It’s easier to get the job done when everything is in its place - 5 (or 6) S's revisited

Last week a team from GBMA did a weeklong kaizen. Staff from Joppa Road, with the help of GBMA COO Ben Beres and others, worked to systematize how their office was setup with a subsequent plan to extend this to other offices.

On August 30th of last year (http://ahealthydialogue.blogspot.com/2012_08_01_archive.html), I wrote about the 5 or 6 S process: When Safety is added the 6 S’s are:

1. Sort: eliminating everything not required for the work being performed
2. Separate: efficiently placing and arranging equipment and material
3. Shine: tidying and cleaning
4. Standardize: standardizing and continually improving the previous three
5. Sustain: establishing discipline in sustaining workplace organization
6. Safety: creating a safe work environment

The team: Elaine, Susan, Vivian, Maryanne, Jeanne, Joyce, Robin, Janice,
Jennifer, Courtney and Ben 

The team did a fantastic job of organizing all of the “stuff” required to get the job done in a primary care office and made it much easier to know what needs to be replenished. They started by throwing away all of the accumulated things that they didn't need and then planned to store things to minimize steps to get things when they were needed. They bought bins and created audit forms to make re-ordering easier. The process also creates the discipline of standard work. I am very proud of the team!

Annual Competencies
I was completing my annual competencies last week and stopped for a moment to reflect on the importance of knowing a core of information for all of our GBMC employees. While it does take time to complete these tests, it’s imperative that we know what to do in a fire, that we know how to keep ourselves safe on the job, and that we understand the importance of keeping information about our patients confidential. Unless all of us have this basic knowledge, we cannot get to higher reliability and to our vision. I want to thank everyone for completing their annual competencies by July 31st.  

Connecting with and educating a segment of the business community on healthcare reform

Last week I participated in a panel for Biz Now, a meeting with real estate brokers, developers and others from the local real estate community and some healthcare leaders. Also on the panel with me from healthcare was Bonnie Phipps, President and CEO of St. Agnes Hospital. The topic for discussion was healthcare real estate. The discussion was lively and centered on the changing healthcare real estate needs as they relate to healthcare reform, the affordable care act, accountable care organizations and value-based purchasing.

I raised the point that it’s a problem that the business community doesn't understand the dilemma of our national healthcare system.  I explained that our country’s need for healthcare reform really has nothing to do with politics. Whether you’re a fiscal conservative or a wide eyed liberal you should be concerned that we’re spending 40% more on healthcare  than any other country.  And, the business community should be demanding reform regardless of whether or not they are for or against the affordable care act. To fight against reform is absurd, especially when healthcare impacts businesses just as much as individuals.

We went on to talk about the playing field and the fact that some Maryland hospitals get higher prices than others, but that with insurance exchanges and the notion of restricted networks, this is starting to change. We also explored the concepts of the GBMC transformation and our focus on the patient centered medical home as the fundamental building block of the healthcare system.  

As I talked about GBMC’s transformation I was extremely proud when Bonnie Phipps told the audience that GBMC is way out in front in the evolution to accountable care organizations and with our work developing the patient centered medical home model. This was really nice to hear and is important for everyone at GBMC to know…

The business community is slowly waking up to the need to demand greater value for their healthcare dollar and this panel discussion was a great exchange of information.  I was glad to have had the opportunity to educate these real estate professionals about the changing tide of national healthcare and GBMC’s role in creating a value-driven system. I believe that there are a few more business leaders who now see a new roadmap for change and their role in designing a new and better system.

Welcoming New Physicians Who Will Help Move Us Closer To Our Vision

Delivering the kind of care we want for our own loved ones starts with adding the most passionate and dedicated healthcare providers to our system. Over the next several months, GBMC will be welcoming a great group of new physicians, both employed physicians and private practice doctors, who have such a drive for superior care. From stellar surgeons to family practitioners, we’re fortunate to have some of the best doctors joining the GBMC family.

Dr. Jillian Verby

Just this month, a new family physician, Jillian Verby, MD, hit the ground running in our Primary Care Associates practice. Dr. Verby completed her residency training at Montana Family Medicine where they already have the patient centered medical home model. She knows the importance of collaborating with case managers and nurses and understands how well this model of care works for the overall well-being of patients.

