Tuesday, April 30, 2013

In Service to Others …with a Warm Smile

I think I consumed too many calories last week… (Why should that week have been any different than others?) 

April 21-27 was National Volunteer Appreciation Week. GBMC had a luncheon every day of last week to recognize our volunteers who were on duty and I stopped by each day to have a bite to eat and say thank you to them. 
Sharon Barnes and Anne Pidcock
staffing the Family Waiting area.

We have more than 800 volunteers in the hospital and at Gilchrist Hospice Care. Every day I meet them in our hallways and I am always struck by how they, to the person, seem so joyful in their service to our patients. Many days I feel a bit grumpy for this or that reason but when I walk out of my office and walk by the front desk, I am always greeted by at least 3 or 4 smiling volunteers. 
Charlotte Maranto assisting a telephone caller
at the hospital's front desk.

These are people with wonderful personal stories of accomplishment who could be home with grandchildren, at the art museum, taking a stroll in the park, or reading a good book. But instead, they dutifully come to help us. They don’t ask for much…actually they don’t ask for anything. They just give of themselves. They remind me everyday what life is all about and I am grateful for their work and also for this reminder.

Last week, they also gave us something else….another financial commitment. Our Volunteer Auxiliary pledged a $1 million dollar gift to help us fund our new Neurology Center! As you know, our goal is to develop a system to deliver patient-centered care from birth to end-of-life. Therefore, a Stroke Center and comprehensive Neurology program is essential.  When doctors Michael Sellman and James Bernheimer come to join Dr. Arash Taavoni this summer, much of the Neurology Center start-up costs will be covered thanks to another selfless act of our volunteers!  
Norma Houck & Doris Wilhelm
at the front desk.

We are so grateful for all that they do, from the smiles, to their daily work, and their financial commitment.

…And it was Laboratory Week!
Last week was also Laboratory Week. GBMC is so lucky to have the highest reliability laboratory that I have ever seen. We are blessed with outstanding pathologists, technicians, phlebotomists, managers, administrative personnel and others on the Team. They are truly unsung heroes who we sometimes take for granted. Thanks to our lab personnel for all that they do!

Tuesday, April 23, 2013

Welcoming Our Brothers and Sister from Tanzania

Last week was difficult for us Americans…especially those in Boston because of the tragic bombings. Our sentiments at GBMC included anger, sadness, and dismay. However we ended the week on a hopeful note.

Since 2009, through Gilchrist Hospice Care, we have had a partnership with the Nkoaranga Lutheran Hospital in Tanzania. Since then, we have donated just more than $100,000 to help our African partners with their work. Over the past two years, we have sent two small delegations to visit Nkoaranga and last week they sent a group to visit us.

Our visitors included Mr. Jeremiah Kaaya, the Hospital Administrator, Ms. Sarah Swai, the Director of Nursing, and Dr. Bartholomew Bakari, a physician and medical director of their Palliative Care program.

I spent some time chatting with our visitors before taking them on a tour of our main campus along with Tony Riley, MD, our Chief of Geriatrics and Medical Director of Gilchrist Greater Living; Cathy Hamel, our Vice President for Post-Acute Services and Executive Director of Gilchrist Hospice Care; and Debbie Jones, the Director of Volunteer Services at Gilchrist. We went to Unit 35, the SICU, the Newborn Nursery, the Dance Center, the cafeteria and a number of other places. Our guests were impressed with all of the resources that we have and the fact that in the U.S. almost all babies are born in the hospital (not the case in Tanzania).  

After the tour, our visitors gave a one hour presentation on their country, their region, and their work. Mr. Bill Benson, Cathy’s husband, did an excellent job of facilitating a question and answer period. I was amazed at how much our colleagues from abroad accomplish with so few resources. Most in the audience were re-energized and more than one person told me that they were going to make a special donation to help them.

The major underlying cause of the catastrophe in Boston is hatred. Hatred often begins with a fundamental lack of knowledge of the other. Working to communicate and understand people both in our country and in other countries is one thing that we can do to reduce the hatred that often leads to violence. Reaching out to others in a spirit of friendship, and seeking mutual understanding and respect is wonderful work to help bring peace to the world. 

Our relationship with our friends at the Nkoaranga Lutheran Hospital is a wonderful example of this and spending some time with these friends last week helped lessen the sadness of the events earlier in the week. 

Tuesday, April 16, 2013

Tragedy in Boston – Resilience and Solidarity Among Healthcare Providers

The bombings at the Boston Marathon are another example of senseless violence. Our thoughts and prayers go out to all of those affected and their families. My wife’s brother crossed the finish line about a minute and a half before the first explosion. We are particularly grateful that he was not injured. But we know that others were not as lucky.

