Thank You to All Who are Helping GBMC Transform to be Even Better

On the last day of 2013, it is once again time to reflect and take account of our progress toward our vision. How much farther have we progressed in becoming truly patient-centered? What have we done to treat every patient, every time, the way that we want our own loved ones treated?

Aim #1: Better Health

Since the opening of Greater Baltimore Medical Center some 48 years ago, our system has been blessed with very talented physicians, nurses, and other clinicians who work very hard to maximize the health of those we serve. Over the last few years, we have gotten better at measuring and at getting in action to change things that we used to take for granted. In fiscal year 2011, we had 20 serious safety events. Through the first six months of fiscal 2014, thanks to the hard work of those very same talented clinicians and others in creating standard work and making us more reliable - we have seen three. Zero is the only ethical stopping point but we have come a long way. In 2010, we did not have a robust system for people to report minor events and near misses. Now, we have over 1500 incidents reported monthly so that we can learn from them and redesign our systems to plug “the holes in the Swiss cheese” so that they don’t align to create bad outcomes. In fiscal ‘11, we had 216 hospital acquired infections and we did not count all of them. Through the first six months of fiscal 2014, we have less than 50 total incidents of patient harm (central line associated blood stream infections, catheter associated urinary tract infections, surgical site infections of the hip and knee, falls with Injury and pressure ulcers)! We had 10 pressure ulcers alone in fiscal 2013. This year to date we have had zero! GBMC nurses and nursing technicians deserve a huge THANK YOU for this!

And we have begun moving upstream on measurably improving health. In 2013, Greater Baltimore Health Alliance made its first ever quality report to the Centers for Medicare and Medicaid Services under the Medicare Shared Savings program. We now know exactly how our diabetics are doing, for example, in getting evidence-based care and we know how many of our patients are hypertensive. Our Patient-Centered Medical Homes are in action improving these outcomes before patients require hospitalization.

Aim #2: Better Care

In 2013, we made significant progress at making continuous improvement in our culture. In April, we rolled out Lean Daily Management (LDM). LDM has helped us improve clinical outcomes, but perhaps the aim that it has had the biggest effect on is Better Care. A huge example of this is our success in moving admitted patients out of the Emergency Department to a floor bed faster. Units 35 and 38 have led the charge here by creating a pull system and measuring their success daily. The median time that an admitted patient spent in the ED in fiscal 2013 was 395 minutes. We have reduced this time to 305 minutes – a 23% reduction. The score on our patient survey question regarding waiting time to be admitted has reached an all-time high showing that the patients are truly feeling the effect of this work. In 2013, Greater Baltimore Medical Associates (GBMA) began seeing patients on Saturdays and their overall patient satisfaction scores reached all-time highs. And as I reported recently in this blog, GBMA has embarked in 2013 on the physical design of a new patient-centered medical home to minimize waits and delays and waste of all kinds. Gilchrist Hospice Care, already functioning at award winning levels in so many areas, redesigned communication with families and significantly improved the families understanding of the dying process and their feeling competent to deal with the impending death of their loved one.

Aim #3: Least Waste

Our nurses work very, very hard. A great example in 2013 of lessening their burden a bit has been achieved in the reduction of the number of “missing” medications. Nurses have enough to do in providing care for their patients without searching for things that should be there! Through the hard work of our pharmacy team collaborating with our nurses, we have reduced missing medications by 30% in 2013. Unit 45 has worked with materials management and has drastically reduced missing supplies. What used to be a major waste of nursing time has now become an uncommon event. There are many other examples of waste being driven out throughout the GBMC HealthCare system.

We finished fiscal 2013 a bit ahead of budget and we raised more money in Philanthropy than we had in many years. We are on track to break that record in this fiscal year.

