A Great Decision for Our Country…. Our Work Continues!

Today, the Supreme Court announced its decision that the Patient Protection and Affordable Care Act is indeed constitutional. This was a great decision for our country. Our health care system is not meeting the needs of the American people, it is too costly, and it is placing unacceptable burdens on our industries, especially on small businesses, where most of our jobs are created. The Affordable Care Act sets in motion many necessary changes to get us to better health, better care, and lower cost.

We of the GBMC HealthCare system have been worried that the law would be found unconstitutional but we were committed to moving forward with the transition of our system to a "fee for health" model no matter what the justices decided. Now, we will have no excuse! It’s now clearly on us. We must stay in action.

We have a great hospital, a great hospice, great doctors, and great nurses. We have great clinicians of all sorts and a wonderful leadership team and fantastic support staff. Everyone is working very, very hard. We have come a long way and the metrics support this. But we have a long way to go to get to perfection for every patient, every time. We have a long way to go to create the system of care that is integrated and that anticipates what the patient will need before she needs it.

But we are well on our way. At our hospital, errors and near misses are now much more likely to be reported and our “time to action” in using what we learn from errors to redesign the system is shorter. Our people are now much more likely to understand the causes of patient harm, that people make mistakes and that we must design systems to mitigate the effect of human error.

In the hospital, we have appropriately moved to electronic ordering and record-keeping to make information necessary for the care of a patient more visible and reliably available. We have embedded many evidence-based order sets in the computer system to help assure that patients get the right care.

We are measurably cleaner and measurably better at communicating with our patients. We have created a better organizational model for empowering our physician leaders. It is very hard to create the necessary workable structure to get private-practicing physicians to believe that they have a voice and that it is heard. I think we are closer now to that reality.

We have been known at GBMC as being a great surgical hospital. We have recruited a number of surgeons from other hospitals who have begun working at GBMC to fill gaps and to restore our surgical case volume. When the evidence is that a patient needs surgery, we want it done in our hospital.

We have created the Greater Baltimore Health Alliance and have welcomed nearly 20 privately practicing primary care providers to go with our nearly 80 employed primary care providers to serve as the fulcrum of integration. They are nearly all now using the same electronic outpatient record and that information is available to clinicians throughout our system. In a few weeks, we will begin implementing our electronic medical record in specialists’ offices and connecting our record to those specialists who already have their own computerized record. We are looking forward to GBHA being accepted as an accountable care organization in the very near future. We will have our first GBHA Board meeting and our first Specialty Advisory Board meeting by the end of the month and we hope to have some exciting news to report around July 10^th!

Our GBMA primary care offices have extended their appointment hours and the GBMA leaders are working on an after-hours plan the will reduce the need for the use of non-integrated urgent care centers. Our Hunt Valley office has achieved level 3 patient-centered medical home status and by the end of the year, the rest of the offices will have achieved the same distinction. We have implemented our patient portal, myGBMC, so that the patient can get access to his or her records and help coordinate his or her own care. On August 1, we will launch our new Geckle Diabetes Center. Building on our diabetes educational center, we will now have a team that oversees diabetes care throughout our system and that will be actively working to continually improve diabetes outcomes and avoid hospitalizations.

We have recreated our employee health insurance plan to attract our people to stay within our system for their care. This new plan will give us the opportunity to generate better health and care for our own workforce and their dependents.

These are certainly exciting times. They are times of change for the better. Our community needs us to do this. Future generations are desperate for us to be successful. We must keep moving towards our vision. 

What do you want in end-of-life care?

We need to have a dialogue about end-of-life care in the United States. This is one of those medical issues that most people unfortunately avoid planning for and discussing until it is way too late.

At a recent orientation session for our medical residents, I talked about GBMC’s vision of Better Heath, Better Care, Less Waste, and More Joy. Most in the room kept quiet (they were undoubtedly thinking about what they would do when they were paged to their first code).  One new resident did share with me a poignant story about how within the last month he had spent three weeks at the bedside of his dying grandmother in an intensive care unit at another hospital.  He was there because he loved her and wanted to spend some of her final moments with her, but also because he felt the need to protect her against medical harm.  That says it all.  An insider felt he had to be there because the system is not as well-designed as it needs to be.

Aside from thoughts about patient safety, this young physician got me thinking about what most people want for themselves at the end of life – do they want to die on a ventilator with so much medication that they might not even know where they are?  What is the goal of that care?  If that is something they want, then that’s what they should get. I’d contend that many Americans dying in the hospital don’t actually want that, but the system either can’t deliver what they truly want in their final days or no one has had the conversation with them to know what it is that they want.

