Time Flies

It’s hard to believe that another year is ending. As we get ready to make our resolutions for 2013, it’s good to take a moment and reflect on how well we met our commitments in 2012.

In 2011 we committed to a new vision – a new direction for GBMC. We committed to becoming a true system of care through the eyes of the patient. Since we and our family members are all (at one time or another) patients as well, we created the vision phrase To every patient, every time, we will provide the care that we would want for our own loved ones. For our own loved ones we want the best health outcome, with the best care experience, at the lowest cost…so we said that this is what we want for everyone. We created a strategic plan to get to our vision. 2012 was essentially the second year into that strategic plan, so did we continue doing what we said we would do?

A fundamental building block of our system of care is the new primary care team: the Patient-Centered Medical Home (PCMH). In 2012, our Hunt Valley office was the first primary care team to reach Level 3 PCMH status and now most of our employed primary care offices have achieved this. The primary care teams now reflect on how they are doing for groups of patients and actively work to improve the health of individual patients with chronic disease with the help of care managers who work side by side with their doctor and nurse teammates. They have all extended their office hours and now some are open on Saturdays. In 2012, we implemented our patient portal, myGBMC, to make it easier for patients to participate actively in their care, see their own records, and to communicate with their physicians.

Now that we designed the foundation of a better system to help keep people well and to help people with chronic illness to better manage their health, we created a new company, Greater Baltimore Health Alliance (GBHA), that includes not only our employed physicians, but also many of our wonderful private practicing doctors working together on our vision. In 2012, we learned that GBHA had been accepted into the Medicare Shared Savings Program as an accountable care organization. In 2012, GBMC HealthCare became the first company in Maryland to sponsor an accountable care organization that included a hospital.

In 2012, we made our outstanding hospital even more outstanding. We made our care even safer than it had been. We rolled out a mandatory course called Getting in action for patient safety and all of our employees took the course. Teams made outstanding quality improvements in areas such as hand hygiene, central line associated blood stream infections, surgical site infections and catheter associated urinary tract infections. Our outstanding surgeons made patient care even better by participating in the National Surgical Quality Improvement Program. We are one of a few community hospitals to participate fully in this program. We opened our simulation lab as a place for people to learn and practice as individuals and in teams in a safe environment. We opened our Geckle Diabetes Center building on the strengths of the education center and now focusing also on the actual care of diabetic patients wherever they are in our system.  We empowered our physician leaders in Medicine, Surgery, Oncology, and Women’s Health to run these service lines and continually move us in those areas towards our vision. We added medical directors to all of our inpatient units and now have them working in partnership with our wonderful nurse managers to continually improve the quality of our care. We improved our ability to create standard work and use continuous improvement tools, specifically LEAN and the Model for Improvement and ran a number of value stream mapping and redesign events. An example of this was our weeklong 3P event to design our new inpatient pharmacy. Through the hard work of all, but especially our nurses and housekeepers, we achieved the highest overall inpatient satisfaction score in years and perhaps in our history (see the chart below). We added new flooring in many places in our hospital. We are the first hospital that I know of to scientifically calculate bed need for Medicine patients using queuing theory. This work resulted in our opening 12 more beds. In 2012 we opened our new Domestic Violence Program, becoming one of only seven such programs in Maryland. All of this work and much more combined with the wonderful dedication of our staff led to a very successful Joint Commission survey.

Gilchrist Hospice Care and Gilchrist Greater Living continued their spectacular work and truly lead the region in compassionate, evidence-based care to seniors and those at the end of life. Their year culminated in an outstanding outpouring of support from the community in the 2012 Holly Ball.

Our Human Resources Team redesigned our employee health benefit that reduced out of pocket costs for most of our employees and kept more of our dollars within our own system.

120 of our outstanding physicians were named to the Baltimore Magazine Top Docs list. Once again, GBMC had the most physicians of any community health system or hospital on this list. We are so fortunate to have outstanding surgeons, internists, pediatricians, family physicians, and other wonderful specialists.

In 2012, GBMC was recognized for the wonderful work of our Green Team. We won the Trailblazer award from the Maryland Hospitals for a Healthy Environment organization for our work in waste reduction and healthier food options. Our fantastic volunteer auxiliary again broke records in fundraising through our Nearly New sales and our Foundation ran a spectacular Legacy Chase steeplechase event that showcased our HealthCare system to the community.

I realize that these things only represent a small fraction of what the GBMC family did to move us closer to our vision. All I can say is thank you! I look forward to all of our accomplishments to come in 2013.

