Friday, September 7, 2012

Learned People Know that We Can Do Better

This week, the Institute of Medicine (IOM) of the National Academies of Science, published a report entitled: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. (

The report’s summary states: “America's health care system has become far too complex and costly to continue business as usual. Pervasive inefficiencies, an inability to manage a rapidly deepening clinical knowledge base, and a reward system poorly focused on key patient needs, all hinder improvements in the safety and quality of care and threaten the nation's economic stability and global competitiveness. Achieving higher quality care at lower cost will require fundamental commitments to the incentives, culture, and leadership that foster continuous "learning”, as the lessons from research and each care experience are systematically captured, assessed, and translated into reliable care.”

The report pointed out (again) the facts about the functioning of our current system. These experts concluded that 1/3 of the money we spend annually on healthcare, $750 billion, is pure waste.  (This runs in the face of politicians screaming into the microphone that we have the best healthcare system in the world. I believe that we have the best doctors, nurses, and other clinicians in the world and that they are working very hard but they are let down every day by a system that is not the best in the world and must be redesigned.)

True to form, the IOM report spends little time lamenting the status quo and moves quickly to discussing the solution. The IOM listed some goals for our country’s system and how they might be achieved by adopting practices already in use in other industries.

Let me highlight their solutions and talk about what the GBMC HealthCare system is doing in these areas.

1. Use Information Technology More Effectively – Clinicians and patients should have real-time access to medical records and use technology to streamline administrative tasks.

What the GBMC System is doing: We have rolled out the electronic record to all of our employed physicians and to our affiliated GBHA doctors and other practitioners. We are now beginning to connect our private practicing specialists. We have created our patient portal myGBMC. We have implemented computerized ordering in our hospital and we are now converting from hand-written doctor notes in the hospital to computerized ones. We have much more work to do here but we are well on our way. (Hospital companies, as opposed to health systems, have no hope of leading on this one.)

2. Create Systems to Manage Complexity – Prompts, technologies and delivery systems should help clinicians manage the growing complexity of medical knowledge and care required.

What the GBMC System is doing: We have teams working in many areas to create better systems to get to better outcomes for the patient. In the hospital we are using more and more evidence-based standardized order sets. In our employed primary care offices we are designing the patient centered medical home to bring evidence-based medicine to every patient with chronic disease. Our readmissions team is designing a better handoff from inpatient care back to primary care. The Gilchrist Hospice Pain Team is reevaluating on a daily basis the performance of its design to make patients pain free within 24 hours of entrance into hospice.

3. Make Health Care Safer – Hospitals and providers should constantly assess performance and learn from experience to reduce errors and harm.

What the GBMC System is doing: We now have a Board Quality Committee that sets our annual goals, reviews our performance monthly, and demands improvement. 99 percent of existing GBMC employees and all new employees have taken our course in patient safety. We have implemented a new error reporting system that is now being used throughout the organization. We have taken a culture of safety survey and all departments and units have created action plans to improve their scores. The survey will be redone this fall to measure our improvement. Our Board, our Senior Executive Team, and our Physician leaders have all read Why Hospitals Should Fly and the Board all participated in a day-long facilitated retreat on their role in quality and patient safety. All leaders learned about the concept of Just Culture and their role in creating a safe environment. We opened our simulation lab to better train individuals to do procedures and teams to function well in emergencies. Our Women’s Service has begun Team Stepps Training to make care in the delivery room even safer.

4. Improve Transparency – Patients and clinicians should have easy access to the prices of tests and procedures and to reliable information about care outcomes and quality.

What the GBMC System is doing: We now have some data about our clinical quality on our internal website and by the end of this year, we will be showing our quality data on our public website.  Comparative information about GBMC is also available at . As for prices, we have some work to do here. Our prices are set in Maryland by the Health Services Cost Review Commission and they fluctuate regularly. Check out some hospital prices by clicking on the HSCRC URL below and then click on Maryland Hospital Pricing Guide and you will see that GBMC is a lower price hospital in our state.)

5. Promote Teamwork and Communication – Clinicians and hospital staff should communicate to provide seamless, coordinated care within and across different care settings.

What the GBMC System is doing: We are building the patient-centered medical home, making medical records electronic, using standard work tools like S-BAR in communications between clinicians, and standardizing hand-offs. See also what I wrote above in patient safety.

6. Partner with Patients – Clinicians should fully incorporate the needs and preferences of patients into care decisions.

What the GBMC System is doing: Again, the concept of the patient-centered medical home is fundamental to the provision of patient-centered medical care. A system that is not totally dependent on brief, face-to-face illness specific visits, but rather builds a relationship between the patient, the patient’s physician, and her Team, is better able to query the patient at regular intervals about the patient’s needs and preferences and then deliver on them. As a result of conversations with our patients, our employed primary care sites are now open weekdays from 7am to 7pm and on Saturdays in some sites. At a system level, we have added patients to some of our committees. An example of this is that we now have three patients on our Board Quality Committee. We also have a patient on the board of the Greater Baltimore Health Alliance.

7. Decrease Waste and Increase Efficiency – Money should not be spent on unnecessary administration, inefficiencies, and care that doesn’t improve health.

What the GBMC System is doing: We have significantly increased the number of our system level value-stream mapping events for this fiscal year. We have a system goal to reduce the time from arrival in the Emergency Department to placement in an inpatient bed for those patients that need to be admitted. We have trained a new crop of Performance Improvement Masters, and we will redouble our efforts to improve our systems. Our Medicine Service Line, under the direction of Neal Friedlander MD, our Chair of Medicine, has created standardized order sets and pathways in the care of congestive heart failure and diabetes among other clinical entities.

I am glad that the Institute of Medicine has taken the time to identify the problems with our national healthcare system and has also set some attainable goals to improve the system. I am also very proud of all that GBMC is doing to be a part of the solution.

Your loved ones deserve better than the status quo. None of the problems identified by the Institute of Medicine are fixed by the building of new hospital towers, the lumping of existing hospitals into one company, or the expensive propping-up of inpatient capacity that the community does not need.

GBMC is building a better system of care for our own family members and yours.


  1. I am proud to be part of this healthcare system -- we really are doing some great things that differentiate us from other organizations. The leadership at the board and executive level have been driving the change. We all have to get on board, though, and get engaged in each one of these actions. I challenge all of us to think about how we meet them in our own department and practice.

  2. It's good to hear about the work GBMC is doing to improve the health care system. Big changes must start with all of us.


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