Aim #4: More Joy

Our work in creating a hierarchy that engages and empowers our physician leaders through our service line model has had a positive effect in our physician engagement scores. Our overall physician satisfaction score increased significantly in 2013. We still have a lot of work to do in making all of our doctors believe that they have a voice and that it is heard. On a local level, our nursing staff has begun working on things like assuring that everyone gets an uninterrupted meal break and that they can get their work done and get home without having to do overtime. We have committed to reducing employee injuries at work and we are making great progress. In fiscal year 2013 we had 327 injuries on the job and half-way through this year we are at less than 100! In 2013, we changed vendors on our employee satisfaction survey so the results were difficult to interpret. We will continue to work at a senior team level on things like benefits and providing career growth opportunities and at a local level to bring more joy and to make the GBMC system an even better place to work in 2014.

So I think the evidence is clear. GBMC HealthCare made great progress towards our vision in 2013! We have many, many people to thank for this. Our doctors, our nurses, other clinicians, our administrators and all of our non-clinical employees have done a fabulous job. We must thank our phenomenal Volunteer Auxiliary, who in 2013 celebrated 50 years of service to GBMC! We also need to thank all of our donors who gave of their treasure. And lastly, we must thank our patients – you are the reason we do what we do and you will make us do it even better in 2014!

Please click on the video link above to be thanked!

Peace on Earth

This week I did what most Americans do during the holiday season….I went shopping. I think I am the stereotypical male in that I really don’t like shopping, but I do it to try and find gifts for the people I love. I remember when I lived in Rome in the 1970’s seeing how the Italians celebrated the holidays. It was much less about gifts and more about gatherings and joyous meals together.

Tuesday I went on our Lean Daily Management walk and realized how wonderful our staff is and how not just on Christmas Eve, but every day, they give so much to our patients and their families. It’s like most of them have the spirit of giving all year round. After rounds, I had three patients and families I wanted to see. One was a phenomenal volunteer who gives so much to GBMC. One was quite an accomplished gentleman who I did not know personally, but I knew of him, and was asked to visit him by a mutual friend. The third patient was a woman who had just delivered her first baby and her husband. They were so glad to have this new, wonderful gift in their lives. Making all three visits really got me thinking about what the season is all about, so I gathered my things and went home to be with my family.

I am writing this next to our Christmas tree listening to holiday music and looking at the ornaments that we have collected over the past 30 years. My favorite ornament sits atop our tree. It’s a paper angel that my son Mike made in Kindergarten and it has a photo of Mike’s face at age five glued on the body of the angel. It reminds me of how lucky I am. I wish that everyone in the world could stop during this season and reflect on what is really important.

I wish everyone a peaceful and joyous holiday season and for those who celebrate it – Merry Christmas!

Patient Safety and the Man-Machine Interface

We know that humans make errors and we also know that we can eliminate some of those errors through the appropriate use of technology. For example, the computerized order entry system (CPOE) has just about eliminated medication errors due to misinterpreted handwriting or the use of dangerous abbreviations.  
However, machines don’t fix everything and computerization creates new opportunities for error at what is known as the man-machine interface.

An example of a catastrophe created at this interface was the crash of American Airlines Flight 965. The aircraft was a Boeing 757, and it was on a scheduled flight from Miami International Airport to Cali, Colombia, when it crashed into a mountain in Buga, Colombia on December 20, 1995, killing 151 passengers and 8 crew members.

Cali's approach uses several radio beacons to guide pilots around the mountains and canyons that surround the city. The airplane's flight management system already had these beacons programmed in, and could have told the pilots exactly where to turn, climb, and descend, all the way from Miami to the terminal in Cali. Essentially, once the pilots had programmed the computer, the plane could have taken off and landed itself successfully.

Cali's controllers asked the pilots if they wanted to fly a straight-in approach to runway 19 rather than coming around to runway 01. The pilots agreed, hoping to make up some time. The pilots then erroneously cleared the approach waypoints from their navigation computer. When the controller asked the pilots to check back in over Tuluá, north of Cali, it was no longer programmed into the computer, and so they had to pull out their maps to find it.

