Friday, March 25, 2011

Thanking Our Doctors for Doing Great Things…Big and Small

National Doctors’ Day is Wednesday, March 30 and I’d like to take a moment to reflect on the vast contributions our physicians make every day to GBMC and the patients who count on them for the very best care. It’s very clear that the American healthcare system has the advantage of the best trained physicians in the world. At GBMC, our physicians are wholeheartedly committed to this profession and have made great sacrifices through years of training and education, having to frequently put their lives and their family lives on hold to meet the needs of patients. But they do this because they are committed to helping others. Being a doctor is truly a giving calling.
When I reflect back on being a physician, I can recognize that the most beautiful part of the profession is the relationships that are developed with individual patients. Sure, we talk a lot about reform and redesigning our systems, but the heart of this profession is caring for people.  In our zeal to make things better in this country’s healthcare system, we can’t lose sight of the phenomenal work our physicians do.
There are so many ways in which doctors touch the lives of people - in service to individual patients, dedicating themselves to redesigning and improving systems, and partaking in endeavors outside of their normal daily work. Look at physicians like Dr. Carol Ritter and the team of doctors and healthcare providers who selflessly give incredible amounts of time and help to the citizens of Haiti. It is often the small heroic acts that truly make a difference in this world.
When I think about it, GBMC is a little different from the other places I’ve been – it’s a community teaching hospital with a truly phenomenal group of doctors. As a group, the physicians have been so welcoming to me since I first joined the organization last year, and I have found them to be so willing to reflect on how their work can be even better. I haven’t found that everywhere in a medical staff. I’m truly grateful for the support of the entire medical staff – both the wonderful rank and file doctors and the terrific physician leaders at GBMC. I owe a debt of thanks to Dr. Hal Tucker, Chief of the Medical Staff, and Dr. John Saunders, Chief Medical Officer – they are not only incredible doctors who have a great reputation for better health, better care, and efficiency in their own practices, but I also know them as great leaders and people who go above and beyond to not only make things better for patients, but also for fellow physicians. I have certainly been impressed by the dedication of the entire GBMC medical staff and thank them for the great things they do – both big and small. 
So, we should take a moment, or at least one day, to thank physicians for their commitment to serving others. Doctors’ Day is the one day we really stop and say, “thank you,” for all that our physicians do.  And, if it were my loved one, I would be most confident that they would be in the very best of hands being taken care of by a member of GBMC’s medical staff.
Do you have a story to share about a dedicated GBMC physician? If so, please share your comments…
P.S. - I had the experience of being a patient here at GBMC last week, having had minor elective surgery. My surgeon, Dr. John Thompson, is another wonderful example of a phenomenally talented doctor who cares. Everything went very smoothly and I thank all of the individuals who took care of me…It was quite interesting, in fact, as I have been speaking about what we all need to do to better serve our patients, and I got to see firsthand the wonderful care our patients receive every day.
(GBMC’s Foundation is also celebrating Doctors’ Day by recognizing the dedication and good work of physicians – click here for more information about this year’s Doctors’ Day campaign - 

Thursday, March 17, 2011

A Well Designed System, and a Crisis Averted

“Every system is perfectly designed to get exactly the results that it gets.”
On Sunday, March 6, an electrical transformer fire on Schilling Road left the Hunt Valley at GBMC office with smoke and carbon monoxide damage and destroyed electrical and telecommunication lines, closing it for business for the next two days. Yet, despite the closure, the practice continued to provide care for more than 70 patients.
How? The ability to access Electronic Medical Records (EMR) allowed the Hunt Valley team to notify patients of the closure and develop alternate plans. The practice’s six clinicians traveled to five sites on the GBMC campus and other satellite locations, where they were able to care for more than 60 percent of the 118 patients whose appointments were affected. Having the EMR and other IT tools in place proved absolutely invaluable in this unplanned emergency and enabled the physicians to access their patients’ records remotely.
This is a prime example of the need to design a record system that is not dependent on paper. Because of the EMR technology and a well designed system, Hunt Valley at GBMC was able to remain patient-focused and operational.  
The staff of the Hunt Valley practice worked tirelessly, calling patients and making sure they could be reasonably accommodated during the days the office was closed. Additionally, GBMC’s IT professionals are also to be commended for their key role in this crisis. They got in action, finding laptops and bringing them to practices where Hunt Valley clinicians were being relocated so that there could be a seamless connection to patient electronic records. The IT team quickly got the FAX technology within EMR up and running to ensure that prescription requests, consultation reports and the like could be easily communicated. Most patients, despite having to see their physician at a new location, were still able to keep appointments with their own physician and receive care, which is a great testament to this team effort.
This is certainly an experience from which we can all learn. We in healthcare should do more when it comes to failure modes and effects analysis so that in times of crisis, we can be prepared to continue to serve our patients, as was the case in this instance.
Finally, we must keep in our thoughts the Japanese people as they continue to experience human suffering in the wake of the earthquake, tsunami and now a potential nuclear catastrophe. Our prayers are with them during this time of great tragedy.

