What can we do to get more collaborative action with our physicians?

Neal Friedlander MD, our Chairman of Medicine, sent me an email last week that made me very happy. Neal has been working with John Saunders MD, our Chief Medical Officer, Hal Tucker MD, our Chief of Staff, Jody Porter RN, DNP, our Chief Nursing Officer and with our great nurse managers to make our new system of having Medical Directors for each of our inpatient units really come alive. In the email, Neal told me and others about the wonderful early successes that these local leadership teams of doctors and nurses have had on improving health outcomes, patient satisfaction and staff satisfaction, while eliminating wasteful practices.

I am very grateful for Neal's work and for the work of the nurse managers and medical directors. They are collaborating wonderfully and our patients, and GBMC are benefiting from this. We have many other fabulous examples of collaboration. Tony Riley MD, our geriatricians, Cathy Hamel and the other leaders of Gilchrist Hospice Care are doing marvelous things. Mark Lamos MD and our wonderful Medical Directors and Practice Managers are doing great things with our primary care practices. These are just a few.

But I have to ask myself the question, "Why is this not happening everywhere at GBMC?" In some other areas, we don't have collaboration to make things better.

For example, a group of physicians will get together and identify a problem. They will then put together a letter with their concerns and send it to me or some other manager/leader at GBMC. One-way communications like these do not generate meaningful change very quickly. I have to admit, I also contribute to this problem with one-way communications to clinicians about problems that I see. Sometimes, I am at a table with other leaders trying to fix a problem but doctors that will be affected by the change are not adequately represented. I need to recognize this and work hard to create a system that leads to better collaboration and less one-way communication. I need to work more closely with our Medical department chairs and our service line leaders to get more clinicians, especially physicians, to the table as collaborators.

Jack Flowers MD, our Chairman of Surgery, has been working very hard to improve surgery at GBMC. The world around us is changing very fast, and Dr. Flowers needs all the help that I and others can give him. I must redouble my efforts to get our surgeons to believe that we really care about what they think and to get them to the table to work with us as collaborators for everyone's benefit. We need new ideas about how to structure meetings and other forms of communication to lead to more collaboration.

Please share your ideas with me on how we can get more collaboration throughout our healthcare system.

Keeping Our Healthcare Dollars In Our Family

The cost of healthcare benefits for employees and their dependents in most organizations is a significant percentage of the organization’s budget, and it’s a challenge to manage this expense. This is certainly true at GBMC.

In calendar year 2011, we spent $23.7 million for healthcare benefits for our employees and their dependents. How did we spend this money? Well, we spent $4.1 million on drugs/prescriptions. Of the remaining $19.6 million:

$8.5 million was paid for care at GBMC, GBMA (our employed physicians), and  
          to other GBMC medical staff members.
$11.1 million was for care from other hospitals, physicians who are not on our
          staff, and to other providers of care

Now, I am well aware that there are things that we don’t do at GBMC. Heart surgery is one of them and we don’t do transplants. I also know that some of the $11 million was paid for emergencies, durable medical equipment, and rehabilitation. But a lot of it went to other hospitals and other physicians for things that we and our medical staff do within the GBMC family.

We have to ask ourselves the question, even when taking into account those employees living far away from GBMC and its doctors, what are we doing when we are spending GBMC money at other healthcare organizations?

I have to hold myself to my words that I don’t want to do anything for our employees and their loved ones that I wouldn’t do for my own loved ones. We have very high quality physicians and other providers and excellent clinical outcomes in our GBMC system, so we ought to try to keep as many of those dollars in our own family as possible.  The onus is on me, our senior leadership team and our physician leaders to continue building and improving our system so that our employees wouldn’t consider going anywhere else for their care as long as the service is available at GBMC.

We need to spend as many of our GBMC healthcare dollars in our own system as possible.

A related issue that has been called out by our Employee Relations Council is we are not very good at promoting wellness among our staff and need to make improvements.  We’re working on some ideas, such as possibly changing our health benefits to be able to provide more wellness initiatives– like additional exercise classes on campus for employees before or after work.  We’ve done a pretty good job of making healthy meals available in the cafeteria but recognize that we need to do even more.

The Platinum PPO plan is by far the preferred insurance coverage option for our employees, with 87 percent of staff choosing this plan.   I encourage all of our employees to attend one of the spring Town Hall meetings to learn details of changes that will soon be made to our health benefit plans, including this PPO option.  The amount contributed by employees for some benefits may actually be lower this year, and a new "Friends and Family" plan will provide the plan participant and their dependents with less expensive healthcare if the care is delivered within the GBMC family.

