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

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

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


Some GBMC highlights of the VON report:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Smaller is Often Better

Every couple of weeks someone will ask me when we are going to be acquired by or merge with a larger company. This question always frustrates me. That’s because I think we have communicated often that our Board would prefer that we maintain our “independence” (no healthcare provider is really independent) so that we can fulfill our mission and move toward our vision as a true community based system of care through the eyes of the patient.

However, I know that this question is a very honest one and is almost always coming from someone who accepts that bigger is better. While it is true that bigger companies often have more assets and can weather storms better than smaller organizations, in healthcare in our local market some of the companies actually have less flexibility because they have such high debt relative to their assets. 

But finances aside, is bigger always better? I have recently finished reading Small Giants: Companies that Choose to be Great Instead of Big by Bo Burlingham. Mr. Burlingham studied 14 companies who decided that rather than getting as big as possible as fast as possible that they would focus on becoming the best at what they do. The group did not include a lot of household names but did include companies like Clif Bar and Company, a leading maker of energy bars and other foods; Anchor Brewing, the original American microbrewery; and Zingerman’s Community of Businesses, the company that includes the world-famous Zingerman’s Delicatessen in Ann Arbor, Michigan. All 14 companies have had many opportunities to be bought out, to merge, to expand quickly or to otherwise grow fast. Instead, they decided to stay focused on their mission. Their collective vision was to continually make their products better and delight those they were serving. 

Mr. Burlingham found seven threads that ran across all 14 companies. First, the leaders of these companies recognized the full range of choices they had about the types of companies they could create. They hadn't just accepted the belief that they had to get big to survive. Second, they had overcome the pressure to take paths they had not chosen and did not necessarily want to follow. Third, the companies had an extraordinarily intimate relationship with the local community in which it did business. Fourth, the companies built exceptionally intimate relationships with customers and suppliers. Fifth, the companies had unusually intimate workplaces that were little societies that addressed a broad range of their employees needs as human beings. Sixth, they had developed a variety of corporate structures that gave them the freedom to develop their own management systems and practices. And seventh, their leaders had a passion for what their company did. 

I am sure that Mr. Burlingham would be the first to say that very big companies could also do a lot of these things but it would be (and is) much harder. 

Reading Small Giants caused me to reflect on how GBMC HealthCare is doing across these seven elements. I think our Board and our senior team clearly recognize what our choices are and have consciously chosen to stay focused on continually improving our healthcare product. We are frequently “courted” and have resisted the temptation to merge. This does not mean that we don’t understand that we can’t do it all alone and that we don’t value the gift of working with outstanding partners - we do. 

GBMC has an excellent relationship with the community and we are working to grow it even stronger as we reach out during our 50th Anniversary celebration. We have good relationships with our patients (see the Alexis Watkins video in this blog for an example) and we are working to make them better one at a time. We do well with our suppliers, although I am sure that we have room for improvement in this area. We are consciously working to make GBMC a better place for our employees and our private practicing physicians, although again, we can do better. Lean Daily Management is an example of a management practice that we have committed a large amount of our time to that would not necessarily be possible if we were just one hospital in a large company. And lastly, I think that most GBMC leaders are showing the passion for achieving our vision. 

I would love to hear your thoughts. Do you agree that smaller can be better?

P.S. In case you think that I only read management books, I just finished reading Tatiana, the most recent in Martin Smith Cruz’s Arkady Renko series. Renko is a detective in post-Soviet Russia. For those of you who like suspense and intrigue, Tatiana (and the rest of the series for that matter) is a page-turner.