I was the Chief Medical Officer at Boston Medical Center on September 11, 2001. BMC is the largest trauma center in New England. On that horrible day, we stood ready to aid overflow victims from New York City….but none came. I remember reflecting that week that we were in a large brotherhood and sisterhood of care providers and even though we didn’t know many people in the New York City hospitals, we felt their pain and stress and wished that there was more that we could do to help.

Today, I feel the same solidarity with my colleagues in Boston. We at GBMC and at other hospitals in Baltimore stand united with the Boston Medical Center team and with the other Boston area hospitals.

We feel their pain and we unite in spirit to alleviate suffering and bring a ray of hope in the aftermath of a horrible event.

The news about an innocent 8-year-old boy being one of those who tragically lost his life while waiting to greet his father after he finished the race is especially devastating. As a father and a pediatrician, I am sure many parents, in addition to trying to process this senseless tragedy themselves, may also be wondering what resources are available to help them discuss this with their children.

The American Academy of Pediatrics has a detailed tip sheet “Talking to Children About Disasters”  and Claire McCarthy, M.D., a pediatrician and Medical Communications Editor at Boston Children's Hospital, assistant professor of pediatrics at Harvard Medical School and a senior editor for Harvard Health Publications, provides some excellent suggestions in her column, "After the Boston Marathon explosions, what parents should do first." 

Friday, April 12, 2013

What is a Pareto Chart and a Gemba Walk And How Will They Help GBMC Reach Our Goals?

The GBMC HealthCare system is working hard to redesign our systems to achieve our  Quadruple Aim and to ensure that every patient is cared for the way we’d want our own family members cared for.

We’ve been using LEAN tools to help us get to our goals, and this week we have had a team working on the design of Lean Daily Management (LDM).

LDM is a tool to get our people on a daily basis to be reviewing their performance and finding and removing impediments to reaching their goals.  This week a Team has been working with our consultant Neil Crockett of Next Level Partners to help us get LDM started in a disciplined way. 

Every morning the team calculates how well they did on their chosen key indicators from the day before.   For example, the process may be teaching patients about their medication, hand hygiene compliance, the percentage of patients leaving the Emergency Department within our time goal, or the percentage of occupied rooms cleaned the previous day.

If the goals are not achieved, the team documents the reasons why, which are essentially the system failures. Knowledge about the system failures is then used by the team to redesign their system.  It has been shown that organizations that do this is in a standardized way make a lot more progress than organizations that don’t. 

The success rate is displayed on a LDM board on the unit or in the department and that is coupled with a Pareto Chart where team members can document the reasons for the failures and see what needs to be worked on and changed.

Another key component of LDM is the senior team gemba walk. Every morning, at a prescribed time, members of the senior team go to visit the team at their LDM board. A team representative tells the senior execs how they did the day before and what the reasons were if they did not reach their daily goals. The senior execs hear if there are any barriers that the execs need to remove so that the team can get their work done.  
Kim Vohrer, RN, Clinical Partner, reviews the Unit 38 LDM board during a gemba walk.

Helping facilitate the LDM project is Lisa Griffee, project manager from MIS.  Our initial units or departments where we are rolling this out include Physical Therapy / Occupational Therapy (Sandy Sofinowski), Unit 35 (Kathy Bull), Unit 38 (Kimberly Vohrer), Residents (Dr. Paul Foster, Dr. Rameet Thapa), Hospitalists (Dr. Chris Greenawalt, Dr. Rekha Motagi, Dr. Fred Chan) and Emergency Department (Stephanie Topscher & Dr. Jeff Sternlicht). Also supporting the efforts are Cate O'Connor-Devlin, Jill Wheeler and Justine Kellar from Nursing Leadership and Performance Improvement Masters Lisa Griffee, Cheryl Vankuren, Shannon Baumler and Julie Gabriele.

I am very excited about using LDM as a way for us to improve faster. This week, I was surprised to learn how often nurses don’t have the medications they need for their patients.

I look forward to using this tool in a disciplined fashion in all departments and on all units to help us achieve our vision. Thanks to everyone as we learn how to do this together!

Friday, April 5, 2013

Acting as if the Patient was Your Loved One or Just Checking Boxes?

We have made good strides in making healthcare safer at GBMC, but I am concerned that some of us are still where commercial aviation was in our country in 1987. Students in patient safety are often directed to commercial aviation for learning on how to make our care safer. After all, there has not been one death on a commercial plane in the US in 5 years…but it wasn’t always that way. I remember a horrible airline disaster from Detroit, Michigan. I lived with my family in Toledo, Ohio at the time and we often flew out of Detroit. Let me give you a brief version of what happened that I have taken from the National Transportation Safety Board official report that you can find online: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR88-05.pdf
I also found two youtube clips that are recreations of the accident. http://www.youtube.com/watch?v=dgPYY4pAKao and http://www.youtube.com/watch?v=XKTQvIVXL7Y.