As we grow the Greater Baltimore Health Alliance (GBHA) with our wonderful employed (GBMA) and affiliated (private practice) primary care and specialty sites, our implementation of electronic medical records, and moving toward the patient centered medical home – we will have more choices for our employees to use our system to get to better health, and better care at a lower cost.

What ideas do you have for keeping healthcare spending within the GBMC family?

Upcoming Town Hall Meetings

We are in the process of having our Spring Town Hall Meetings. The Town Hall Meetings are an opportunity for direct communication between employees and senior management. If you would like to submit a question prior to the meeting, please submit it via email to abrecht-castle@gbmc.org or drop your written questions off to the reception area in Human Resources. Appropriate questions deal with the hospital/organization, not with personal issues that are best resolved through your manager.

All are encouraged to attend a meeting. Raffles will be conducted at each meeting, and lucky employees can win gift certificates! The value of these meetings is directly related to your participation so we look forward to seeing you there!

The meeting schedule is:  
· April 23 – 2:00 p.m. (South Chapman)
· April 24 – 12 p.m. - GBMC Conference Center (Lunch Served)
· April 26 – 9:00 a.m. - GBMC at Owings Mills
· April 30 – 12 p.m. - GBMC Conference Center (Lunch Served)
· June 8 – 08:30 a.m. - Gilchrist Hospice Care

Medical Testing That Leads to Better Health and Lower Cost

The work of a physician to make the correct diagnosis for a patient is often quite challenging. Few tests are truly “gold standard” tests, which tell if a patient has a disease or she does not. Most tests are not gold standard tests; they are imperfect, so when the doctor gets the result, the probability that the patient has the disease under question goes up or goes down but the physician is still not sure.

Before ordering a test, the doctor needs to ask himself or herself: “What will I do with the result?” If the result is not going to change the treatment, then why order the test? Physicians are concerned about not doing the right thing by the patient. There are also some patients who believe that “more” is always better. This is clearly not true since tests that are not gold standard tests may lead the physician and patient to do something that might actually harm the patient.

Have you ever questioned why you or a family member were getting a particular medical test because you wondered how it was going to help? Or are you the type of patient who urges your doctor to do every possible test and procedure under the belief that more is always better?

There have been many studies throughout the years documenting that many patients are having tests where the evidence says that they will not benefit from having it done. The conversation about “overtesting” has often quickly turned to a discussion of the fear of being sued for not doing a test and it has stopped there. But now, probably because in our country we can no longer afford to deliver care that doesn’t actually lead to better outcomes, the pendulum is swaying in the other direction, toward eliminating testing  that might do more harm than good to both the patient and the community.

Recently, nine major medical specialty groups identified 45 common procedures and tests that they recommend eliminating from routine patient care because they are often not needed, duplicative, wasteful, or can potentially harm the patient. These professional societies, which collectively have 375,000 physician members, are: The American Academy of Allergy, Asthma & Immunology; The American Academy of Family Physicians; The American College of Cardiology; The American College of Physicians; The American College of Radiology; The American Gastroenterological Association; The American Society of Clinical Oncology; The American Society of Nephrology; and The American Society of Nuclear Cardiology.

The entire list of 45 often unnecessary diagnostic tests and therapeutic procedures that don’t actually lead to better health for the patient is available online at  http://choosingwisely.org/?page_id=13 
(you have to click on the name of each of the 9 societies to see that society's list of 5).

I’m very pleased to see this happening, because I have been upset for years that doctors, even some who I have great respect for, have said, “I know that (procedure X) isn’t going to help the patient, but they demanded it so I did it.” I don’t accept that.  I believe that we doctors, by not acting according to the evidence, have sometimes led patients to the position they are in, where they believe that more is always better.

The Society for Medical Decision Making was founded more than 25 years ago by a group of doctors who believed there was both an art and a science to medicine, but that these two were frequently confused.  The art is about the relationship between the physician and the patient and knowing how to approach each individual patient and what guidance he or she may need.  Knowing what tests to order is a science.  Oftentimes hard evidence exists about whether to do a test or not but it is invisible to the physician or it is ignored. The physician must have the evidence about the expected benefit of the proposed test in hand and he or she must discuss this with the patient to help him or her make an informed decision.