Before joining GBMC, Dr. Verby worked as a rural general practice physician in Oxford, New Zealand and she has some incredible insights on primary care medicine from different cultural and regional experiences that she brings to GBMC. She’s very motivated to further incorporate this patient centered medical home perspective into our practices and tells me:

“The patient centered medical home model is really about relationship-based, coordinated  care and paying attention to each individual’s needs instead of just treating a general diagnosis. It’s a really exciting  concept and that’s why I’m in family medicine – to develop these lifelong relationships and to get to know the patient as a whole person.”

“During my residency training at Montana Family Medicine, we initiated the patient centered medical home model. Every patient was greeted and evaluated by a team, from the front desk person, medical assistants, nurses and care managers to the physicians. We were all a team working on behalf of an individual patient. And, if we needed to involve other healthcare professionals in a patient’s care, we had case managers, behavioral health specialists, and clinical pharmacists available as needed, which allowed us to provide a coordinated, comprehensive care experience.” 

“We also initiated the concept of accessible care by offering extended evening hours and providing continuity of care in the hospital. We offered more same day visits for acute concerns through physicians or nurse practitioners so that we could make care accessible. These are all things we are doing here at GBMC, which is great.” 

“I’m very excited about the future of the patient centered medical home here at GBMC. Ultimately we’ll see better access to care for patients and a big focus on preventative screenings. One major study in 2007 found that people have higher quality care with less racial and ethnic disparities in the medical home model. I’m optimistic we’ll see better patient oriented outcomes in the future once we have fully initiated this model. It takes a lot of adaptation on the provider side, but in the end, all patients will have continuity of care, build a lifelong relationship with their provider and be in a system where everyone contributes to a person’s overall care and well-being.”

Dr. Elizabeth Dovec

Similarly, we welcome a new bariatric surgeon, Elizabeth Dovec, MD, who has such passion for her work and the development of a truly comprehensive bariatric program that accounts for the health of the whole person. Dr. Dovec completed a fellowship in minimally invasive and bariatric surgery and says that being a bariatric surgeon enables her to combine her love for surgery, nutrition and helping patients achieve overall health through weight loss surgery. She doesn't just stop at being a truly skilled surgeon;  she has a vision for bariatric care that, as she shares with me, “Will take complete control of the entire well-being of the bariatric patient.”

Dr. Dovec is out to beat morbid obesity. She understands that weight loss surgery has many important components and that preparing patients for life before and after surgery can make a tremendous difference in a patient’s long term health. Here’s what she had to say about her vision for the future of GBMC’s Comprehensive Obesity Management Program:

“Becoming a part of the GBMC team was a perfect opportunity for me. GBMC already has the outstanding Comprehensive Obesity Management Program and this is an opportunity to focus all my energy on bariatrics. My vision is to add an exercise therapist to help in our office, as well as add a psychologist, and a primary care physician with a special interest in treating bariatric patients. We will continue providing excellent nutritional services and really take complete control of the entire well-being of the bariatric patient. I have always loved all aspects of bariatric care – the surgery as well as incorporating the psychological, nutritional and exercise components of the surgery.”

“This type of comprehensive program is so important as obesity is a national crisis. At some point, just diet and exercise alone doesn't work for these patients. I’m very empathetic to this fact. I understand that it takes a lot of courage to make the decision to have this surgery. The road is not easy for bariatric patients and creating a supportive environment is just as important as the surgery itself.”

I am confident that physicians such as Dr. Verby and Dr. Dovec and all of those joining our system will continue to move us closer to our vision: To every patient, every time, we will provide the care that we would want for our own loved ones.  Please join me in welcoming all of our new providers to the GBMC Healthcare system family.

Town Hall Meetings and GBMC’s Bright Future in an Evolving Healthcare Marketplace

Yesterday, I did the first in a series of Town Hall Meetings. These meetings are one of our tactics for narrowing the distance between the “front office” and the “front line.” It is very important that all of the members of the GBMC family know what is happening in the national and local healthcare environment and how this affects the GBMC HealthCare System. 

We are well into our transformation as a health system and we are better prepared for the changes to come than most hospital companies, but there are challenges out there and we need wide open conversations to give us the best shot at effectively dealing with these challenges. 

Real changes described in the newspaper like layoffs at other organizations or rumored changes heard about in hallway conversations make our people nervous and generate questions about job security, salary and wages, and the future of our own healthcare system, among others.

The Town Hall Meetings are an opportunity for me to keep people focused on our vision and the work of transforming ourselves into a high performing system through the eyes of the patients we serve. If we do this work, our company will continue to thrive. I will share our recent accomplishments and the reasons why hospitals are at risk and why our strategy to move to a system of care is now paying off. 

Holding the town hall meetings also provides our staff with the opportunity to ask questions, raise concerns and let us know what they are thinking.  