The staff at Gilchrist Hospice Care gets it, they were one of the winners of the American Hospital Association’s Circle of Life awards, which honors innovative programs in palliative and end-of-life care.  They understand that the practice of hospice care does not have to be sad.

One of these staff members is Jill Campbell, RN, a case manager with Gilchrist’s Central Home Care who began working as a home care nurse three years ago after working as an operating room nurse, in home care with developmentally disabled adults, and with an agency specializing in immunizations for travel abroad.

Campbell was recently featured in a national Ladies Home Journal article alongside some of her patients / family members. The LHJ article, “It Doesn't Have to Be Sad: The Life of a Hospice Nurse” and accompanying A Hospice Worker's Life: Photo Essay provide a poignant look at hospice care through Jill's eyes.  Featured are some individuals and families who have made the decision that when they can’t be saved by the medical system that they want to be in a respectful place and be as comfortable as they can be.

In a blog post Campbell shared, “Even though I have a varied nursing career, I finally feel at home as a hospice nurse."

Too often acute care hospitals are doing things that many people at the end of life wouldn’t want if they had a choice. In the US we are spending a significant percentage of healthcare dollars on taking care of individuals in their last six months of life.  We should spend every penny that will make their lives better or more comfortable. But if it’s not helping them we need to call that into question.

Absolutely if it’s my daughter and she can get better, then I want her to receive every type of care possible.  But once it’s clear she’s not going to get better, I want her to be comfortable and in the setting that she wants to be in. That’s the way all of our patients deserve to be treated.  Even if the family can’t support the patient at home, we have to have options for them other than just the hospital.

Do you have a personal story about Gilchrist Hospice or end-of-life care that you would like to share?

I’d be remiss if I didn’t take a minute to thank the more than 900 participants who spent part of their Father’s Day with GBMC and helped raise more than $110,000 at the 24th Annual Father’s Day 5K to help support the NICU babies and their families. In 24 years, the GBMC Father’s Day 5K has raised more than $1.5 million for critically ill and premature babies. GBMC’s NICU is one of the largest in the area, caring for over 400 babies annually.  It’s not too late to give – you can click on http://Foundation.GBMC.org and still make a donation. I ran the race and I am happy to report that I did not sustain a significant injury.

Finally, I’m pleased to announce that GBMC’s Sandra and Malcolm Berman Comprehensive Breast Care Center has again received a three-year full accreditation from the National Accreditation Program for Breast Centers.  Three years ago, GBMC was the second breast center in Maryland so recognized, and this re-accreditation is a testament to the excellent care and treatment our clinicians provide.

Dealing with harsh realities and continuing to work towards our vision

Our US healthcare industry is beginning to deal with the harsh reality that we must reduce costs. GBMC is not immune to this reality. Our vision contains the commitment to drive waste out of our system and reduce costs, so we should not be surprised when we see a real need to reduce our own expenses.  

While our organization is in a transition period, moving from a fee-for-service world to a fee-for health world, several developments have created an immediate financial challenge for us.  These include the impact of Maryland’s Health Services Cost Review Commission increasing reimbursement rates at a level below inflation, and the decrease in the number of elective inpatient surgeries being done in our region (and nationally).

As we finalized the Fiscal Year 13 budget and worked to remain profitable, we needed to make the difficult decision to “right size” the organization in response to these issues.  Unfortunately, this meant the elimination of 50 positions. While 30 of those positions were vacant, 20 people lost their jobs this week.  Although this is a small percentage (about 1%) of our entire workforce, it is very sad when anyone who is doing a good job loses their job. As the leader of this organization, I know that is my responsibility to do whatever I can to protect the jobs of our people.

At budget time we often are facing the need to reduce expenses. I believe that we must take waste reduction very seriously throughout the year, so that we don’t find ourselves with so many hard decisions at the end of the fiscal year and the need to lay-off people. Unfortunately it’s a fact of life that if we don’t reduce expenses to keep them in line with revenue we put everybody’s job at risk.

We have also reduced expenses in many other areas. Some of these include:

• We have renegotiated many of our contracts with vendors to ensure lower pricing and improved utilization of services.
• We have delayed some capital purchases to reduce depreciation and interest expense.
• We have refinanced a number of our bonds to generate interest expense savings. 

Rest assured, our strategy of Better Heath, Better Care, Less Waste, More Joy is right on.

• We are getting recognition by decision makers who are excited about us driving measurably better health, measurably better care and measurably lower cost and we need to keep going. 
• We have private insurance companies who are excited to create insurance products with GBMC as the preferred hospital due to our lower cost and high quality outcomes. Local small business owners are excited about this.   
• We are expecting a decision very soon on our application with the Centers for Medicare & Medicaid Services (CMS) on the Shared Savings Program which will allow us to grow Greater Baltimore Health Alliance, our network of employed and aligned physicians.
• Our Patient Centered Medical Home pilot in Hunt Valley is getting rave reviews from patients, and local executives from big companies are coming to visit because they want us to be successful in providing Better Health, Better Care and Lower Cost to their employees.