By the time they found Tuluá's coordinates, they had already passed over it. In response to this, they attempted to program the navigation computer for the next approach waypoint, Rozo. However, Rozo was identified as R on their charts. Colombia had duplicated the identifier for the Romeo waypoint near Bogotá, and the computer's list of stored waypoints did not include the Rozo waypoint as "R," but only under its full name "ROZO." In cases where a country allowed duplicate identifiers, it often listed them with the largest city first. By picking the first "R" from the list, the captain caused the autopilot to start flying a course to Bogotá, resulting in the airplane turning east in a wide semicircle. By the time the error was detected, the aircraft was in a valley running roughly north-south parallel to the one they should have been in. The pilots had put the aircraft on a collision course with a 3,000-meter (9,800 feet) mountain. They realized their error too late and the plane crashed into the mountain. A system designed to make flight safer had been misused by the humans flying the plane and this had resulted in 159 deaths.

Recently, at GBMC, we had a near miss from a human error at the man machine interface. An ED doctor was trying to order a CT scan of the head and neck on a patient and inadvertently clicked on the next name in the list and ordered the CT on the wrong patient. In the old system, the doctor would have taken an order sheet and stamped the patient’s name on it, but in the computerized world, this type of new opportunity for error presented itself.

The wrong patient did not get the scan because our design for safety has a check that worked that day. Jana Sanders, the C.T. technician who was working reviewed the patient’s record and questioned the orders because there was no mention of a fall or head/neck pain. Jana called the physician to make sure he wanted these exams on the patient before doing the scans. At that point, the physician realized the error, thanked Jana for catching it, and put the order in for the correct patient.
 
It is said that in highly reliable systems, operators have a preoccupation with failure. Operators, like Jana, have a questioning attitude because they know that humans make errors, so they follow the design for safety and do the check to make sure they have the right patient. They also realize that computerization prevents many types of errors but creates some new ones at the man-machine interface. Our hats are off to Jana on a job well done!

What opportunities for error do you see in your work at the man-machine interface?

A Just Culture Fosters a Safer Culture

When I was a medical student I had the opportunity to scrub on a bowel resection surgery for a patient with colon cancer along with a second year resident and the attending surgeon. I was holding a retractor and watching the case up close, watching as the surgeon sewed one end of the anastomosis (reconnection of the two pieces of bowel) to the other. But then, I watched as he started cutting right through the bowel he had just meticulously stitched. I knew this was wrong and I was scared. Could it be that this surgeon was actually cutting through the bowel section he had just stitched or was I not seeing this correctly?  I thought, ‘I’m just the med student,’ and I stayed quiet. As he was almost finished with the procedure, he stopped and looked at me and the resident and said, “Why didn't you say anything?” He realized that he was cutting through the anastomosis he just stitched. Not speaking up because of the hierarchy and the fear of retribution is very dangerous in any high risk industry, and especially in healthcare.

One of the problems in healthcare is that our field is very paternalistic and hierarchical. We must make it safe for people to speak up in order to make the care safer.

No one questions that the doctor is the captain of the team by training and by law, but to get it right it takes the whole team. For the team members to perform at maximum capacity there has to be a culture of respect and openness to full participation by all.

The Just Culture is a concept where individuals are consoled if they make a human error. They’re coached if they are drifting into at-risk or risky behaviors and they are only punished if they are involved in reckless behavior or knowingly put someone in harm’s way by violating the established rules.

Let me give you some examples of this:

A busy hospitalist physician inadvertently clicks on the wrong patient in the order entry system and orders insulin on the wrong patient. The pharmacist, not seeing the diagnosis of diabetes in the patient’s record, calls the physician who realizes her error and apologizes, feeling terrible for her mistake. The pharmacist consoles her.

A nurse later draws up the insulin but gets distracted by her phone ringing and draws up the wrong dose. Because insulin is a high-risk medication and patients can be harmed by receiving too much or too little insulin, we have a double check on insulin delivery – one nurse draws up the insulin, checks it against the physician order and then hands the syringe to a second nurse who must double check the dose against the written order to make certain it is the correct amount. In this case, the second nurse, also feeling pressed for time to give care to his patients looks at the syringe but does not check it against the actual order. The first nurse then gives the incorrect dose to the patient.