Some of the important topics we will be covering over the next month include:
- The GBMC healthcare system’s progress toward our vision
- Financial challenges to hospitals in Maryland and nationwide
- Positive changes to GBMC’s benefits and wellness initiatives
- Employee wages and bonuses – an update on our FY’13 incentive plan and merit pay for FY’14

To ensure that every employee has an opportunity to attend a town hall meeting, they will be held in large and small group settings on the GBMC campus as well as at satellite locations including Hunt Valley, Owings Mills and the South Chapman building. The detailed schedule is available on the GBMC InfoWeb. 

As always, our town hall meetings are a place to learn more about your role in assuring the success of the GBMC HealthCare System and your opportunity to have your opinion heard. I encourage all employees to attend at least one of the 14 scheduled meetings that run from July 8 through July 26. 

Training the Next Generation of Physicians

GBMC is known as a system that has excellent doctors. Educating the next generation is a great way for any professional discipline to stay on top of its game. So, it’s wonderful that GBMC sponsors an Internal Medicine Residency training program, a Colo-Rectal Surgery fellowship program, and hosts residents in Gynecology and Otolaryngology from Johns Hopkins and residents in Ophthalmology from the University of Maryland. Led by Dr. Paul Foster, our new first year medical residents began their training last week. It’s been great to see the young, smart men and women joining our healthcare system as they embark on their post-graduate training.

The environment that these interns are coming into is quite different from the one that I found when I graduated (more than a few years ago). I was curious to see what a couple of our interns thought about the work world they were entering, so I posed a few questions to get their thoughts on how the practice of medicine is changing, some of the challenges they face and some of the positives they see as a result of healthcare reform.

Medical resident Abdimomun Iuldashev, MD, comes to GBMC from Marmara University School of Medicine in Istanbul, Turkey, where he completed a one-year internship and received his medical degree. Coming from another country and culture certainly has its challenges but also provides residents like Dr. Iuldashev with new opportunities and experiences.  Bryce Harbertson, MD, is a Maryland native who received his medical degree from the University of Maryland School of Medicine. As a student from the U.S. educational system, Dr. Harbertson tells me that there is still a great deal of unknowns regarding the future of healthcare. It is interesting to hear their perspectives on what lies ahead for the practice of medicine:


Q: How do you see the practice of medicine changing as we move into a new era of healthcare? 

Bryce Harbertson, MD

Dr. Iuldashev: “Practicing medicine is getting better because of advances of medical technologies. By using MRI, CT, echo or other medical devices, we can diagnosis with high sensitivity and specificity. As we move into a new era of healthcare, accurate diagnosis and treatment rates are increasing so we have more satisfied patients and an increasing number of doctors satisfied with their jobs.”

Dr. Harbertson: “We will continue to see technological advances that make patient care more safe and efficient.  I imagine individual hospitals will continue to figure out how to improve communication and care coordination among physicians, nurses, techs, therapists, social workers, and other patient care services.”

Q: What are some of the challenges you may face in this new healthcare arena? 

Dr. Harbertson:  “We are going through changes that hopefully will lead to better care and lower costs. In addition, we have an always growing body of clinical evidence to help us make patient-care decisions. The challenge will be staying abreast of all the evidence so we can use it to provide cost-effective care.”

Abdimomun Iuldashev, MD

Dr. Iuldashev: “The population is aging and this means an increasing number of patients per doctor. This is causing doctors to work more and spend less time with each patient. The other challenge is that we are becoming more dependent on technologies. This is good if you practice where you have the technology, but can we become handicapped as doctors if we go to underdeveloped countries that do not have this technology?”



Q: What are some of the positive aspects of the practice of medicine today?

Dr. Iuldashev:  “Being a doctor is exceptional because every day you have a chance to make a difference in somebody’s life. Today, we have technologies that are helping us in every way. We can teleconference with hospitals thousands of miles away and watch the live procedures they are performing. We have advanced drugs that act at cellular levels, and we can treat many diseases that were untreatable in the past. These things make us lucky to practice medicine today.”

Q: How do you see the changing landscape of healthcare and healthcare reform benefiting the future of medicine?

Dr. Harbertson:  “The anticipated benefits are improved patient care in terms of quality and safety while also making it more efficient to keep costs down. I think the hope is that as more people are able to have insurance they will regularly go to PCPs. However, we have to have a sufficient number of PCPs, NPs or PAs in order to handle the increase in the number of insured patients. Perhaps as patients regularly visit their providers, they can better manage their chronic illnesses, reducing complications and hospitalizations.”


