executive director, and Tony Riley M.D., medical director, and is designed to ensure that the frailest of patients receive care that is compassionate, coordinated and comprehensive.

(L-R) Proudly representing Gilchrist and GBMC HealthCare at the AHA Circle of Life Awards were Regina Bodnar, R.N, Gilchrist Director of Clinical Services; Lori Mulligan, Director of Development and Marketing, Gilchrist Hospice; Catherine Hamel, Executive Director, Gilchrist Hospice; W. Anthony Riley, M.D, Medical Director, Gilchrist Hospice; and John Chessare, M.D., President and Chief Executive Officer, GBMC HealthCare.

When I read in the award brochure, “Because the geriatricians at Gilchrist Hospice Care monitor patients and oversee patient care in multiple settings, ranging from home to skilled nursing facilities to hospital to hospice, their patients benefit from the greatest possible coordination”, I realized what a wonderful gift it is to have Cathy, Tony, and all the Gilchrist staff as part of our GBMC family. Our strategic plan is about coordinating care for the patient and this part of our family is already doing it exceptionally well.

The day began at 7 a.m. with a “sunrise session” in which Dr. Riley and representatives from the other recognized organizations discussed how they met the needs of patients and families and continually worked for even better care for the elderly. I then went to a plenary session where Dr. Atul Gawande, the noted Harvard surgeon and writer for the New Yorker, spoke about his work to improve health care in America (and across the globe) by the use of the checklist.

Dr. Gawande noted that there are three new values that health care providers needed to embrace to improve care. The first was humility. We should celebrate the intelligence, training, hard work and dedication of our physicians and nurses. But these professionals (especially physicians) must understand that they too are human and the practice of medicine has gotten way too complex for any individual to be able to deliver the care as a “lone ranger” that we would want for our own loved ones. The second new value required was discipline, required in complex endeavors to do things the same way every time according to the evidence of what works best. Gone are the days of allowing professionals to do things in whatever way feels right to them if the evidence shows that one way is best. Dr. Gawande suggested that the third required value was teamwork. Because healthcare is now too complicated for any one provider to be able to meet the needs of the patient, providers must value the input of all of their teammates. I found it interesting that he said that studies now show that the most powerful element of the use of checklists is not the checklist itself, but the teamwork required to use the checklist correctly. While he was speaking, I was thinking that Gilchrist displays these values daily.

We had a great lunch with the Circle of Life Award Committee and the other honorees and then went to the award ceremony. When Cathy received the award on stage it was another proud moment for me and our organization.

We then heard a presentation by Chip Heath, a Stanford University professor, who with his brother Dan wrote the best-selling book: Switch: How to change things when change is hard. Chip is an outstanding speaker. He presented a “change methodology” that was quite compelling (and again got me thinking about all that we are asking our people at our health system to change at once.) Chip said that research from the field of psychology has shown that humans have an internal conflict between their analytical self that thinks about and plans change and their emotional self that does the change. He  offered as an example that the analytical self knew that he had to exercise to maintain his weight but the emotional self wanted to hit the snooze button rather than get up and go to the gym. The planner knew to count calories but the doer wanted to eat the Oreo cookie. He used the analogy of the rider as the analytical planner and the elephant as the emotional doer. The rider of an elephant can plan, think and analyze but sometimes the elephant has a mind of his own that overwhelms the rider’s plan.

Chip pointed out that the research literature had generated three surprises about change. The first is that what looks like resistance to change is often a lack of clarity about the change. You need to direct the rider. In this case, if you want to make change happen, rather than repeating the time honored dictum about “people just don’t want to change”, you should provide clear direction …and simple steps. The second surprise about change is that what looks like laziness is often exhaustion. People can’t do too many changes at once. “The rider can’t get his way by force for very long.” You need to motivate the elephant.  Mr. Heath added that telling moving stories is generally better than giving data to get people in action. The data are needed but the stories ignite the fire. The third surprise about change, Mr. Heath said, is that what looks like a people problem is often a situation (or process, or path) problem. When things go wrong, or not as we would like, we have a tendency to attribute the problem to a fundamental flaw in the people involved rather than to the situation they are in. By blaming the people for the difficulty with change, we make the solution impossible. How do you make a stubborn person not stubborn? Chip said to try making the change easier and forget trying to change fundamental characteristics of the people involved in the change. He called this shaping the path.

Again as I was listening to Mr. Heath, I thought of Gilchrist and their work to eliminate the pain typically experienced by a patient new to the hospice service. The national standard is 48 hours but Gilchrist has made a commitment to reduce it to 24 hours. Cathy, Tony and the Gilchrist Hospice team motivated the elephant by telling stories of new patients and their families and got team members charged up to make major improvements. They directed the rider with a clear message about the goal and they made it easier to achieve that goal by shaping the path with daily conference calls and small tests of change. Now greater than 75 percent of patients are pain-free within 24 hours!