Compassion

For this week’s blog post, with her permission I am sharing a letter I received from Tara Holicky, a practice manager in Geriatrics, about her experience as a patient at GBMC when delivering her second baby.  Tara’s story is a wonderful example of GBMC delivering the kind of care that we would want for our own loved one.

After sometime, I’ve finally found the words to write to say thank you to hard working employees at GBMC.  I, myself, am actually a GBMC employee.  I started here after my first child was born in 2005.  It’s taken me some time to write this letter, because despite multiple attempts I’ve been unable to find the right way to express how grateful I am to the nurses, techs, doctors, and downright everyone for the miracle I have today.

In 2011, I was pregnant with my second child.  It was a very uneventful, normal pregnancy.  I had a c-section with my first and planned to have a scheduled c-section on 8/29/12 at 8 am.  (I wasn’t due until Labor Day, ironic I know).

To my surprise on the evening of July 11, 2011, my water broke.  I honestly thought I had an accident at first, and ignored it.  But when it seemed to be continuing, I called my OB’s office who advised I go in just in case.  Imagine my horror when I was told that indeed my water had broken.  I wasn’t even 32 weeks yet.  I panicked at the thought.   But the nurses were there for me.  They explained what would happen – I would be admitted.  They wouldn’t actively try to induce labor since it was a slow leak and the baby seemed okay, but they also wouldn’t try to stop labor if it happened either.  I would be staying in the hospital one way or another until my baby was born.  Fear cannot explain what I went through that first night in Labor and Delivery.  Wondering if I would get transferred to high risk, would everything be ok?  What would the NICU consult mean?  I didn’t sleep the entire night.  My nurses comforted and talked to me even though they were busy with other families having babies.  Each person who came into my room took time to really talk to me, knowing how scared I must be.

After a few days, despite not going into labor my fluid levels were too low for the baby to be safe, and I was whisked to the OR for an emergency c-section.  I was again terrified.  I had been through a c-section before, but this was different she was too early, I had to prepare myself that she might not cry, she may not make it, all the “what-ifs” that go along with a preemie.  But again, GBMC employees were there for me.  They explained exactly what was happening; the team in the OR all explained what would happen when she was born.

On July 13, 2011, around 10 am, my beautiful little 3 lb miracle was born at 32 weeks and 1 day.  And she screamed!  It was the most beautiful thing I’d ever head.  As it turned out she actually had a true knot in her cord, so it was quite lucky my water broke when it did.  The NICU team gave me a quick look and hug before they whisked her off to be fully evaluated.  My husband quickly followed them out, and the remaining OR team was there to comfort me while they sewed me up.  In recovery, I was fraught.   All the other women got to see their baby and I was there alone.  But the nurses understood my pain, and helped me deal. 

In postpartum, again, my family could all go to the NICU but I wasn’t able to yet.  Nurses, techs, housekeepers, even the people who delivered meals, were all sensitive to this.  They took the time to ask how she was, asked to see pictures, etc.  They were truly caring.  That evening when they told me I could up to the NICU, I was thrilled.  The NICU nurse who said I could hold her was my hero in that moment.  I had never seen a baby so small, much less held one.  To have my baby there in my arms doing okay, was such a miracle to me in that moment. 

It is tough to be in Post Partum when you can’t just have your baby in the room.  It is difficult to see families going home with their new little bundle of joy, knowing you will not get to do the same thing.  The nurses in Post Partum and the NICU were amazing people.  On my discharge from GBMC I cried so hard.  And Taylor my nurse sat down and cried with me.  She made me understand that it was okay to be sad, but I would be back tomorrow morning to see her.  The nurses in the NICU encouraged me to call in the middle of the night if I wanted to check in.

Since I worked at GBMC, my plan was to just go to the NICU for the full day while my husband was at work.  I could sit my office when I needed to.  Monica, a NICU nurse, knew that I wasn’t thinking clearly as woman who was recovering from her own surgery and arranged for me to use a room to rest during the day when I needed to.  I was so thankful to be able to take a nap during the day.  I was in the NICU essentially every day for at least 8 hours thereafter during the day.  I would cry when my husband came at 5 pm knowing we’d have to go home for the night. 

However, we were extremely lucky, despite her small size, my little girl was a fighter, and even though I was told she would need to stay until she was at least 35 weeks, she was discharged after only 13 days.