We are exploring new ways for our employees to share in profits when GBMC does well financially. This model works at some of the country’s best health systems, and serves as an incentive for people to make work redesign happen faster. We hope to announce our new plan later this summer.

Given recent developments, some people may be wondering about the A-word: acquisition.  I can say with confidence that is not something the organization’s Board or senior leadership is considering.  There is no advantage for us to become part of a larger hospital company at this time. Our vision of better health, and better care with lower cost and more joy would be hampered by our need to fill more beds than we have now. We are entering a time when the excess capacity of hospital beds in Baltimore will begin to be squeezed out. Companies that have large numbers of beds will need to close many of them. We are fortunate that we only have 300 beds in a fantastic hospital with the highest patient satisfaction and health outcomes that we have ever had!

In the long run, we’ll be fine. This transition period is full of challenges but we are moving quickly towards our vision. We strongly believe that we are now better positioned to meet our goals as we move forward and that, while painful, the staff changes were necessary in order for GBMC to thrive in the future.

We need to come together around our vision, and drive the waste out. This is what our community, and our country, needs us to do and I am convinced that we will all do well together in doing this work of change!

Being Conscious of Those in Distress and Working to Alleviate It.

The Merriam Webster dictionary defines compassion as sympathetic consciousness of others’ distress together with the desire to alleviate it. We certainly see compassion among our teammates in our healthcare system every day. When we or our loved ones are hurting, we are looking for compassion and therefore, compassion for all who are in distress is a requirement of our vision.

Once a year, we gather nominations from our people of those among us who are exemplars of compassion; those who demonstrate compassion more often, more deeply, more consistently, than the rest of us. We had many nominees this year who were deserving of recognition for their compassion.

Heidi Dorsey (L) and Amy LaMoure (C)
accept their Compassionate Caregiver Award

So, once again, we have called out a winner of the GBMC Compassionate Caregiver Award. Actually, we called out two winners at a ceremony this past Wednesday. They are: Heidi Dorsey, LGSW and Amy LaMoure, LCSW-C, social workers at the Towson Inpatient Unit of Gilchrist Hospice Care who work together to help patients at the end of life and their families. 

Their co-workers nominated Heidi and Amy because they routinely demonstrate true compassion. They call them both gentle and kind and point out their sensitivity to patients and families “in shock” with a new diagnosis or sudden decline. It is very easy for caregivers dealing with dying patients to develop their own defense mechanisms and distance themselves from the pain.

Heidi and Amy were recognized for being able to be “present minded” even though they have “seen this before” knowing that it is the patient and family’s “first time.” One colleague said that Amy and Heidi “ask questions that others can’t and think of things the family has forgotten.” Some ways that Amy and Heidi have supported patients and families include the special celebrations of birthdays, baptisms, and even weddings! The colleague said: “They advocate for patients to make final hopes reality.”

Another colleague remarked in her nomination that Amy and Heidi “can often be found on the unit after their ‘shift’ ends, closing the loop with families they come in contact with who could not make it in during regular hours.” They often take calls when off duty. Amy and Heidi never show the frustrations of the fragmented health care system to patients and families.

I read through the pages of valedictory comments submitted by Amy and Heidi’s co-workers and I realized that they are a model of compassion for all of us to try and emulate.

Congratulations Heidi and Amy! And thanks to all at GBMC who are compassionate every day.

A group photo from the Compassionate Caregiver Awards ceremony

Compassionate Caregiver Award Honorable Mention recipients include anesthesiologist John Kuchar, MD; Christine Clevenger, RN, a Gilchrist Hospice Care homecare nurse; pathologist Howard Siegel, MD; and Ruth Nolan, a volunteer at Gilchrist Hospice Care. 

Another area of our system where concern and compassionare always on display is Oncology Services, and last weekend, GBMC celebrated its 21^st annual National Cancer Survivor Day. More than 240 GBMC patients, family members and staff attended a "paradise themed" celebration. 

Survivors enjoyed food, fun and festivities as well as a message of Health, Healing and Hope. Speakers included Marshal Levine, MD, GBMC Oncologist/Hematologist, who summarized what makes GBMC special and unique when treating those diagnosed with cancer, and GBMC four-year cancer survivor and motivational speaker Vicki Hess, RN CSP, author of Shift to Professional Paradise. In her keynote address, Hess spoke about her experience of practicing what she preaches; lessons she learned when she herself was diagnosed with cancer and how to shift to "personal paradise."

