Wednesday, April 30, 2014

Improving the Patient Belongings System in the Hospital

Do you know someone who lost a personal item in a hospital?  Hospitals around the country misplace thousands of articles every year from eyeglasses, dentures, and hearing aids to favorite sweaters and a myriad of other belongings. I have been at many places that tried to fix this. Think of one typical trajectory of a patient in a typical hospital: from the Emergency Department to the Operating Room to the PACU to the ICU to a floor bed and finally home, and then think of all of the places that the items could get lost.

Keeping the patient’s belongings in a safe place and knowing where they are at all times requires more than hard work and good intentions alone…it requires a designed system and standard work. We have standard procedures for documenting and taking certain belongings from the patient but we don’t always follow our design. But now there is hope…

I have written about our wonderful Unit 36 before. Unit 36 is a Med-Psych unit and some of its patients are at risk of injuring themselves or others. For this reason, it is critical that the staff knows exactly what belongings the patients have access to. Unit 36 began to participate in Lean Daily Management last month and they chose to measure the compliance with our patient belongings procedure as something to study and improve. They have now been measuring this daily and have not only improved their own performance but have also begun to work with other units to improve theirs.

Last Sunday, Nancy Amann-Santos,  the Unit 36 Nurse Manager, held the monthly Clinical Unit Coordinators’ (CUC) meeting on the Unit. CUC’s Nicole Stuckey, Rachel Price, and Christina Mosner realized that they had an opportunity to improve their performance in storing belongings on the Unit so they decided to do a 5S (sort, separate, shine, standardize, and sustain) on the room where the belongings are kept.

This is a BEFORE photo of storing belongings...

The CUC’s worked together to clean, organize and label the room to have an organized and standard process for receiving and storing patient belongings. This was to not only reinforce a need for a safe environment but to ensure that patients were leaving the hospital with the belongings they came with.

The AFTER photo of storage for patient belongings...

What a difference! I am very proud of Nancy and her team and grateful for all that they are doing to move us closer to our vision. After all, if it were your loved one you would want her safe and you would also want her to come home with her glasses and her favorite sweater!

The Creation of a New Playground in a GBMA Neighborhood: Perry Hall

There is an outstanding new playground and amphitheater coming to Perry Hall in the Spring of 2015. It will be one-of-a-kind, community-built, privately and corporately-funded and located next to the Perry Hall Library —a place that promotes active play, stimulates the imagination, is fully accessible and all-inclusive for children, regardless of their physical abilities.  The playground is to be named Angel Park.

The dream of this amazing playground began with an idea that came to Kelli and Andy Szczybor after the loss of their baby boy Ryan. From a sad origin, a bright and life affirming idea emerged – to build a place for laughter, activity and fun for families and friends throughout the surrounding neighborhoods. The playground is being designed with the help of over 2,500 local schoolchildren who shared their drawings and brainstormed ideas.  If you want to learn more about this playground and how you can help, visit 

Tuesday, April 22, 2014

The Cost of the Misuse of Prescription Drugs

The ever increasing cost of pharmaceuticals is a major driver of the American healthcare crisis. At GBMC, the cost of pharmaceuticals for our employees has gone up by 13% this year. We see drug expenses rising for many reasons. We are all willing to pay more for drugs that truly generate better health. But what about paying significant amounts of money for drugs that really don’t, or paying for drugs when they actually cause harm?

I am a pediatrician and a fellow of the American Academy of Pediatrics. Last week, I received an alert from the Academy that got my attention. The alert said that the majority of pediatric Clostridium difficile infections, which are bacterial infections that cause severe diarrhea and are potentially life-threatening, occur among children in the general community who recently took antibiotics prescribed in doctors’ offices for other conditions. This came from a new study by the Centers for Disease Control and Prevention (CDC).  The study showed that 71 percent of the cases of C. difficile infection identified among children aged 1 through 17 years were community-associated—that is, not associated with an overnight stay in a healthcare facility. By contrast, two-thirds of C. difficile infections in adults are associated with hospital stays. The CDC has data to show that many patients get prescriptions for antibiotics when the evidence shows that they are not necessary.

The FY 2015 Federal Budget requests funding for CDC for an initiative to reduce outpatient prescribing of antibiotics by up to 20 percent and healthcare-associated C. difficile infections by 50 percent in five years. A 50 percent reduction in healthcare-associated C. difficile infections could save 20,000 lives, prevent 150,000 hospitalizations, and cut more than $2 billion in healthcare costs.

After reading this, I was reflecting on people rushing to Urgent Care Centers and their doctor’s office to get antibiotics, frequently for viral illnesses where the antibiotics don’t actually help. I am curious about what would happen to business at Urgent Care Centers if the rate of antibiotic prescribing went down, as the CDC is trying to encourage. I also wonder if physicians in their offices would have more time to spend with their patients talking about what would actually improve their health if they were not writing so many prescriptions.