These two nurses are drifting from the design for safety – they did the second check but did not do it the designed way. In this case, their behavior is risky and they need to be coached on why the second check is done and why it is critical to do it correctly.

Reckless behaviors, on the other hand, need to be punished. Take, for example, the medical technician who was sentenced to 39 years in prison for infecting more than 45 patients with Hepatitis C after he stole syringes filled with narcotics intended for the patients, injected himself with the drug, refilled the syringes with saline and then used the syringes on patients knowing he had hepatitis C. This is reckless and dangerous behavior and in a just culture, should be, and is, punishable by law.

To err is human

Commercial aviation had to make dramatic changes to its culture because of the worst airline disaster in history - the Tenerife crash of 1977 where two 747s crashed into each other.  The co-pilot of the one plane on the runway was aware that they hadn't been cleared for take-off but feared speaking up to the pilot who was the most distinguished captain in the KLM fleet at that time. The co-pilot failed to speak up to this pilot and they died, along with 500+ other people. After this disaster, commercial aviation began to work on removing the barriers to open communication in the cockpit and everyone who travels on planes benefits from this today. Building a just culture is a step towards making our care safer.
 
Humans make mistakes; this is a simple fact. But without a just culture, people who make human errors may be punished, thereby decreasing the likelihood that they will report errors that lead to harm. When errors and near misses are not reported, we miss the opportunity to learn from these events and design systems to catch the errors.

Last week, our physicians of Greater Baltimore Medical Associates spent some time learning about the Just Culture and studying examples of its application. I am very grateful for their engagement in making our care even safer than it already is.

What would your ideal primary care office look like?

I have been both a provider of care and a patient in many primary care offices. As a provider, I often thought that the way things were laid out could be improved to make us more efficient. As a patient, I have often reflected how similar all physician offices are – front desk, with or without a glass window, relatively large waiting room and exam rooms arranged along corridors.  I can remember as a physician, coming out of a room and walking down the long corridors to find another member of our team, to ask for help with something. As a patient, I was once “forgotten” in an exam room over the lunch hour (I didn't complain too much because I had back pain and lying on my side on the exam table felt comfortable).

GBMC has embraced the patient-centered medical home concept. We have taken our existing primary care offices and have used them in a new way. On a recent visit to our Hunt Valley site at mid-afternoon I noticed that the waiting room was empty….the way we want it to be because we don’t want people waiting….and I realized that the waiting room was now just a lot of wasted space.

So I am very excited to tell you about a 3P going on this week on the ground floor of the North Pavilion on the GBMC campus. A team, led by Sarah Whiteford MD, and Ben Hand MD are designing the new home of Family Care Associates, one of our GBMA practices! Drs. Whiteford and Hand spent some time last month in Seattle at the Virginia Mason Institute, part of the Virginia  Mason Health System. Virginia Mason is a national leader in patient centered care and one of the first healthcare companies in the country to fully adopt Lean as a business model. A consultant from the Institute is guiding our team’s work this week.

Dr. Sarah Whiteford (left), Bryan Niles, construction project manager (center),
 and Dr. Ben Hand (right) work at designing a more efficient office that
 will not only enhance the patient experience but create more joy for the staff. 

Do you remember what a 3P is? We discussed the concept in What’s a 3P, the blog installment of October 26, 2012, when we talked about the process for designing our new inpatient pharmacy.

3P is a lean tool that stands for production, preparation, and process. The tool helps us invent new designs that follow lean principles and drive out waste. In this case, waste is defined as anything that the customer would not pay for. Most patients will pay for time discussing their problems with their doctors but are not excited about paying for waiting rooms or filling out forms.