She is now a happy, healthy almost 17 month old, that you just saw the other day at the T. Rowe Price Scholarship award ceremony.  Despite her small size she is bundle of energy.  I thank the superb employees of GBMC for making this happen.  I am certain I cannot remember everyone by name and for that I am sorry, but I want to specifically thank Post Partum nurses Taylor, Suzie, Susan and all the others I know I’m forgetting.  The NICU nurses, Monica, Tamara, Janice, Pat, Ellen.  The doctors, my OB. Dr. Allen, the NICU team, Dr. Pane, Dr. Birenbaum and Dr. Helou, and the countless others at GBMC, housekeepers, techs, and meal servicers.  You are all special to me in that you each contributed to making my family whole.

What a great example of Team GBMC rallying around a patient and her family!  We need to continue our work to make this happen for every patient, every time.

This story is a good reminder that during this time of year we have many things to be thankful for and appreciative of, both in our personal lives as well as at work. Happy Holidays to all and best wishes for a safe and enjoyable holiday season.

On Becoming A Learning Organization

I ended last week’s blog by inviting people to comment and they did. I stopped replying to every comment as it appeared because I didn’t think that it would be helpful once I saw the emotions that were being released. So, let me try to respond to the comments now.

The blog is a mechanism for communicating. A regular reader of the blog knows that I am usually trying to accelerate change toward our vision of being the healthcare system that treats everyone the way that we would want our own loved ones treated, every time. Sometimes I highlight a “technical” concept, like the relationship between the number of hospital beds in an area and the cost of healthcare in that area, or the ability of the patient-centered medical home to make care less fragmented for people with chronic disease. Sometimes I highlight great work by our people in making change happen, like the blog on standard work and improving our hand hygiene scores, or the one on the great work of the team that created the design for our new inpatient pharmacy (see "What's a 3P?".) Other times I have interviewed patients to let them tell their stories about their care as a way to recognize our wonderful nurses, doctors, therapists, technicians, and other staff (see the February 24, 2012 blog with Chris Brandau’s Mom).

But until last week, I had only used “negative” incidents from other industries to highlight room for improvement, like the blog I wrote in which I talked about the poor (giving the appearance that the Southwest employee didn’t care) service that I saw at BWI airport; or my poor service due to a poorly designed system in getting a hot dog on the New Jersey Turnpike (see the August 24th blog, "Good Leadership, Poor Leadership, Well Designed Systems and Random Behavior"

Last week I took a chance. I decided that we had developed enough as a learning organization to begin to openly discuss negative feedback from one of our patients. I picked the letter in part because the author said many nice things about our people. I removed two names from the letter so that the individuals whose reported negative behavior was focused on by the writer could not be identified. I also removed the name of a nurse who had been complimented so that the floor of the hospital could not be identified by people who did not know of the episode.

The purpose of the blog was to get us all to reflect on how our behavior is perceived by those who we serve so that through this reflection we may all become better. The blog was not meant to hurt any individual. After the blog was published, more than one person told me that they knew of many incidents where we had left the appearance of callousness, the appearance that we did not care. All of these people also told me that they thought that GBMC had great people who really do care and who work very hard and usually delight their patients with their caring. But these folks agreed that it is good to reflect when we do appear to not care so that we can improve ourselves.

I know how hard people are working in our GBMC HealthCare System and I know that it is my job to make sure that they have what they need to get the job done; whether it be staffing or equipment. I realize that it is my job to see that they are empowered to improve the systems that they work in to make it less hard for them to get the job done. But I also am aware that it is my job to assure that we reflect on how we are doing because ultimately we are here for the people we serve.  

The Appearance Of Callousness

Have you ever seen the short film It’s a Dog’s World? (The “new” edition can be seen here).  This is a short film that makes the comparison of how a dog is treated with empathy, dignity and respect after an injury, while his master, also injured, does not get the same. The owner of the dog has to deal with among other things, people who don’t really seem to care about him.

I am very fortunate to be the CEO of the GBMC HealthCare system. I get so many wonderful letters about members of the GBMC family who do marvelous things for our patients. But I also get letters where we did not treat people the way we want our loved ones to be treated. When I read these letters, I most often believe that our people did care but they gave the impression that they didn’t.  I have come to call this the appearance of callousness. We often give the impression that we don’t care when we are overwhelmed or when we are busy trying to protect our teammates from being overwhelmed.