At about 8:46 PM on August 16, 1987, Northwest Airlines flight 255 crashed shortly after taking off from runway 3 center at the Detroit Metropolitan Wayne County Airport, in Romulus, Michigan. Flight 255, a McDonnell Douglas DC-9-82, was a regularly scheduled passenger flight and was en route to Phoenix, Arizona.

According to witnesses, flight 255 began its takeoff rotation about 1,200 to 1,500 feet from the end of the runway and lifted off near the end of the runway. After liftoff, the wings of the airplane rolled to the left and the right about 35” in each direction. The airplane collided with obstacles northeast of the runway when the left wing struck a light pole located 2,760 feet beyond the end of the runway. Thereafter the airplane struck other light poles, the roof of a rental car facility, and then the ground. It continued to slide along a path aligned generally with the extended centerline of the takeoff runway. The airplane broke up as it slid across the ground and post impact fires erupted along the wreckage path. Three occupied vehicles on a road adjacent to the airport and numerous vacant vehicles in a rental car parking lot along the airplane’s path were
destroyed by impact forces and/or fire. Of the persons on board flight 255, 148 passengers and 6 crewmembers were killed; 1 passenger, a 4-year-old child, was injured seriously. On the ground, two persons were killed, one person was injured seriously, and four persons suffered minor injuries.

Later in the report, one can read: The National Transportation Safety Board determines that the probable cause of the accident was the flightcrew’s failure to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.

You see, prior to that time, airline pilots were revered as smart, brave, independent sorts, who were well-trained and could overcome any obstacle put in their way. In the 1970’s and 1980’s, however, as the study of airline mishaps became done in a standardized way, experts saw that often crashes were the result of these smart, well-trained people getting distracted or just plain forgetting to do something that then led to the catastrophe. The planes themselves were getting more complicated and there was a lot to remember. So, the Federal Aviation Administration began working with the airlines to create checklists that the pilots and co-pilots were told that they had to do prior to starting the engines, prior to leaving the gate, and prior to takeoff. What do you think the pilots initial reaction was? My reading tells me that many thought that checklists were an insult to their training and experience. A common reaction was: “This is stupid!  I have never forgotten to configure the wing flaps safely for take-off. These stupid regulators are wasting our time!” The NTSB’s review of the cockpit voice recording documented that the pilot and co-pilot only did some parts of the checklist and they did not do it in the manner prescribed. It appears that they were just “checking a box” and not understanding the reason why the checklist needed to be done. The NTSB also concluded that they and some other pilots had been doing the checklists in a cursory fashion routinely. The NTSB report quoted from the Northwest Airlines procedure manual:

During all ground operations it is the Captain’s responsibility to call for all appropriate checklists. . Giving consideration to other required crewmember duties and allowing for adequate time for completion. The First Officer will query the Captain if there is abnormal delay in the call for any checklist. The checklist items will be read in a loud clear voice and the proper response will be equally clear and understandable. Where a challenge and response item is performed, a response is required from another crewmember, the crewmember reading the checklist will repeat the challenge if necessary until the proper response is provided. Undue haste in the execution of any checklist is neither necessary nor desirable.

The checklist tools were well designed and would have prevented 156 deaths that day if the standard work had been done but the prevailing culture of cockpit crews killed them that day.

In the last couple of weeks, we have had a number of events at GBMC where I am concerned that some members of our family are “just checking the boxes”. They are acting as if things like our universal protocol and the use of the timeout before any procedure are “not really necessary”. We must find a way to get into the hearts and minds of all of these people and get them to realize the absolute necessity of not only doing our checks as they are designed, but also of understanding the reason why we are doing it. I and other leaders must spend more time listening to them and coaching them.

Just like the Northwest Airlines manual said in 1987, it is the Captain’s responsibility to call for all appropriate checklists and to see that they are done appropriately and in the spirit of protecting the patient. In medical care, the Captain is most often the physician.
The physician must take the lead, but the co-pilots, our nurses, technicians, and everyone else involved, must play a role and demand that the safety procedure be followed. I and the other senior leaders of GBMC will back all physicians and nurses that stand up to assure that our safety procedures are followed. If your daughter was the patient, you would stand for nothing else. We will be in action on this until we see that the culture has definitely changed for all and then we will stay vigilant. If anyone needs help with this please contact me.