P.S. March 30 is Doctors’ Day – do you have a physician you’d like to honor or recognize for exceptional care?

Friday, March 11, 2011

Making the Road to Optimal Care as “Smooth” as Possible

Over the past several weeks, our physicians and nurses in the Emergency Department have had to rise to the occasion to care for a significant number of “boarders.” A boarder is a patient who needs to be admitted to an inpatient bed, but there is no bed available. If it was my daughter (or me) I would not want her to be on a stretcher in the ED if she needed to be on an inpatient unit. I know that it is no fun for our doctors, nurses, and other clinicians caring for admitted patients in the ED, either. Overloading the ED because we can’t get admitted patients to the right bed is unsafe for the patient and it creates undue staff stress and dissatisfaction.
There are two ways to fix this. One way is just to open and staff more beds for these “crunch” times of high census. This takes care of the problem but at a significant financial cost. Hospitals can no longer afford to have a lot of extra beds and staff that are used only during peaks in demand.
If the peaks in demand were due to the “natural” variability in illness in the community, we would have to open the extra beds and just deal with the extra cost (although I am not sure how we would do this) because it would be the right thing to do for the patient. The good news for us is…our peaks in demand are very often created by us. They are “artificial.” They are created by the way we schedule some of our admissions.
Elective surgery patients who require overnight stays in the hospital take up some of our inpatient beds. We have not done as well as we might at spreading these cases to an inpatient unit over the 5 weekdays. We might send 10 post-op patients to Unit 58 on a Monday, three on Tuesday, 12 on Wednesday, four on Thursday and 10 on Friday. On “peak” days, we have a hard time finding a bed for every patient, so patients backup in the ED and in the Post-Anesthesia Care Unit (PACU) and nurses are asked to work overtime or come in on a day off. On “valley” days, we may be asking nurses to take an unexpected day off because we don’t have enough patients to care for.
Over the past few weeks you may have heard the term Surgical Smoothing. And many of you may be wondering, what is this? What it means for GBMC is smoothing the number of elective surgery patients by day of the week to improve patient flow…the flow out of the Emergency Department and out of the PACU and the OR’s...and therefore reduce waits and delays.
We need to stop “batching” and move to more continuous flow. Patients are admitted and discharged in batches. Tests are run in batches. Surgeries are done in batches. Our goal is to serve every patient in need the way we would want our own loved ones served. The goal is easier to reach with continuous flow and not with the artificial variability of batching. And the goal of this “smoothing” initiative is to improve surgical flow, which will ultimately reduce wait times in the ED and ensure patients have a bed when they need to be admitted.
Think of it this way – You’re going to Ocean City. Traveling across the Bay Bridge at 2:00 a.m. on a Tuesday in February, you’ll have no problems with traffic. But try to cross the bridge at 11:00 a.m. on a Saturday in July and you’ll encounter backups for miles. These peaks and valleys in traffic are what we are experiencing in the hospital setting – and at the highest peak, we have the longest wait times and lowest satisfaction rates.
Surgical smoothing and assessing the flow of patients is also about the application of science and logic as opposed to managing by intuition. Scientifically we can calculate our bed need for medicine patients using queuing theory, and that’s what we will do. We will create urgency criteria to calculate how many ORs should be dedicated to urgent/emergent cases. We will study the flow of patients to individual units so that we can eliminate “artificial variability” in demand and smooth the flow of patient to units. We will also develop a new group of “flow engineers” to manage the system moving forward. And, we will do nothing that makes it harder for surgeons to do their work; In fact, the idea is to be able to do more surgery quicker and better.  Jack Flowers, MD, Chairman of Surgery, and Lewis Hogge, MD, Medical Director of Perioperative Services will oversee any changes to surgical schedules to assure that this is the case.  
This initiative is the single best thing we can do to improve our patient satisfaction as well as employee satisfaction because the wait times and staff overload will be reduced. This will also help improve patient outcomes because research has shown that the mortality rates on a unit where the nurses are overwhelmed goes up significantly.
And at the end of this journey, we will be a more efficient and even safer healthcare organization, and will ultimately achieve the quadruple goal of better health, better care, lower costs and more joy for those providing the care.  