In addition, 23 GBMC staff members were nominated for the Susan M. Murphy Making a Difference award with Donna Lewis RN, recently retired manager oncology support services, recognized as the winner for her many contributions to the GBMC oncology program. The patient award was given to Marci Cooke, a four year GBMC colon cancer survivor, for her work in raising funds and awareness in the community through the American Cancer Society Relay for Life.

Checking In On Our Strategic Plan

It may be warm outside and not typical “end of the year” weather, but our year-end from a business perspective is coming up in a few weeks, and as we come to the end of the first year of our three-year strategic plan to get to our vision, it’s time to reflect and see how we are doing and what accomplishments we have reached.

As I outlined last July in “New Year, New Vision, A Need for More and Faster Improvement” , our strategic goals are centered around the Triple Aim of Better Heath, Better Care, Less Waste --- and we added a fourth bullet of More Joy.  I stressed that in order to achieve this vision, we have to get better at executing change through the eyes of our patients, and I think we’ve been quite successful in doing so in Fiscal Year 2012.

The essence of our strategy lies in two parts – better coordination of care and a compact with our physicians for better care coordination. We have great doctors who work very hard but we need their help in redesigning systems so that everyone gets the care that we want for our own loved ones. We are also embracing physicians who want to remain in private practice as long as they will join us in pursuing our vision.

In order to coordinate care, we must have electronic records.  We’ve now fully implemented electronic health records in the 40+ offices of all our employed physicians (Greater Baltimore Medical Associates), both primary care and specialists.  This use of electronic health records is giving us the ability to create disease-specific patient registries so, for example, we can see how our diabetic patients are actually doing. This also gives us the opportunity to get messages about who has recently been discharged from the hospital so we can check-in with those patients and keep them on the road to recovery. We also now can make discharge summaries available within the electronic health record for employed physicians.

In the hospital we’ve fully implemented Computerized Physician Order Entry and have taken a lot of wasteful steps out of the processes that were created by having orders done on paper.

There’s been a lot of change with our GBMA practices on the Towson campus and locations across the region this year.  The GBMC at Joppa Road practice is brand new and started seeing patients last month, our GBMC at Perry Hall office moved to a new and larger location, and the GBMC at Hunt Manor practice was renovated. GBMC at Hunt Valley achieved NCGA Level 3 status as a patient centered medical home and is the model for our future and we opened the GBMC Gastroenerology group with several providers of GI services on the hospital campus.

We also launched Greater Baltimore Health Alliance and extended our primary care reach through Baltimore County.  To date, we have signed up providers in eight primary care private practice sites in the network: Chapel View Family Care (Perry Hall); Joseph T. Pallan, MD (Lutherville); Richard C. Habersat, MD (Hereford); Feirtag & Ramos PA (Lutherville); Alan Kimmel & Donald Weglein (GBMC Physicians Pavilion North); Jarrettsville Family Care (Jarrettsville); Josephs, Turner, O’Malley, PA (Towson); and Vincent P. Wroblewski, MD (Lutherville), all of whom have the same electronic health record that GBMC employed doctors have. These physicians are now in a better position to work with us in achieving  the Triple Aim, and its much easier for them to refer patients to specialists and to communicate with those physicians about how their patients are doing – again, a huge step in coordinating care.

GBMC has also enrolled in the Chesapeake Regional Information System for our Patients (CRISP) network, Maryland’s statewide health information exchange. Soon our providers will be able to access realtime messages about patients if they seek healthcare beyond the walls of the GBMC HealthCare system.  We are now beginning the dialogue with our private practice specialists about adopting our electronic record or linking their record to ours.

We’ve made a lot of progress in the area of informatics, but we’ve also made significant progress in care coordination doing things like freeing up primary care visits for emergency department patients who don’t have a primary care physician, extending office hours from 7 a.m. to 7 p.m. in many primary care offices, and launching the “myGBMC” patient portal to make it easier for patients to get lab results, schedule their next appointment and communicate with their doctor.  So far, 17,000 patients have registered at www.gbmc.org/mygbmc.

In addition, we have gone a long way toward educating our staff about high reliability and patient safety issues, and are eagerly awaiting formal word of our application for the Medicare Shared Savings Plan through the Affordable Care Act.  For employees, we’ve made changes to the health insurance plan, lowering the out of pocket healthcare expense for many staff members and keeping their contributions at the same level as it was last fiscal year.

What I’ve highlighted here is only a small sample of all of the things that we have accomplished this year to get to better health, and better care with less waste and more joy for those providing the care. Thanks to all of my colleagues for all that you have done!

Have you benefited from any of our wonderful changes in the last year? What do you like the most in these improvements? What changes will you make to help us get to our vision faster? What other ideas do you have to improve the patient experience?