For example, the evidence is clear that many patients with an ankle injury do not benefit from an X-ray. In addition to the cost, they get unnecessary radiation and a longer stay in the ED. There’s a set of questions called the Ottawa Ankle Rules http://www.ohri.ca/emerg/cdr/ankle.html that is 100 percent sensitive for ankle fractures. Therefore it is a gold standard test. If the answer is “no” to all five questions, the patient does not need an x-ray and should be sent home with an ankle wrap, pain medication and instructions to rest the ankle. But when a patient walks into many emergency departments in the country with an ankle injury often the first thing they are going to get is an x-ray, with many of them being unnecessary.

We need to build a system that uses evidence-based test ordering to get to better health at lower costs.

What do you think about the reduction in potentially unnecessary medical tests?

Kudos to Hunt Manor Staff

Continuing with the “best practices” theme, kudos to the staff at our Hunt Manor practice, especially Chelsey Schaffer, a patient services assistant, and Kimberly West, a nurse practitioner. A Hunt Manor patient mentioned in a letter what a significant impact their smiles, compassion and caring meant when he came for an appointment recently and was severely depressed.  “I left the exam room feeling that someone actually did care about me, and a total stranger!  It made a world of difference to me.”    That’s treating a patient the way we’d want our own loved ones to be treated.  Nice job Chelsey and Kimberly!

Using Technology and Standardized Work to Make Care Easier and More Reliable

Once again, GBMC clinical and non-clinical staff are collaborating across departments in an effort to put the patient first and make management and discharge of patients as efficient and effective as possible.

Recently, 55-inch and 40-inch monitors were installed at the nurse’s stations on units 35 (Acute Care for the Elderly) & 38 (Telemetry) in a LEAN/Kaizen discharge initiative being coordinated by Nursing Administration and MIS staff.  Soon, all inpatient units will have these screens, which display the patient teletracker data and replace the old wipeboard (which will now be used only during downtime).

Caring for patients efficiently requires a team effort. If it’s your daughter waiting for a bed in the emergency room, you want her to move as soon as possible to the floor. You want the team caring for her and her room to be ready. Coordination in a complex system is critical. It wasn’t so long ago that logs were kept on paper of which patient was where, which room was clean and which room needed to be cleaned. We then began keeping track in a computer database but we had a hard time giving up the paper logs.

The existence of both systems often meant that neither was correct. The hospital computer system would say that Mr. Smith was in room 3501 but the nurses on the floor knew that he had moved to 3510 and the erasable board on the wall documented this. Some people would update the computer before the whiteboard. This lack of standardized work and people believing that it was ok to do things the way that felt right to them was actually making the job of patient care harder. The nursing supervisor would see an empty bed in the computer but because the system was unreliable, she would have to call the floor to see if it were true. Think of all the added steps and rework!

Coordinating efforts is much easier with standardized work and the correct use of technology. The pharmacist can see from the pharmacy who has been discharged. The food service worker in the kitchen can see that a new patient has arrived. The accurate  information available in realtime plays an integral role in helping all members of a patient’s care team be on the same page. The new screens make the information more readily visible to the team and allow us to synchronize our efforts. For example, when transport moves a patient from the unit for testing elsewhere in the hospital (i.e. Interventional Radiology), the teletracker will show this so everyone involved with that patient’s care knows where he or she is.

I believe that the work of a nurse on a medical unit is among the hardest jobs there is.   We must make sure that we remove steps in the nurse’s work that are wasteful. Using technology, like the 55 inch monitors, and standardized documentation of patient movement is a step in this direction.

Maria Baxter, RN, Unit 35’s Clinical Unit Coordinator, agrees. “Now the information is updated in realtime making it much easier for the staff. Often the staff is so busy around the unit that the wipe boards just were not updated as often as they needed to be,” she said.

Do you have other ideas where using technology and standardized work in the hospital might improve operations?

Congratulations to Unit 35 Staff

I’d be remiss if I didn’t extend congratulations to the staff of Unit 35, who have gone a year without a Central- Line  Associated Blood Stream Infection (CLABSI).  At GBMC we are participating in a national collaborative called "CUSP Stop CLABSI" (Comprehensive Unit Based Safety Program). Along with U35's tremendous accomplishment, it is important to note that housewide, GBMC has gone 134 days without a central line associated bloodstream infection, our longest stretch since housewide surveillance began!  Great CLABSI prevention work has been happening on all patient care units and our patients are reaping the benefits. The CDC estimates 41,000 CLABSI cases occur in United States hospitals annually and these infections are serious and cause a variety of problems for the patient, so anything we can do to reduce and eliminate these incidents will keep our patients safer.