Dedication

I just finished writing my holiday cards. No, I’m neither real late nor real early. The cards are for Doctors’ Day, the one day in the year that we take time to thank physicians for all that they do.

Our GBMC HealthCare System is blessed to have such talented doctors.  I recall when I was interviewing for the job of CEO, everyone wanted to tell me what a wonderful medical staff we had. I remember thinking that no one would say that they didn’t have a great medical staff. But I have been a member of a number of medical staffs and seen many more. After almost 3 years on the job, I now know that those who were telling me that GBMC had an exceptional medical staff were not exaggerating. It is true.

As a group, our physicians are very talented. But on the day that we recognize them, most patients call out their physician’s dedication as the thing that they are most grateful for. And our GBMC doctors are very dedicated.

Webster’s dictionary defines dedication as self-sacrificing devotion. I see examples of this everyday at GBMC. The surgeon who has spent the entire day in the operating room who just arrived home for dinner and is now quickly back in the car to take care of a patient who needs emergent care. The obstetrician and the neonatologist who come in at 2 am for the birth of a premature baby. The radiologist coming in on Sunday to do an intervention. The internist coming to the hospital in the evening to explain a bad diagnosis to a worried spouse.  The emergency medicine physician volunteering at a community event on his day off helping an injured little girl or the pediatric emergency physician staying late at the hospital to make sure that the same little girl gets precisely the care that she needs.

When physicians of a certain age get together and discuss their concerns about the future of medicine, they always talk about their fear of the loss of this dedication.  They are concerned that the push-pull of career vs. personal and family life will cause the deterioration of self-sacrifice. I must say that I do not see any loss of dedication.

This week I was at the quarterly meeting of the Greater Baltimore Medical Associates, our employed physicians. The primary care site physician leaders were discussing the fantastic success of Saturday office hours. In turn, each physician manager minimized the effect of giving up some family and personal time and highlighted what the change meant to their patients. Hearing this, I was reassured that the future of medicine as a profession is bright. Dedication to the call of patient care is alive and it is strong.

So, if there is a doctor who has shown her dedication to you, why don’t you send her a note, an email, a card, or give her a call and just briefly say thank-you. You can even find free "e-cards" for Doctor's Day here.  And don't forget that the GBMC Foundation is still accepting donations if you wish to recognize a GBMC physician - just click here.

On Doctors’ Day it is right to show gratitude for the dedication of our physicians.  

Thoughts and Prayers Needed

Please keep Dr. Ted Houk, an Internal Medicine physician and member of the GBMC family since 1992, in your thoughts and prayers.  Dr. Houk is well-known for jogging every day, no matter the weather, from his Lutherville home to his York Road office.  On Thursday morning, his daily commute turned tragic when Dr. Houk was struck and critically injured by an automobile not far from the GBMC campus.  Dr. Houk is being cared for by the world's foremost experts in trauma medicine at Shock Trauma in downtown Baltimore, and our thoughts and prayers are with Dr. Houk and his family at this difficult time.

Happy Holiday

On a final note, the GBMC HealthCare family sends its best wishes to everyone celebrating Easter this Sunday.

What Does a Great Team Look Like in Health Care?

One day last week I spent some time in our Endovascular Lab at the invitation of Carter Freiberg, M.D. Although it’s clear that sending pediatricians (or worse, administrators) to operative areas may not be in the best interest of patients, I was glad to go and learn about state of the art vascular care at GBMC.

Dr. Freiberg welcomed me to the lab and told me about the lab’s capabilities, successes, and challenges. He then told me about the case that he was about to do. The patient was a man with a popliteal aneurysm found on exam who had poor blood flow to his foot. While Dr. Freiberg explained his approach to me, the rest of the team got the patient and the equipment ready. The Certified Registered Nurse Anesthetist, Kathleen Murphy, spoke with the patient and made sure that all of the monitoring equipment was set to go. Mark Stuckey, the scrub tech made sure that all of the surgical equipment was ready including the catheter to be used. Bill Barron, the radiology technician, checked that the contrast material was ready and that the ultrasound machine was setup and the screen was clearly visible from the operating field. Bill was assisted by Crystal McDaniels, senior radiography student. The supervisor of the Vascular OR staff, Marjorie Enriquez, RN, was standing in for her colleague who was on break, and she was getting the documentation of the case setup in the computer.

Dr. Freiberg scrubbed and gowned and went and said hello again to the patient. The timeout was then called, to assure that the team had the correct patient and all new the plan for the procedure. Dr. Freiberg then introduced a wire into the patient’s groin and threaded a catheter into the patient’s arterial system and took X-rays, documenting major arterial problems. The popliteal aneurysm was seen and the man’s right leg was getting blood flow only from collaterals. It was clear that the man was going to require both an open procedure and another catheter procedure to take care of his problems.