I am delighted that our young colleagues see the next years as an opportunity to improve care. Their responses show that they are aware that there are challenges ahead and that the availability of technology brings new efficiencies, but also new risks. They recognize that it is their duty to use resources wisely and that the coming increase in need brought on by the aging population will require greater teamwork and cooperation with the other members of the healthcare team. I am excited for them as they begin the next phase of their careers and I am delighted that they have come as our colleagues. Please join me in welcoming all of our new residents! Say hello to them when you meet them in the corridors of GBMC.

How Much Progress Did We Make Toward our Vision in Fiscal Year 2013?

Our fiscal year ends this week so it’s time to reflect on our accomplishments. We won’t have the final tally on our system goals until the fall after our financial audit is complete, but we can already see that it has been a great year for our system. We all know that we measure our progress toward our vision of becoming the healthcare system where every patient, every time, gets the care that we would want for our own loved ones by assessing our four aims: better health,  better care, with the least waste, and the most joy for those providing the care.

Better Health

Our work in standardizing care around the evidence has helped us achieve great things this year. Since fiscal year ‘11, we have reduced our serious safety events by 45%. We went from 20 events in FY’11 to 11 in FY’13. While we did not achieve our goal of 10 or less in FY’13, the knowledge that we have gained from studying our events and creating more reliable systems where care is delivered will serve us well for the future. We have made significant progress in healthcare acquired infections. In this year, two highlights are the dramatic reduction in catheter-associated urinary tract infections and the big improvement in hand hygiene, where we are now close to 10 points above the statewide average. See the charts below. These achievements were made by redesigning systems and monitoring the performance of the new designs.

We would have clearly reached our goal of reducing incidents of harm by 20% had we not uncovered the fact that we were not counting falls at home for Gilchrist patients in our overall falls reporting. Our reporting of near misses, great catches, and lower level safety events has also improved significantly and we achieved our annual goal.  Our Board Quality Committee continued to mature in its ability to drive meaningful change with the addition of our patient members. Our Board authorized the release of our quality indicators to the general public. We now update the data monthly for all to see at www.gbmc.org. The Greater Baltimore Health Alliance, our Accountable Care Organization, has successfully reported all of its required quality measures to the Centers for Medicare and Medicaid Services for our first year in the Medicare Shared Savings program. Our work with the outpatient medical record and standardized order sets with prompts has made our primary care much more reliable. The attainment of level 3 certification for our patient centered medical homes has increased our ability to manage chronic disease.

Better Care 

While we will not reach our goal in many of our patient satisfaction areas averaged over the entire year, last month, May 2013, we achieved the highest overall inpatient satisfaction score in the history of the organization. I attribute this to many things but most importantly to the increased study and testing of changes that are now happening on our inpatient units and other clinical departments fostered by Lean Daily Management. On many floors, our nursing teams are now asking patients on a daily basis about their care and then problem solving to fix defects in care like inadequate communication or responsiveness.  

Gilchrist Hospice Care has achieved a 96% success rate with making patients comfortable within 24 hours of admission. This is a phenomenal accomplishment. Our employed physician group, Greater Baltimore Medical Associates (GBMA), has now reached its goal for overall satisfaction rating by truly focusing on the patient’s needs. In this year, GBMA primary care offices have opened on Saturdays, greatly increasing their patients’ satisfaction with access to care.

Less Waste

It is too soon to tell if we will achieve our 1.2% operating margin for the year but we are at 1.6% through May. Many Maryland hospitals are currently operating in the red. Our system is in the black, even though we get lower prices than many of the other nearby hospitals. I am very proud of our ability to drive waste out of our system. Our redesign efforts in the arena of moving admitted patients out of the Emergency Department and to the inpatient units are starting to payoff. Our overall throughput time for admitted patients in the month of May was 6.23 hours, a 1.45 hour reduction over May of 2012!

More Joy

Our employee and physician satisfaction surveys will happen later this summer. We have been working to address issues raised since our last survey. We have worked hard to empower our people to make changes to make their work lives easier. We have gotten better at moving decision making to the people doing the work (although we still have room for improvement in this area). We have listened hard to concerns about our benefits and we have worked to improve them. We plan to give raises based on merit in the fall.
While we will not achieve our goal of reducing employee injuries by 20%, we will have had fewer in FY’13 than in FY’12. The number of employee injuries for the preceding day is now a Lean daily metric for the senior executive team. Every morning we hear of the injuries from the previous day and we are beginning a daily problem solving process to root these out.

