In the GBMC System, Transforming Healthcare Begins at “Home”

Last week I spoke about healthcare reform and GBMC’s vision of doing what is right for our patients by providing better health, better care, lower costs with more joy (for our healthcare providers). It’s quite clear that healthcare reform as a whole is an evolution and these types of major transformations don’t happen overnight. We’re at the beginning of our own evolution and I’m proud to say that GBMC is leading the way in changing the status quo and the way in which we will be providing healthcare for the future. One of the first steps we’ve taken in this era of change is the creation of Greater Baltimore Health Alliance (GBHA), which will serve as the guiding force for implementing an integrated system of care including the creation of a patient-centered medical home healthcare model for GBMA practices and in private physician practices in the community.

Dr. Mark Lamos, who has been practicing internal medicine at GBMC for more than 20 years and who leads the primary care physician side of Greater Baltimore Medical Associates (GBMA), has been a visionary leader in the development and implementation of the medical home model at the Hunt Valley practice and for GBMA. He, along with the dedicated physicians, nurses and staff at this practice are paving the way for the future of healthcare at GBMC.  Dr. Lamos explains that they moved into their new, expanded office space one month ago and are in the process of making their “house into a home,” getting the new Electronic Medical Record (EMR) system up and running,  establishing care coordinator teams, and extending office hours until 8 p.m. Monday through Friday with hours on Saturday.

“Over the next few months, our team will be learning and moving forward together,” says Dr. Lamos. “Change is never easy and evolving into a patient-centered model, which is a completely new mindset for how we deliver care, will take some time. But, what we are doing is building the best world for our patients. As we continue to transform, we will only see improvement in the health of our community.”

Dr. Lamos says that when it comes to the medical home model, GBHA has four guiding principles for improving a patient’s health by:

·         Providing better quality care

·         Providing less expensive care

·         Improving the health of our community, and

·         Changing from a transactional way of delivering care to a focus on long term preventative care and management of chronic disease.

[Please click on this video to hear Dr. Lamos define medical home and what it means for the future of healthcare at GBMC]

With an emphasis on evidence-based medicine, we’ll be able to decrease risks and improve wellness for our patients. By focusing on disease management, our patients who are dealing with obesity and/or have diabetes or hypertension, for example, will have a team coordinating their care so that their condition, their medications, and even follow-up appointments are all monitored and managed, ensuring that the disease remains in check for the long term.  A medical home model also allows us to establish metrics and put systems in place to track diseases and compile data so that we can follow up with our patients and make sure they stay on the path to wellness.

As Dr. Lamos states, “If one of our physicians refers a patient to a specialist, we will check to see if that patient went to the specialist. It’s all about long term, coordinated care to help our patients thrive.”

Regardless of what the ultimate healthcare reform bill looks like all of the measures we are putting into place now make good business sense and are simply the right things to do for our patients and the community we serve.  Our GBMC at Hunt Valley practice are pioneers in this new movement. They will continue to put these systems in place, to grow, learn and reinforce the medical home philosophy of patient-centeredness. The outcome? They will be the first GBHA practice to become an accredited medical home site, setting the standard for all of our other GBMA practices, and our private practice physicians.

Dr. Lamos explains that we’re at the beginning of a new journey. “It’s no longer an individual system, it’s a patient-centered medical home,” he says. “Home meaning that we’re all in this together.”

P.S. If you want to learn about “accountable” care from the man who coined the term, click on this link to hear a panel presentation moderated by Dr. Elliott Fisher of Dartmouth University - http://fms.acpe.org/acpeTV/aco/aco.html

Healthcare Reform- Healing America

I was asked to join a book club by Drs. Gary Cohen and Rob Brookland…they are good guys and I enjoy spending time with them. I think they invited me because they are reading a powerful book on healthcare reform that they thought I would have a strong opinion on. I have to say this is a phenomenal book. It’s written by a long time Washington Post correspondent named T.R. Reid and is called “The Healing of America, The Global Quest for Better, Cheaper and Fairer.” I wish I knew about it six months ago. I would have said to anyone wishing to talk about healthcare reform, “You have an opinion on reform? Go read this book and then we’ll talk.”