Finally, I wish to end this week’s blog on a personal note because I feel it’s important that we remind ourselves of all the good in our lives and that the things we think are so bad, maybe are not all that bad after all…This past weekend I was in church twice in one day. In the morning I attended a funeral of a 21- year old family friend gone too soon, a truly tragic event that touched the lives of so many people; and in the afternoon I was fortunate to attend my niece’s confirmation, a true celebration of a young life full of promise for the future. Talk about polarizing events. This day really put life into perspective for me. It reminded me that life is a gift – we have to reflect on what’s good in our lives and make the best of every minute we are given.

Friday, March 4, 2011

The Best Way Should Be the Only Way

We have been talking a lot about patient safety over the past several months, and with the week of March 6 – 12 being National Patient Safety Awareness Week, I feel it’s only appropriate to continue to discuss the importance of safety and quality in healthcare. I’ve said before that the hard work of our well-trained staff is, of course, critical when it comes to patient care and ensuring the safety, but it’s not everything. We need well designed systems that bring us to a high level of reliability to ensure safety and quality. All of our systems for delivering care need to be foolproof to get to 100% compliance with all of our patient safety initiatives. It comes down to creating the rules and then following them – every time. If there is a best way to do something, it should be the ONLY way.
Reliability means what should happen…happens…and what should not happen…does not happen. This is a core principle of safety in every high risk industry. 
A perfect example of how GBMC has redesigned the system and follows national best practices can be seen in the steady decline in Central Line Associated Blood Stream Infections (CLABSI), which can increase a patient’s morbidity and mortality. Only five years ago, the incidence of CLABSI at GBMC was about 7 per every 1,000 patient days. Today, it’s about 1 incidence per every 1,000 patient days. Why is this? Because we have standardized the way we put in central lines and the way we care for them while they are in. People follow the design.  It is a reliable system that has been proven to be the best way.

In fact, I’m very proud to report that the SICU has gone 75 weeks without a CLABSI and the MICU has now gone 40 weeks.  Unit 35 has gone 21 weeks without incidence of CLABSI.
Pretty impressive numbers!

The MICU and Unit 35 are also working on the Maryland Hospital Association’s "CUSP" project (a quality and patient safety program) to implement a culture of safety around prevention of these blood stream infections and have been recognized as making the MHA’s 100% list for prevention of CLABSI.    

These are achievements we must celebrate. These units didn’t get to ZERO by telling staff to work harder or pay attention- they already were. They achieved 72 weeks, 40 weeks and 21 weeks without incidence of CLABSI by taking a design that has been proven to reduce infections and then utilizing this system every day. And, the patients on these units are reaping the benefits of this reliability. 

We’re seeing more of these reliable systems across the hospital. For example, Labor and Delivery has had 100% success for 2010 with their goal of getting those patients with the urgent need for C-section (STAT cases when the fetus is in distress) into the OR within 10 minutes (decision to incision), with excellent infant outcomes.
Along these lines, implementation of CPOE among our internal medicine physicians went off without a hitch and I am most grateful to our in-house team (led by Dr. Allison Habas and Lisa Griffee) as well as our physicians and nurses who helped them learn to use the computer for ordering. CPOE implementation is just one more way for us to improve reliability.
Finally, the March 15 off-site leadership conference will focus on the topic of reliability and patient safety, so I certainly look forward to our leadership team continuing to discuss and embrace the culture of safety.
And speaking of culture of safety, thank you to all of our clinical staff for your frank input and participation in GBMC’s Culture of Safety survey. We had an 89% response rate to this survey, which shows me that our clinical teams truly recognize and appreciate the importance of creating reliable systems for improving patient safety and quality care.
Culture of Safety Survey section leaders
 and team members celebrate an
89% response rate to the recent survey.

Special thanks to Dr. John Saunders, Chief Medical Officer and our VP of Patient Safety and Quality, Carolyn Candiello and their dedicated team for all of their hard work. Results of the survey will be reported at the March 15 off-site leadership conference – stay tuned for action plans to be rolled out in the coming months.