Most physician offices use “batch” processing and move the patient from point A to point B to point C throughout the process. You come in and you wait. You are called to register and you wait. You are then called to have your vital signs and height and weight taken, you are brought to a room and you wait. Your physician or nurse practitioner comes in and deals with you and you wait to then be checked out of the office. The time waiting is nothing more than a characteristic of the design for patient flow.

If you were going to design the process that would be used for you as the patient how would you design it? I would like to arrive, be welcomed, brought to a room, my vital signs taken if necessary and then have my physician begin the visit with me. When he or she was done, I would like to leave with my instructions for the future.

Drs. Whiteford and Hand, along with medical assistants, care managers, and other members of their team now have the wonderful opportunity of designing a space that is better able to deliver care with less waste of time, effort and resources for all - I will be excited to see what they come up with! Stay tuned.

Much to be Thankful For

Thursday is Thanksgiving and I have a lot to be thankful for. I am very grateful that I will be with my wife and children on Thanksgiving – they are the loves of my life.

I have a lot to be thankful for at GBMC, too. Last Friday, I was on a panel sponsored by the Baltimore Business Journal, discussing health care reform. While I was on the stage and listening to the conversation, I reflected on how lucky I am to have so many people in the GBMC family focused on our vision of being the healthcare system where everyone, every time, gets the care that we would want for our own loved ones. Our system has embraced the need to change. We are focused on our four aims because they are what we want for everyone getting care and for everyone delivering care – better health, better care, and lower cost with more joy for those providing the care. We are not lamenting change or struggling to hold on to the status quo. We are in action because that is what our community and our country need us to do! 

I was also very proud on Monday of this week when we hosted Carmela Coyle, the President of the Maryland Hospital Association and other leaders of the MHA at our GBMA Hunt Valley office. Our colleagues had come to learn about the transformation of our company, our accountable care organization, and how we were implementing the patient-centered medical home concept.  With the State’s new Medicare waiver, the MHA will be convening hospitals to help them transform toward managing the health of a population.  I again realized how much I had to be thankful for. 

So let me list just a few of those things here:

• The GBMC HealthCare Board of Directors who had the courage in 2010 to set a new course for our company
• The incredible GBMC Volunteer Auxiliary that is celebrating its 50th Anniversary and is made up of people who give of themselves to help others 
• Our phenomenal medical staff – because of their capabilities (once again GBMC had the most Top Docs of any community hospital in Maryland), their hard work, and their dedication our system does many things that cannot be done by others
• GBMC’s wonderful nurses – they are the core of our organization. Our nurses are smart, tireless and giving. Their work in the last year at improving our patient safety and service has been remarkable.
• Our nursing support technicians who are the face and heart of GBMC to so many patients in our hospital
• The nurse practitioners and physician assistants that work so hard to deliver exceptional care to our patients
• All of the rest of GBMC’s fantastic clinicians: therapists, laboratory personnel, and other technicians who use their expertise to improve clinical outcomes
• GBMC non-clinical personnel: from managers to patient access reps to billing personnel to food service workers and environmental service workers and everyone else who goes above and beyond for those we serve
• Gilchrist Hospice Care – our hospice along with Gilchrist Greater Living set a very high standard for patient-centeredness and the rest of our system learns from them every day
• The GBMC Foundation and its staff – where would we be without our excellent fundraising team?
• The GBMC campus – we are blessed to have such a beautiful environment for healing
• Our patients – they come to us for help and they show their gratitude even when we don’t get it perfectly right
• The staff at Einstein Bagels on the third floor of the hospital who make me smile every morning

I could make the list much longer - we really have a lot to be thankful for. Please enjoy Thanksgiving with your families, and Happy Hanukkah to all those in our GBMC family who celebrate the Festival of Lights. 

OUR PEOPLE, GIVING BACK TO OUR COMMUNITY, IN MORE WAYS THAN ONE

As a not-for-profit organization, GBMC exists to serve the community. Our HealthCare system is “owned” by the community and a group of people from our community, the Board of Directors, oversee it and hold the CEO accountable for serving the mission every day. The directors give of their time and talent to help GBMC. The Chairman of the Board, Harry Johnson, Esq., has served on our board for more than 10 years and has been involved with GBMC since the 1980’s.