What’s interesting about the author is that he has no vested interest in healthcare reform. But, as a reporter who has lived overseas, he decided to set out on a global quest to see if there is something the United States could learn from other countries. He traveled around the world to witness firsthand how other developed countries are able to provide affordable healthcare to their people. 

Right from the beginning he says, there is no perfect healthcare system. Many developed countries have wrestled with the same problems we have and have done quite well for their citizens. What T.R. Reid is saying is this – let’s learn from the success of others.

The book enlightened me about how the many different healthcare systems around the world were born, and how they work. It amazes me that there are no other developed countries where people pay out of pocket for healthcare like we do. Even those Americans with good health insurance pay way more out of pocket than in any other developed country across the world. That’s just incredible.

In 1996, when former President Bill Clinton first started getting this country to think about healthcare reform, both Taiwan and Switzerland were confronting the very same issues. Yet, both of these countries managed to redesign their systems and now rich and poor alike are covered. Look at Otto Von Bismarck, the leader who virtually created the modern state of Germany in the late 1800s. He understood that it was not right for some people to have everything and others to have nothing.  Today, Germany is voted by the World Health Organization to have the second best healthcare system in the world. France was ranked number one. These countries have much higher patient satisfaction and they have clinical outcomes as good as or better than ours. In these countries, people don’t have to worry when they get sick because everyone is covered. People are happy with their healthcare, which is not the case for many in the U.S.

There is a lot of “political noise” about reform in our country. We owe it to ourselves and our children and grandchildren to change the system for the better. The Affordable Care Act moves us a long way in the right direction. The law is not perfect and even after it is fully implemented there will still be some Americans who have no coverage, but it is a start. Let us make sure that it is not selfishness that derails change. I am concerned about people who think, “The system works for me, I have coverage, why should I want anything to change, and I don’t want to pay for others.” If we let this sentiment prevail, we will bankrupt the country and accomplish nothing.

The United States spends TWICE what other countries spend on healthcare, yet we have 40-50 million Americans without insurance. In other developed countries everyone has coverage regardless of socio-economic status.  If we reform the system, we can easily cover all Americans, and even save money in the long run. But it requires people to get educated, work together and change for the better. T.R. Reid’s book shows us how important it is to change the status quo.

A number of people have asked me, where is GBMC going with regards to healthcare reform? If the healthcare reform bill changes with the political landscape, how much of the hospital’s strategic focus will change? The answer is simple – everything we are doing now, all of the changes we are implementing make good business sense and are the right things to do for our patients and our community.

We are putting in place the building blocks that are important for a strong healthcare system:

·         Electronic medical records

·         Extended practice hours, and

·         An overall focus on wellness and coordinated care

We are doing this now so that we can deliver on the vision of better health, better care, lower costs, and more joy. All of these factors are positive even in the fee for service world we live in right now.

A prime example of this new way of approaching patient care can be seen at GBMA’s Hunt Valley practice where Dr. Mark Lamos and the dedicated physicians, nurses and staff are piloting the CareFirst Medical Home project. The pilot program will demonstrate how reform can work to provide the coordinated care necessary for long-term wellness for our patients. Stay tuned for more information on this practice and the pilot program in my next blog.

If you have the time, I urge everyone to read T.R. Reid’s book. It’s certainly eye opening and thought provoking. I’d love to hear your thoughts on this book and on reforming America’s healthcare system – what do you think is the right thing to do for our future?

Redesigning our Systems, Renewing the Culture of Safety

The tragic shooting that took place in Arizona this past week has many people questioning their safety. The individuals who were injured or tragically killed by the gunman went to a public forum never thinking twice that it may be an unsafe place. Our hearts go out to the victims of this senseless shooting and to their families.

Our patients come to GBMC trusting that we will provide the safest, highest quality care. We must rededicate ourselves to making our health system as safe as it can possibly be. That our patients are safe while in our care must be a given. It is our duty to them.

I am delighted that Carolyn Candiello has joined us as our Vice President for Quality and Patient Safety. Carolyn and Dr. John Saunders, our Chief Medical Officer, are redesigning our Quality infrastructure, beginning with the creation of a Quality Committee of the Board of Trustees.  