Here is an excerpt from a letter that I received this week:

“I am writing you about my recent inpatient stays at GBMC. I was admitted to GBMC for 4 days, went home for 2 days, but needed a readmission for another 3 days. My two stays couldn't have been more dissimilar. So I am writing about my observations, those who did a great job, and the few problems I found.

First, I think in general I got very good care. In the ED, I actually thought that the waiting was reasonable, they gave me a reasonable expectation of time delays etc. I found the ED nurses and techs very good- both in doing their job and giving the personal attention. One is struck by how busy they are and how they have to juggle many duties. Despite that, I didn't find it detracting from my care. Transport was fine, CT and sonogram people were pleasant, capable, and helpful.

I was admitted to an inpatient unit. My hospitalist was Dr. Renu Thomas, whom I found to be excellent. She was very thorough, had good insight into my care, was prompt about writing orders, and showed compassion and concern. Medically I thought she was excellent.  I was in a typical GBMC room- very small, but it was quiet.  I didn't really require a lot- mainly IV antibiotics etc. The nurses were all excellent, caring. One is struck by how busy they are, how they have to juggle many things. I liked that they wrote their names down each shift and left the direct number to the nurse. Once I used the call button, didn't get a response, but just waited since it wasn't that urgent. Later, I just called the nurse. Once a tech forgot something I asked for, and she was so apologetic. It really was fine. I had one aide who could have been a little quicker to help, but in general I found the staff great. The phlebotomists at 5:30 am were incredibly quick, quiet, and excellent at getting the blood work done. A night nurse, who clearly has many years of experience, was particularly helpful with her suggestions.

I was discharged home but the symptoms returned, so I came back for more intravenous medication. On my second visit my ED stay was again appropriate, not too long a wait, good staff. Then I was readmitted back to an inpatient unit. However I was put by the nurses’ station, in between a demented woman, and a hard of hearing man. And I was down from the ice machine- which is very noisy. So the room was very noisy and not ideal. This time I had a different doctor, whom I was not very impressed with. I found her manner not very caring. She made a mistake ordering me a medicine. When I mentioned it the next day- next time I saw her- she didn't even apologize. She just said that the computer wouldn't accept her code etc. When it was time to be discharged, she said I would have to wait at least 3 hours because she had sick patients she had to care for. I am sure that this was true but not what I needed or wanted to hear.

However my worst experience was from the unit coordinator. During my second stay, I developed a headache (my headaches often progress to severe migraines), and at 7:10 am hit the call button to ask for Tylenol. I was answered right away and told that it was change of shift so that it would be awhile for the medicine. At 8am when I still hadn't received the Tylenol, I called again. No answer. So I tried 2 more times over 5 minutes. No one even answered the button. So I got out of bed, and with my IV pole in tow, went out to the desk. As I approached, the unit coordinator said she told me the nurse would be coming. I said that no one answered the call button. She then, in front of many people at the desk, said that she had talked to me several times and told me that the nurse would be coming. At that point, I told her that she had only told me once at 7:10 and I wasn't sure that the bell had even worked the next time since no one even answered me. The nurse then came and gave me the Tylenol.

Later that day I spoke with the charge nurse, who was extremely polite, apologetic and helpful. She arranged for my room to be changed to one away from the nurses’ station. I did mention that I thought it was a problem that someone couldn't even get a Tylenol for an hour due to change of shift.

I will probably be returning again to GBMC as an inpatient because of my chronic medical problems. I am hopeful that I will have a better experience than my second stay. But in general the nurses are all excellent, caring, and very busy. You really get a sense of all they are taking care of with their patients. So many things go well at GBMC, but there is always room for improvement.

I am very grateful for the work of our people at GBMC, especially all of the nurses and technicians that this patient thanked and Dr. Renu Thomas.  But, as the patient said:  “There is always room for improvement”.  I called the patient and apologized for the appearance of callousness by that unit coordinator.  I told the patient that our unit coordinators do an excellent job but sometimes people slip and make it appear that they don’t care when they do, and sometimes they say the wrong thing when they are trying to prevent their nurse teammates from being overwhelmed. The patient accepted this and she told me that GBMC is still her preferred hospital. I thanked her for her trust in us.

I know that there was a discussion between that unit coordinator and her supervisor, to get her to reflect on her behavior and change it. I should also mention that our nurses are working to redesign our approach to answering the call light and they have embraced bedside handoffs and hourly rounding to reduce the frequency of patients needing to call them.

But in addition we all need to work to eliminate the appearance of callousness.  I look forward to your thoughts on this.