For inpatient end of life care, Gilchrist offers a unit on the GBMC campus, which recently was expanded to offer 34 beds, and a 10-bed center located within Harmony Hall Assisted Living in Columbia, the first acute care inpatient hospice facility located in Howard County's borders, which opened in May.  This center ensures that terminally-ill individuals in Howard County and their families will have access to the full spectrum of the finest in end of life care, close to the homes they cherish. In addition, meeting a long unmet need, last summer Gilchrist Kids began providing comfort at home for terminally-ill infants, children and teens in Central Maryland, as well as care and support for their extended families.

I am so proud of Cathy, Tony and the entire Gilchrist Greater Living and Gilchrist Hospice team. Please join me in thanking them for making our care better! And please congratulate the Gilchrist staff when you see them. We can all learn from them.

UPDATE: Be sure to take a few minutes to watch this "Circle of Life" video. Dr. Riley and Cathy Hamel do a nice job of explaining Gilchrist palliative medicine and end of life services that help the patient and their family make the best decision for their situation.
http://www.youtube.com/watch?v=IdwmZm8lmKI

Can you relate to Dr. Gawande’s three values required for improving our health care system? Do you have examples of how you have used Chip and Dan Heath’s change model or some other model to improve care?  Please share your thoughts by commenting below.

Further Engaging Our Hard-working Physicians

Earlier this week I had the opportunity to speak at the triennial medical staff meeting about the state of GBMC. I thanked our physicians for their hard work in taking care of patients and also for helping us to be the financially strong organization that we are. We finished the year with a 1.9% operating margin for our system….which is better than what we budgeted. I also shared the results of our annual Physician Satisfaction Survey. The survey showed increased satisfaction among physicians in GBMC’s nursing care, in the overall quality of our care at the hospital, and a small increase in the ease of practice at the hospital. In areas affected by our implementation of CPOE, the speed with which orders are carried out and in the access to information, our scores went up significantly.

Unfortunately, I also had to tell them that in the area of communication and collaboration, our scores went down. The results are not uniform across all members of the staff. In some departments, our scores went up, but in some, they went down. I had to ask myself the question was it really our inability to communicate well with everyone or was it the message?

Our new strategy is about better coordinated care and we cannot do this without building a strong network of primary care providers. So, I have spent a lot of time working with primary care doctors and talking about primary care. I have not spent enough time with our surgeons, and some other specialists and engaging them in dialogue about our future. So, at the meeting, I told the staff that I and the senior leadership team of the system were going to redouble our efforts to hear from them. We will meet with our clinical department chairs individually at regular intervals and we will go to Department meetings.  I welcome any physician that has an idea about how we can make it easier to provide exceptional care to our community, to come and speak with his or her department chair or me.

GBMC grew up as a place for private practicing physicians to practice good medicine. It is becoming more and more important that we act together to bring even better value to those we are serving. This is not possible if everyone is doing their own thing. We need a tighter alliance to make things better for our patients and to make the practice of medicine more fulfilling while maintaining its financial viability. Large complex organizations can’t move forward without a hierarchy and a chain of command that includes strong physician leaders – thankfully we have such individuals in John Saunders, Jr., M.D. (Vice President of Medical Affairs), Harold Tucker, M.D. (Chief of Staff), and our department chairs.

We need to have a tighter affiliation with physicians, and the physicians need to understand that they are part of the team.  Physicians have to be in the mindset that if they have an idea they should go to their department chair and it’s the department chair’s responsibility to feel empowered to change things or kick things upstairs, if they are beyond their control. Hierarchy is not a bad word, it’s a way of making a complex organization work, and we have to narrow the distance between those doing the work of patient care and the organization’s senior leaders.  

We’re looking to our physicians to bring forward ideas.  For example, Dr. Bill Crawley, our division chief of plastic surgery, recently suggested that we begin offering microvascular reconstructive surgery and we are making investments in getting that program started.  That’s one example of how we have to plan together and be able to hold each other accountable if we are going to get to better health, and better care at a lower cost.

We’ll be investing a lot of time and effort in this in the coming months, working through and with department chairs and division chiefs, to make this happen.

I look forward to hearing from physicians and others about how the organization can further engage doctors and strengthen the relationship with senior management. Please share your thoughts by commenting below.

This weekend, I will be flying to San Diego to the American Hospital Association meeting to be present for the Circle of Life Award presentation to Gilchrist Hospice Care and Gilchrist Greater Living. I will share that experience in the blog next week.

New Year, New Vision, A Need for More and Faster Improvement

The New Year is always a good time to reflect on what you have accomplished and what you strive to do better. With July 1 being the start of GBMC’s fiscal year, it’s important to look back on last year’s goals – We had a good year, we remain financially strong, we hit some goals right on, yet there are other goals that still need more of our focus. It’s a new year with a new strategy, new operating plan and goals designed to address this important question - Are we getting closer to our vision of treating everybody, every time with the care we would want for our own loved ones?