As we reinvigorate our quality oversight system, it is a good time to stop and take our patient safety “pulse.” This is why we’re rolling out the Safety Culture Survey to those individuals with direct patient care responsibilities on January 19. The survey results will help us redesign our patient safety practices, help us improve reliability and strengthen our culture of safety.  When it comes to patient safety, think of it this way:

If it were your daughter, “pretty safe” would not be good enough.

I often use the example of the airline industry to demonstrate just why “pretty safe” doesn’t cut it when you have the lives of others in your hands. In the 1980s and early 90s we would have at least five or six major airline disasters per year in our country. Today, these types of air catastrophes are virtually unheard of. Why? Because the safety systems have been diligently redesigned.

And now, everyone involved in flying a plane follows the design. Pilots, co-pilots and air traffic controllers don’t do whatever feels right in the moment. They follow the rules. They follow a checklist so that disasters like the one that occurred on Northwest flight #255 out of Detroit in 1987 never happen again. This plane crashed into a light pole, a rental car building and eventually a highway overpass only a short distance from the end of the runway. In a rush to depart, the crew took off with the wings configured for landing instead of takeoff, needlessly killing more than 150 people.

And in 1977, in what is described as the worst commercial airline catastrophe in history, the KLM/Pan Am crash claimed the lives of more than 550 passengers on the Island of Tenerife. Because of an entire series of unfortunate events including misinterpretations of instructions, miscommunication, not running through a checklist, human error and not speaking up when something was not right, another tragic human disaster became a piece of history.

A prime example of how some clinicians at hospitals are still not following the rules that were designed to keep patients safe is in the use of unsafe abbreviations. It’s inevitable that if a clinician uses the unsafe abbreviation enough times, someone is going to get hurt. If pilots take off without running through the checklist, eventually a plane is going to crash.
 

We must do the right thing for our patients, every time. We must all learn to speak on behalf of our patients and not hesitate to stop any practice deemed unsafe regardless of who we need to challenge. I’ll never forget an interaction I had well into my career as a pediatrician. It was a Friday at 5:15 p.m. and I was in the car on my way home when I received a call from a pharmacist. I had written a prescription for a patient for a malaria prevention drug that I didn’t use very often. The pharmacist called me very sheepishly to question me about the prescription, wanting to double check the dosage I wrote down. I took the time to go through the calculation with her and we both concluded the dose was correct. She apologized up and down for bothering me, but I thanked her for having the courage to call. She did the right thing. She was protecting the patient.

Regardless of a person’s rank, title, training or position, it’s always OK to speak up when something seems wrong or out of place – it’s everyone’s responsibility to protect our patients!

Let’s get thinking about this, folks.

The notion of vigilance will only take us so far. We must emphasize reliability.

Being well-trained, hard working and caring is just not enough to keep our patients safe 100 percent of the time. It’s time to take action and redesign our systems! We’re taking the steps to do this and I urge everyone to play their part in this culture of safety.

So, if you receive the Safety Culture Survey in the coming weeks, please fill it out. We need to find out where we are today so that we can redesign unreliable and unsafe practices to make our care even safer than it is today.  

What if it was your daughter? You’d expect nothing but the best.

Do you have an example of someone doing the right thing to protect the safety of a patient? I’d love to hear about it – Please post a comment so that all of our colleagues may benefit or send me an email at jchessare@gbmc.org.

In Action: Creating a Culture of Improvement at GBMC

Anyone who knows me knows that I love to eat. In fact, when I was in medical school in Italy, I thought that I was in heaven! A good friend of mine, Pino Mauriello, recently reminded me of an interaction he had with a mutual acquaintance who didn’t remember my name. After speaking with Pino, the acquaintance said, “E quell’ Americano che mangia!” Translated: “He’s that American who eats!”

So I got the message when at one of my initial introductory town hall meetings last summer, a nurse gently confronted me on the notion of bringing more joy to the practice of taking care of patients. She told me that it was hard for her to stay focused on the patient when she was feeling constantly rushed. On top of this, on the days she was able to get to the cafeteria to eat a quick lunch there were frequently long lines of people waiting to pay. She reminded me that with only a few minutes to eat, the wait in the line was a pure waste of her precious minutes. She often went back to her unit without eating.

I heard her message loud and clear. I had been talking about change and improvement and a member of our GBMC family was identifying a system that was in need of improvement that was outside of her control.