It is absolutely clear that antibiotics were a major breakthrough of the twentieth century and that antibiotics improve health and save many lives when they are used appropriately, but doctors, nurse practitioners, pharmacists and patients need to do a better job of making sure that the use of all drugs, but especially antibiotics, follows the evidence.

Tuesday, April 15, 2014

Beginning the Celebration: Almost 50 Years Old with a Bright Future

This week we kicked off GBMC’s big birthday celebration. Our Healthcare System is nearly 50 years old. Our hospital opened its doors on September 15, 1965 and a dedication ceremony was held on October 2, 1965.  Our HealthCare Board, under the leadership of our Chair, Harry Johnson, Esq., has created a 50th Anniversary Executive Planning Committee. Bonnie Stein, the incoming Board Chair, is the Chair of the Planning Committee.
(L-R): Harry Johnson, Bonnie Stein and Dr. John Chessare kick
off GBMC's 50th anniversary reception.
(Photo by: Maximilian Franz)

The Planning Committee decided to create a Founders Cabinet – a group of people important in the history of GBMC. This group includes community members who helped form GBMC, physicians, past and present GBMC Board members, long-term employees including many nurses, volunteers and donors. The group is inclusive of people from our hospital but also from Gilchrist Hospice Care, Greater Baltimore Medical Associates and private practicing doctors. The Founders Cabinet will guide the celebration and help us reflect on the many wonderful chapters of service to our community in the first 50 years. The Cabinet members will also be ambassadors to the community helping us continue to get the word out that all are welcome in the GBMC family.

So, to kick-off the 18 or so months of celebrating that will culminate on October 2, 2015 with a gala event, the Founders Cabinet gathered together for a reception. It was wonderful to see so many people who have given so much over the years to GBMC and our patients.

The event was organized masterfully by Jenny Coldiron our Vice President for Development and her staff from the Philanthropy Department. After a reception where people chatted and reminisced a bit, Harry opened the proceedings by thanking people for gathering and setting the stage for the evening. I then spoke about how GBMC has been an outstanding hospital and hospice with fantastic physicians, nurses, and other staff. I mentioned a few of our patient success stories and commented briefly on our work to make our care even better. Bonnie then spoke about the work of the Planning Committee and the role of the Cabinet in helping to make the celebrating and reflecting truly come alive in the community.

We then watched a video that had been created by the GBMC Marketing and Communication team under the direction of Interim Director, Greg Shaffer. You have got to watch this video! It beautifully highlights what GBMC means to so many people using the stories of a few key individuals. What a great highlight of a wonderful evening to commence GBMC’s big 5-0 birthday party!

GBMC is made up of so many employees and volunteers who have been an integral part of GBMC’s past, and so many more staff members who are a part of our future. I thank all of our team members for playing a role in caring for our community for close to five decades. I look forward to reflecting on our past and celebrating our future with all of you.

Wednesday, April 9, 2014

Red is Not a Badge of Dishonor

Since we introduced Lean Daily Management (LDM) a little over a year ago, it has proven to be a very effective tool for generating focused problem solving and continual improvement led by the people doing the work. Lean daily management has been a great way to get people in action redesigning systems to work better. It’s also provided our senior leaders with the opportunity to visit our units and departments and learn about the many ways teams are working to improve patient care and to implement standard work. Through our daily rounding, we’ve also had the opportunity to get to know many of our frontline leaders and team members throughout the hospital who are studying problems and testing changes, allowing us to have open conversations with one another about how we can continue to move toward our vision. I remain truly excited about where LDM is taking us as we work toward continual improvement in our care.

Last week on LDM rounds, I had the chance to talk with Kate Devan, RN, BSN, CAPA, PACU Clinical Partner at Sherwood Surgical Center. Kate is a wonderful leader and she presented the LDM board for starting cases on-time at 7:30 a.m. under our aim of Least Waste. The LDM chart showed the metric in red for the previous day as they had two of the three cases starting on time, instead of all three. It was clear that seeing the red on the chart dismayed Kate and her team as they had been working hard toward achieving the goal of all cases being on-time, and they really care about what they do.

Pictured left to right: Holly Clevenger, RN, Clinical Partner,
Sherwood Surgical Center, Kate Devan and Laura Ghasseminia, RN.
“Sherwood has been working very hard to provide a safe and caring environment to our patients,” explains Kate.  “I felt extremely proud of our team in Sherwood for accomplishing two out of three cases on time, but also felt a sense of frustration that we were still not meeting our goals. I felt that maybe by setting our goal so high we were setting ourselves up for a goal that was not obtainable. It did not celebrate that we were successful in achieving over 60% on time starts, but rather showcased that we had 30% late starts and we were in the red.”

It became very clear that Kate was truly proud of what her team had accomplished already but that having to report that they still were in the “red” was a source of frustration for all of their efforts.

This caused me to reflect on the fact that many of our people see “red” as “bad,” and that I as a leader had done a poor job of explaining the nature of Lean Daily Management. It’s about finding process flaws and then testing changes to the process. If we don’t find the defects - and show the performance as “red” - we won’t know what to try to change. It seems that many of our people believe that LDM is about “catching people doing a bad job” and since we were children when red pens were used to find our mistakes…red is the color of negative judgment.