Dr. Freiberg broke scrub to go and speak with the man’s family and tell them what he had found. Mark assured that bleeding had stopped at the groin site and helped the rest of the team get the patient to the recovery room.

The procedure had gone very smoothly. Everyone knew their job and they interacted very smoothly. Dr. Freiberg told me: “We have a great team.” He then went on to tell me about how Mark and Bill, knew precisely what to do with almost any eventuality. They were not afraid to make suggestions or to ask clarifying questions. Later, while Dr. Freiberg was dictating, I asked both Bill and Mark about the team and the feeling was mutual. It was clear that they enjoyed working with Dr. Freiberg and they felt respected and realized how they were part of a high functioning team that had helped a lot of people. “I love my job”, Bill told me. Bill also made it clear to me that there were real challenges that the team faced but these were not insurmountable. In fact, the team surmounted them every day.  

I left the endovascular lab that day being very grateful for the work of this wonderful team. I also realized that it was my job, along with the rest of our leadership, to make sure that the endovascular team has what it needs to get the job done and to treat everyone who comes into the lab the way I want my own loved ones treated.

What would you do if……?

Last Wednesday, I was racing to a meeting at the Baltimore County Health Department. I got in my car in Tulip garage and went up one level headed to the employee exit. I came upon a very curious situation. There was an SUV that had clearly just bumped into the back of another car. The SUV had its driver door open and there was a woman next to the SUV who was on her cellphone and looked frantic. I rolled down my window and asked her if she needed help. The woman replied, “Yes, there’s a snake in my car!” It seems that she had come from Harford County to see her doctor in Physicians Pavilion North. After the visit, she got back in her car, backed out of her space, and as she was turning to drive out of the garage, she saw a snake on her dashboard and freaked out (as anyone would have!) She lost control of the car, bumped into another car in the lot and got out.

I called Security and our Head Groundskeeper, George Dillon. The woman (who was now calming down) and I took some pictures of the snake. The snake slithered from the dashboard, to the rear view mirror, and back to the dashboard before falling to the floor of the car. Then Security and George arrived. I went on my way and George spent about 20 minutes searching the inside of the car for the snake which he could not find. The woman called her husband and made him drive that car home. If it had been me, I think I would have traded the car in immediately.

Passover Celebration

Finally, on behalf of the entire GBMC HealthCare family, I want to extend best wishes for a Happy Passover to everyone celebrating the Jewish holiday this week.  The eight-day Passover holiday commemorates the emancipation of the Israelites from slavery in ancient Egypt. 

Working Very Hard, Getting Great Results, and Having Some Fun!

Being a nurse or other member of the Team on an inpatient unit in a busy hospital can be a very hard job. Our patients, especially the elderly, have many needs. A nurse must be well schooled in the science of medical care and he or she must also be a humanist. The inpatient’s progression is not always predictable – the Team never really knows what is around the corner.

Our inpatient Teams at GBMC are doing a marvelous job of caring for our patients and also finding the time to improve towards our quadruple aim of better health outcomes, better care experience, less waste/lower cost and more joy for those providing the care. This week our Unit 45 Team shared with me some of their accomplishments. After their Thursday morning huddle, Amanda Stevens, RN ran down the huddle checklist with me. She showed me how the Unit had gone 43 days without a patient fall! We discussed what the Unit had done to get to that fantastic accomplishment including the use of “hourly rounding” where every patient is visited at least once per hour by either a nurse or a medical technician and is asked, among other things, if he or she needs to use the toilet. (Getting up to go to the toilet unassisted is a major trigger for falls among elderly and debilitated patients.) She also credited the standardized use of bed alarms for at risk patients.

We then discussed the Lean Daily Management metric on hand hygiene. Every shift, a nurse audits his or her colleagues’ hand hygiene and the previous day’s performance is discussed at the huddle and then tallied on the run chart in the nursing station. (We will be formalizing our approach to Lean Daily Management with a weeklong kaizen in April). 

Amanda showed me that the daily audits were hovering in the 97% reliability range this week. It is the return to the daily audit that has helped the Unit get its monthly unit measure done by the “secret shopper” back above 85% after the “special cause” of opening new beds in November. Amanda shared a number of other things that were discussed from the huddle checklist and I thanked her for her great leadership. I then thanked many members of the Team and asked them how they enjoyed being actors. They looked at me a bit puzzled and then one of them said: “Oh, you mean the video!”.