Looking Forward

So, we are getting closer to our vision – the measurements bear this out. We are getting more and more recognition from outsiders about our work in creating a value-driven healthcare system. We must stay in action and generate continual improvement.

Fiscal year 2014, which starts next week, will be a pivotal year for our healthcare system. In October, the health insurance exchange created by the Affordable Care Act will create a new marketplace for health insurance. Insurance companies, like the Evergreen Cooperative and Cigna Health Care and others, are racing to create new offerings that will provide measurably better care at lower costs. These companies see what we are doing and are happy to collaborate with us as they construct their new products.  They want to work with GBHA and its 100 plus primary care providers driving value through our patient- centered medical homes. They know of our great surgeons and other specialists providing great care in our lower cost hospital. They also know of the phenomenal work of our geriatricians and their nurse colleagues in Gilchrist Greater Living and Gilchrist Hospice Care and how wonderful they are at patient-centered care in the later stages of life.

While some others are focused on getting much higher hospital rates even though their existing rates are already much higher than ours, we are working to lower costs and drive value…because this is what the community is desperate for us to do.

I am very excited about the future of the GBMC HealthCare System and the next steps in the attainment of our vision. I look forward to discussing this with many of you at our Town Hall meetings which will begin on July 8th.

Let me know what you think of some of the positive changes that have taken place over this past year - I welcome your feedback…

A 5K and a Commitment to Better Health – a Great Way to Begin Summer

I spent part of Father’s Day running at the 25th annual GBMC Father’s Day 5K. It was a great day and I was fortunate to have my wife Tracey, and my daughter, Caroline, running, too. Caroline was being polite and running with me but I encouraged her to go on ahead at her own pace. Tracey finished third in her age bracket. I was happy to finish without an injury.

Dr. Chessare with his wife Tracey (left), daughter Caroline (second from right)
 and WJZ-TV's Denise Koch (right), Honorary Chair and emcee of the event.

Robert Hlavac has been participating in the
Father's Day 5K since the very beginning.

This important event has been helping to raise much needed funds for GBMC’s Neonatal Intensive Care Unit (NICU). Over the years, funds raised through this event have helped purchase lifesaving technology and services for our NICU babies and their families. I thank everyone who ran or walked and participated in this great day, including one 25-year supporter of the event, Robert Hlavac, who has been participating in the Father’s Day 5K since its inception.

I also had the opportunity to meet with the kids from the West Towson Elementary School PlayFit program. As I talked about in the May 21st blog, GBMC partnered with the school to develop an after school fitness program called PlayFit, designed to help kids at risk for childhood obesity. The “Westy’s,” along with our GBMC volunteers, have done a fabulous job staying active while having fun. The culmination of this six-week fitness program was having the kids run in our Father’s Day 5K event or do the one mile walk.  These kids were so proud of what they had accomplished, as were we, and GBMC looks forward to continuing this beneficial fitness program with the Westy’s going forward. Great work, kids!

The "Westy's" from the West Towson Elementary school
 PlayFit program get ready to walk!

As we realized with our work with the kids from West Towson Elementary School, prevention of disease is vital to the future health of our community.  As a system of care, GBMC continues to take important steps toward enacting healthy change. We recently took another step toward this mission of preventative care by introducing a new Employee Wellness program.

The U.S. health care system is struggling to care for the ever-increasing number of people with chronic disease like obesity and diabetes. While we at GBMC are building a better coordinated system to care for chronic disease, we also need to work to prevent these diseases in the first place and what better place to start than with our own GBMC family members. This is why GBMC is adopting a healthcare insurance model that promotes wellness and emphasizes maintaining good health. Through this new wellness program, we are helping our staff focus on staying healthy by providing opportunities for employees to engage in various wellness activities while earning incentives for their efforts. This moves us another step closer to changing the mindset of, “go to the doctor when you’re sick,” to “keep yourself healthy so you don’t get sick.”

GBMC employees and staff who participate in the Platinum health plan will be able to take advantage of this important wellness program as well as savings on healthcare premiums by participating in a biometric screening process and registering with our wellness partner, Allegeant. Employees interested in the screening process should visit the InfoWeb for all of the details and upcoming deadlines for participating or call Allegeant at 410-605-0007.

Those employees who participate are making the effort to maintain their good health and minimize days of illness. This program is all part of GBMC’s commitment to better health.

Schools are out for the summer now and the longer, hotter days are a perfect time for all of us to get outdoors and stay active and healthy.