I am so excited about the great work that the Sherwood team is doing and it bothered me that they felt that the red on the LDM board was a badge of dishonor when nothing could be further from the truth. They have always done an excellent job but since LDM they have made dramatic improvements.

This opened up a candid conversation that provided us all with the opportunity to learn from our different perspectives. I pointed out to Kate and her team that in fact, identifying a defect in their process was actually great news and not something to be ashamed of!

After this conversation, Kate says, “It was reassuring to hear Dr. Chessare say the things that he did.  It felt as though he was in strong support of our efforts and our progress towards reaching our goals.”

When the engineers at Toyota find a defect, they actually celebrate this as an achievement because they know it’s an opportunity to make their product even better and generate problem solving.  Toyota has mastered the concept of daily improvement and at Toyota they know that if everything is green, nothing is being improved. Leaders in organizations that continually improve understand how to find the next opportunity, which requires people to think critically and not start from the presumption that everything is fine. As we discussed last week, we should start from the presumption that everything is NOT fine.

We must also move from the mindset of punishment to the mindset of curiosity. Red is not a badge of dishonor, but we are trained to think that it is. We are trained to believe that if you didn’t get it perfectly right the first time, you’ve failed. Not true!

I was grateful to have had this conversation with Kate and her team because it was a learning experience for me about what our teams are getting out of these conversations at the LDM board during the daily presentation. If everything is good and all of the charts are green, then we should be worried that we’re not asking the right questions or studying the right processes. We must celebrate green and say thank you when green came as the result of a new change. And, if we’re going to assign bad performance to anyone it should be when we learn of a defect in our processes and fail to test changes to fix it.

The Sherwood PACU team certainly has a lot to be proud of in their care of our patients and in their actions to make the care even better.

Experts in improvement have a wonderful phrase – “Every defect, a treasure.”

When you identify the defect, it gives you the opportunity to get better. If you have defects that you don’t know about, you cannot fix them. So, we should always be looking for the defects so we can test changes to improve.

Red is not a badge of dishonor. The only dishonor is to allow poor systems to remain as they are and to not be in action testing changes.

Thursday, April 3, 2014

Preoccupation with Failure and the Prevention of Needle Stick Injuries

In the U.S. healthcare industry, most of us were trained to assume that if we worked hard and had good intentions, everything would go fine. In fact, everything usually does go fine when we provide care to patients. The problem is, when you work in a high risk industry like healthcare, a miss or lapse can lead to a catastrophic outcome.

Think about it this way: If you’re stocking cereal on a supermarket shelf and one box gets put in the wrong place, it’s not a big deal. But, if you’re working in a hospital, where thousands of needles are used every day, and one nurse or one physician gets stuck with a needle, it’s a huge deal. That one nurse or doctor can be exposed to diseases such as Hepatitis C or HIV. Working stocking shelves in a supermarket (which I have done) is not a high risk pursuit. Delivering health care is.

Other high risk industries like nuclear power, for example, teach their people to be mindful. They caution their people about becoming complacent and about ignoring little things that are wrong because they know that these little things can begin to add up.

“It’s okay to ignore the alarm…it’s probably that the lead has come off;” “It’s okay to let the patient leave before the Anesthesiologist has checked him…they frequently do and no patient has suffered before because of it;”  “It’s okay not to put on protective eye wear before I put this NG tube in that may make the patient cough…I've done it tons of times before with no ill effect.” 

The acceptance of these small deviations eventually add up to something bigger.

Nuclear power and commercial aviation have taught their people to be preoccupied with failure. They teach that the best way to avoid catastrophic failures is to look for them developing so as to head them off. They teach their people to follow the design and to be alert that even the best design may fail.

In health care, we often drift and allow failures in following the design because we assume that things will go ok. How many times do healthcare workers fail to use protective devices because they are usually not exposed without them. How often do surgical teams pass sharp instruments using incorrect technique because they have never been stuck before? Before pilots began using pre-flight checklists, most flights took off safely…but some didn’t and many people died because of this. Now, all pilots use the checklists every time and they are still mindful of things that may signal that something isn’t right.

Recently, we’ve had a couple of needle stick injuries where our people assumed that their colleague had disposed of a needle correctly. The colleague, however, did not. They became distracted and left a needle on a bed or on a stand and it became “hidden” in sheeting. Then, another staff member came in, and assuming everything was safe, grabbed for the sheet to throw it into the trash. But when they grabbed the sheet, there was a needle wrapped in its folds and this individual was stuck.

Telling people to always properly discard needles does help, but it cannot get us to higher levels of reliability and safety. We must also be mindful and have this preoccupation with failure and change the way we see our work. Rather than assuming all is well, we need to assume that danger is lurking nearby. If we are mindful that there may be a needle in the sheeting we’re about to throw away, we’ll deal with this sheeting differently and pick it up differently. This concept of preoccupation with failure is something we need to adopt at GBMC.  I welcome your thoughts and comments.