The Unit Manager of Unit 45, Eileen Skaarer, RN had shared with me that to do a little team building, to continue the hand hygiene buy-in, and to have some fun, the Unit had produced a video. I think that you will agree after watching it, that it really does seem like they had some fun doing it, and I am sure it increased their team spirit and further locked in their awareness of the need to “wash in and wash out”. I am very grateful to the staff on Unit 45 for all that they are doing and also that they found a way to put some of the joy back in caring for their patients.

Being Open and Honest with the Community We Serve

An organization that has put a stake in the ground and made clear what it is trying to become, like the GBMC HealthCare System, must take the next step and give those that it is serving the information to prove that it is actually getting there. We have stated to all that our vision is to become the system where everyone, every time gets the care that we would want for our own loved ones. We have further defined that care as the best possible health outcomes, with the best possible care experience, with the most joy for those providing the care, at the lowest possible cost. So how are we doing? It’s time to make it easier for our patients and our community to decide.

Historically, healthcare organizations have been reluctant to show the public that they are not perfect for fear of loss of business and/or litigation. But, we now believe that organizations that make their performance transparent improve faster and therefore have a lower risk of these losses.

Up until now, you could find some real data about us at the federal government website, Hospital Compare. But that data is at least 9 months old.

I’m excited to report that during National Patient Safety Awareness Week, we have launched a new patient-friendly interactive tool on our website designed to show our performance in quality and patient safety.

 The “Patient Safety & Quality Measures” page (under “About GBMC”, “Patients & Visitors tab, “Patient Safety & Quality”) includes a visual display of many of our clinical process measures such as hand hygiene,and healthcare acquired infection rates as well as patient satisfaction scores and clinical outcome data. The data will be updated monthly. 

Our “Patient Safety & Quality Measures” page also provides an explanation and brief video of what each metric means along with our latest performance.  Wherever possible, we have included comparison data to other healthcare entities in Maryland.  We hope that over time these organizations will follow our lead and make more of their data accessible to the public.

We believe that display of this data for all to see will help GBMC move faster toward our vision because now the onus will be on us to continually improve.  On Thursday, the first day the page was live for all to see, we had more than 200 visitors to the site and 248 page views.

I am very proud of our quality champions - John Saunders, Jr., M.D., Chief Medical Officer; Carolyn Candiello, Vice President for Quality and Patient Safety; and Bonnie Stein, chairperson of our Board of Directors Quality Committee, who have gotten us to the point where we are displaying our performance on our public website. The Quality Committee has been working on this for a number of months,  making sure that the data were robust and that there was a good system in place for reporting monthly.

I want to especially thank Jane Mace, Darlene Fleischmann and Jerry McCann, our patient / family representatives on the Quality Committee, who were very instrumental in working with our team, which also included Mike Hartnett, Greg Shaffer, Rob Reese and Matt Ellis from our Marketing Department, who made the display of information interpretable by the average healthcare consumer. I’m proud that we took on this challenge and have made it a reality using all internal GBMC resources.

Healthcare today is an extremely complex process and we know that it is imperfect but we continue to work towards perfection. GBMC believes that our patients have a right to know how we are doing and that we have made a commitment to continually make our care safer and more reliable.  Please hold us accountable to this promise.

All Teach…All Learn

On Monday of this week, I spent the day at Learning Session 2 of our GBMC Improvement Collaborative. In a collaborative, teams that are working on improvements get together at regular intervals to share their progress (and their failures!) so that they can learn from each other and accelerate meaningful change.

Each Team had a storyboard to display and got an opportunity to discuss their work with the larger group. The Teams are working on our system goals. We have teams working on cleanliness (I am the executive sponsor of this team), pressure ulcers, falls, and patient education about medications, to name just a few. The Teams learned more about the Model for Improvement and the notion of testing changes before full-scale implementation.

We also watched a video of Dan Heath, who along with his brother Chip, wrote the book, Switch. The basic premise of this book is that people who want to generate change will make more progress if they understand what fosters change and what gets in its way. Their change model includes 3 components that they call the rider, the elephant, and the path. The rider is our conscious, thinking, self. The elephant is our emotional, urge-driven component and the path is set of external factors that will either make it easier for the rider to navigate the elephant towards the goal, or make it harder. The Heath’s teach that you must first direct the rider with clarity about where he or she needs to go. But it isn’t the rider who has the real say…it’s the emotional self, the elephant. So, you have to motivate people to change with stories that move them. You must get to their emotions. And lastly, you must shape the path by building habits that will help move change forward. 