It’s clear to me that in order to achieve this vision, we have to get better at executing change – change through the eyes of our patients. We place a great deal of emphasis on patient satisfaction scores, and over the past year we’ve made some progress thanks to measures put into place to improve our patients’ experiences…but we need to make the breakthrough changes that will really matter most. So to start, our goals this year about improving the patient experience will be more focused on the most meaningful things to patients, questions like “Was I included in decisions around my care?” And we know that to best understand and appreciate the experience we cannot lose sight of what it is like to be a patient in a hospital.

So, in developing the patient experience and satisfaction goals for this year, we did something a little different. Unlike last year where the senior management team drove the goals, this year we asked the Quality Committee of our Board of Directors to take the lead on creating our goals. A sub-committee was formed that included a number of our physicians and nurses who brought an important perspective to the table as they developed the clinical outcomes and patient experience goals. These providers at the bedside know and understand what the patients need and how to make their experience better.

Our goals this year are again in four areas:
  - Better health outcomes
  - Better [patient] satisfaction with the care experience
  - Less waste and lower costs
  - More joy for those providing the care [employee and physician satisfaction]

This year, we need to get more ownership of our goals by every member of the GBMC family. We must have everyone in action. To this end, the Senior Management Team is working with their people to develop departmental and unit level goals that will drive attainment of the system goals.  

Everyone at GBMC has the ability to create positive change through the eyes of our patients.  But we have to take action, because if it’s just talk and nothing changes, then we will never get closer to our vision.

So I need you – our staff on the front lines of patient care – to tell me:
How can we improve our care even faster than we have in the past?

What do you need and what can I do to help you create better health, and better care, with more staff joy at lower cost?

Please share your thoughts by commenting below…I look forward to the dialogue!

Changing of the Guard

We are fortunate at GBMC to have truly great leaders who believe strongly in the mission of GBMC and in its vision for the future. We have leaders who are undoubtedly passionate about GBMC and believe fervently in ensuring the success of our community’s hospital and health system for generations to come. And as one great leader’s term comes to an end, another takes the reins as Chairman of the HealthCare Board of Directors for GBMC. I am so grateful for the service our outgoing Chairman, Charlie Fenwick, has given and look forward to working with our new Chairman, Harry Johnson, another example of a great leader and community advocate. 

I met both Charlie and Harry when I interviewed for the CEO position a little more than a year ago and both made an indelible impression on me even then. As I have had the opportunity to get to know both of these men quite well over the past year, I realize that both Charlie and Harry share something very special in common – a love for GBMC and a commitment to giving of themselves to benefit others in the community.

Charlie Fenwick…Now here’s a man who has accomplished a lot in his life. Like any great equestrian, Charlie approaches life with passion.  He is one of only two Americans to have won the prestigious English Grand National steeplechase race as well as many other horse racing honors including the Maryland Hunt Cup (which he won five times) and the Grand National Steeplechase (which he won 10 times!). Charlie and his family have strong roots in the community and he has spent a good part of his life training and racing horses in Maryland. And when he’s not racing, he’s busy running a very successful business - Valley Motors. Charlie has served as President of the Board of Trustees of The Gilman School as well as the director of the Land Preservation Trust, which works to preserve open spaces in Baltimore County. One of the Trust’s first projects was to create the Shawan Downs steeplechase course in Hunt Valley as a legacy for future equestrians. In fact, thanks to Charlie’s work, GBMC has been the recipient of proceeds from the annual Shawan Downs Legacy Chase event for the past 10 years.

Charlie has served on the GBMC Board since 1999 and has been an inspiring and strong leader since becoming Chairman in 2007. In addition to knowing Charlie as a true professional, I am also thankful for his friendship. He is as giving as a friend as he is as a community leader. Charlie has helped me and my family get oriented to Baltimore and since I’ve known him, he’s been a guiding light for GBMC.

GBMC’s new Chairman of the Board, Harry Johnson, is a very passionate man who has also accomplished a great deal in his life.  Harry, a partner at the law firm of Whiteford, Taylor & Preston, has become one of the most distinguished attorneys in Maryland. He is a past President of the Maryland State Bar Association and serves on a number of prestigious committees of the American Bar Association. Harry has served a myriad of community organizations through the years. He has been involved with GBMC since the mid 1980s as a lawyer handling medical negligence cases on behalf of GBMC and its physicians. In March of 2000, he joined the GBMC Foundation Board of Directors and was then asked to join the GBMC HealthCare Board because of his excellent leadership and commitment. Harry is clearly a man who gets things done and is keenly focused on fulfilling GBMC’s new strategic plan and moving the organization forward, helping us continue to be committed to providing the best medical care to our community.  

Both Charlie Fenwick and Harry Johnson share a love for GBMC and for giving back to the community. We’re fortunate to have them as part of our team. I’m truly grateful for Charlie’s guidance and service and I’m looking forward to the next chapter with Harry at the helm.

Wishing everyone a safe and happy Independence Day…