I discussed this issue with Keith Poisson, our Chief Operating Officer and Mike Forthman, our Vice President for Facilities, and they told me that significant improvements were in the planning stages. We met with Matt Tresansky, our Director of Food Services so I could learn about the design changes.

Matt educated me on how the operations in the cafeteria work and the measurements that were in place to gauge efficiency. It was good to see he was measuring how many people were served on a daily basis but I didn’t see evidence of measuring the cycle time from when I’m ready to pay to when I actually finish paying. I noticed that there were four cash register stations but only two were open at the height of the lunchtime rush. Matt explained that a big part of the problem was that the cash registers were too slow and outdated. In order to be able to flex to five register lines, we had to upgrade the equipment and the new registers were on order.

The cafeteria received the new, state-of-the-art Point of Sale cash registers in November and since then the lines during the busiest times of the day have been much shorter (see the photos) and we open up to five checkout lanes as the demand requires during peak times. 

The proof of improved efficiency is in the evidence, of course, so consider some of this initial data and future plans provided by Ryan O’Hara, Retail Manager:

• Credit cards now process in three (3) seconds, versus 30 seconds with the older credit card processors; Credit cards are also accepted in all five checkout lanes
• Cashiers currently process on average eight (8) transactions per minute versus four (4) transactions per minute with the old register system
• Total transactions increased from 35,322 (December 2009) to 36,287 (December 2010)
• Barcode scanners help to control inventory and speed up the check out process

The GBMC cafeteria photographed at the height of the lunchtime rush - 12:30 p.m. on January 5...
Short lines, new registers, improved flow and all register lanes open allow staff more time to enjoy lunch!

Ryan has received a lot of positive feedback so far from employees who are pleased with the almost “non-existent” checkout lines and with having more time to enjoy their lunch time rather than wait in line for most of it.

“Nurses have been very appreciative that at least four checkout lanes are open during lunch, and have given several compliments on how their wait time has dramatically decreased.  They also like that credit cards are accepted at all five registers,” says Ryan.

My point is this: We got it. An area for improvement had been identified and we took action. We heard what this nurse and others were saying and we designed a better system and achieved measurable improvements.   

People often talk about an organization’s culture. The way I see it, the culture at any hospital is one of two ways – you either have a culture of inaction, where individuals focus on a problem, place blame and make excuses; OR you have a culture of ACTION, where people focus on the solutions to a problem. Our culture at GBMC is not to look the other way when there is a problem, but to find a solution.

On the issue of wait times…Long patient waits and delays should be looked at as nothing more than a characteristic of our systems for serving patients in need, whether it be in a physician’s office, the Emergency Department or somewhere else. We need to apply the same scientific approach to reduce waits for our patients that we apply to waits for our staff in the cafeteria. We will embark in February on a hospital wide assessment of patient flow. Thanks for getting in action on this with us!

I had another experience this week that did not make me feel good about GBMC’s ability to get in action to fix a problem. I was in one of our patient waiting rooms where I had been told that most of the table lamps had no light bulbs. I went to find out if this were true. When I saw this for myself, I asked a staff member if she had known about this and she responded: “Oh yeah, we’ve been trying to get that taken care of for a while.”

I wondered what she meant by this? I don’t expect individual staff members to buy light bulbs and bring them in from home, but I am too proud of GBMC to let a day pass knowing that family members (who might want to read while they are waiting for one of our patients) are “in the dark.” If it were my area, I would not rest until we got the bulbs. If our process for replacing light bulbs is not reliable, let’s get in action and redesign our system!

What it comes down to is this – You don’t want to hear excuses. Patients don’t want to hear excuses. Whether it is something as simple as putting light bulbs in the lamps, or helping the busy nurse who only has a few minutes to grab lunch to eat, we can’t be complacent. We need to be an organization that takes action to achieve our vision of being the healthcare system where everyone, every time is treated the way we would want our own loved ones treated.

One of my mottos is: control what you can and expect that your colleagues will do the same. In the end, the nurse at the town hall meeting was essentially saying to me, “How can I take good care of the patients when I can’t even get something to eat – you, Dr. Chessare, can control that.”

Are you getting in action on what’s within your control to improve? Have you witnessed a colleague going above and beyond and taking action?  I’d love to hear about it and welcome your thoughts on this important topic.