At the learning session there was a lot of sharing of data and a lot of story-telling for motivation. There was great celebration of accomplishments, like the significant increase in inpatient satisfaction that appears to be coming from hourly rounding, bedside handoff, and faster response to call lights. The Teams recommitted themselves to their goals…all towards our vision of becoming the healthcare system where everyone, every time, gets the care that we want for our own loved ones.

The GBMC HealthCare system is transforming from “hold the status quo” to continuous performance improvement and it is really fun to watch. 

The Quadruple Aim on Unit 36

I have the pleasure this year of being the GBMC Senior Team member who is assigned to Unit 36. Each of us on the Senior Team works with two units to narrow the gap between what the “front office” knows and what the “front line” knows.

Unit 36 is our Medicine/Psychiatric Unit. The Unit cares for people with mental illness who also have acute medical needs. The leadership dyad of Nancy Amann-Santos, RN, the unit manager, and Darin Lerner, MD, the medical director, are two of the most dedicated people I have ever met. Everyone who knows anything about healthcare knows how challenged our mental health system is. Nancy and Darin deal with this dysfunction everyday and they never lose sight of the reason why they and their Team are there…to deliver the care to their patients and families that they would want for their own loved ones.  But boy is it hard!

This morning I went to the Team huddle at change of shift at 7:15 AM. Nancy showed me the Team metric board that showed, among other things, recent hand hygiene audits that were at 100% compliance and many days of no patient falls with injury. I then listened while the staff debriefed on an incident where family members who were not associated with the same patient but who evidently knew each other, got into a verbal altercation on the Unit.

Trina Griffin, RN explained to the group how she had acted to deescalate the situation, avoid getting the patients upset, and get the visitors to act appropriately. The Team quickly brainstormed on other things that they could change to avoid this type of problem in the future. They then discussed two other patients: one who was admitted with a significant medical problem but who also had obsessive compulsive behaviors and the other who could not understand why it wasn’t safe for him to get out of bed by himself.

Working on an inpatient unit where the patients understand the care and are generally grateful is hard enough – dealing with the same issues in a population who does not always understand and who may take actions to harm themselves or others takes it to a whole new level. The Unit 36 Team comes to work every day to get to better health, and better care with less waste for their patients. You can feel their joy in knowing that what they do means so much to their patients and families, even if the patients….and sometimes the families…don’t always understand. I am very proud of them and very grateful for all that they do. 

It Should Be Easy to Move an Admitted Patient from the ED to a Floor Bed….Shouldn’t it?

This week a Team of GBMC people spent 5 days studying our system from when a patient is first seen by an Emergency Department physician until those that need to be admitted to the hospital are actually in an inpatient bed.

The Team was chartered because we identified this as a strategic opportunity for improvement when we created our operating plan for this fiscal year. We set a goal for ourselves to reduce the average time from when a patient arrives in the ED until they are in an inpatient bed from 8.5 to 6.8 hours… a reduction of 20 percent. 

GBMC HealthCare set this goal because our patients get very upset when they are still in the Emergency Department long after they have been told that they need to be admitted. This is no surprise. Almost every adult has accompanied at least one family member who has waited in some ED to be moved to an inpatient bed. If we don’t want this for our own loved one, no one should wait. Not to mention the cost to our system of extra staffing and foregone admissions when other people leave our ED and go somewhere else for care.

The Team included doctors and nurses from the ED, hospitalists and inpatient nurses, secretaries and people from many support services. Their mentor was Neil Crockett from Next Level Partners and they were aided by a number of our Performance Improvement Masters. After getting some training, the team set out to study the current processes. They went to the ED and the inpatient floors and watched them and documented the way they were doing things. The Team identified 89 sources of unnecessary variation and waste.

They were amazed that for almost every step that they studied, each person doing a task was doing it differently.  They then identified 56 actions that they could take to redesign the processes within the system.  The Team then divided these actions into things that they could change right away: “Just do it’s”, things that they could test immediately (trystorming), and more complicated things that could be changed over time. They immediately implemented the “just do it’s” and began implementing the things that seemed to work in the “trystorms”.

I went to the final Team report today and was amazed at how much they had accomplished. Every team member had a greater understanding of how the other team members were doing their job and how complex the system of admitting a patient from the ED actually is.

There is a lot of work to be done to redesign healthcare in our country and in the GBMC system. When we talk about delivering better health, better care, and lower cost, the uninitiated believe that this means more work for those providing the care. It is only when they develop the deeper knowledge of what is going on in our existing system that they see that a lot of what they are doing is not really benefiting anyone and if they do the work of redesign, they will accomplish better health and better care with less work.

It was really exciting to see that this was one of the learnings from the Team’s efforts this week. I am awed by what they accomplished and am more excited than ever about the transformation of the GBMC HealthCare system.