Harry Johnson, Esq.

This is why many of us within the GBMC family felt privileged to have attended the Boy Scouts of America’s Whitney Young Jr. Achievement Award ceremony last week, honoring our Chairman Harry Johnson.  It was a true honor to attend this ceremony and pay tribute to a great community leader.

The Whitney Young Jr. Achievement Award is presented to a member of the community in recognition of their involvement in the development of scouting opportunities for youth from rural or low-income backgrounds. In Harry’s brief acceptance speech he spoke about his dad, who was a Boy Scout leader in Maryland in the early 1960s when Maryland was still segregated. His father led an all-black troop and had to deal with many issues stemming from racial inequality. But Harry’s father was a leader and helped these young boys, including his son, Harry, become leaders and contributing members of their community.

Harry is an accomplished attorney and partner at the law firm Whiteford, Taylor and Preston, yet he finds time to volunteer and give back to numerous organizations. In addition to serving as Chairman of the Board at GBMC, Harry is also very active with the Maryland State Bar Association including the Maryland State Bar Foundation board of directors as well as many others. Harry is a shining example of someone who has dedicated himself to giving back to the community, and GBMC has certainly benefited from Harry’s service and leadership. We are very proud of Harry and grateful for all that he has given to GBMC.

Stroke Center Award

I also want to congratulate our rapidly growing Center for Neurology and GBMC’s Primary Stroke Center which, under the leadership of James Bernheimer, MD and Tracy Lamb, MSN, CRNP, CRN,   recently received the Gold Plus award from Get with the Guidelines®. The award is given by The American Heart Association and American Stroke Association in recognition to hospitals that have achieved 85% or higher adherence to all Get with the Guidelines Stroke Achievement indicators for two or more consecutive 12 month intervals. The award also recognizes hospitals with at least 12 consecutive months of 75% or higher compliance with five or more Get with the Guidelines Stroke Quality measures to improve quality of patient care and outcomes.

This award is the result of the hard work and commitment of our entire stroke team and demonstrates GBMC’s high level of commitment and expertise in caring for stroke patients. With an aging population, we are at the ready to provide superior care to all GBMC stroke patients day in and day out. Great work!

Are our Top Doctors Speed Dating?

Once again, GBMC had more doctors recognized in Baltimore magazine’s annual listing of Top Doctors than any other community health system or hospital in the region – a true accomplishment and a testament to the top notch physicians caring for our patients. In fact, 171 members of our medical staff were named to this year’s list in 71 different specialties – truly outstanding.

But, unlike many other healthcare surveys that poll people with very little knowledge or understanding of healthcare, Baltimore magazine’s Top Doctors list is actually compiled by surveying other doctors, nearly 10,000 area physicians, in fact.

The annual Top Doctors recognition isn't another popularity contest – it’s about people who really know about the quality of care being delivered by their peers. And, it’s clear that with 171 member of GBMC’s medical staff on this list, the medical community, as well as our patient population, recognizes this medical excellence. So, when we ask people, “What if it was your daughter?” the physicians surveyed for this year’s Top Doctors recognition feel confident enough in so many of GBMC’s medical staff to send their own loved ones to them for care.

I congratulate GBMC’s Top Doctors - we are extremely proud to have such excellent, caring clinicians on our team and very grateful for all that you do to care for our community.

Speed Networking Doctors

And speaking of GBMC’s great medical staff, I had the privilege of attending GBMC’s first ever Physician Speed Networking event on November 6. Just like speed dating, 140 GBMC clinicians – along with members of the GBMC senior leadership team, service line administrators, Physician Relations and GBHA representatives attended this special “meet and greet” event.

This speed networking event was one of the best medical staff events that I have ever attended! 

The idea was born out of general “meet and greet” sessions that our HR department has held over the past couple of years for our employees to meet with GBMC doctors. The creative idea of the physicians speed networking provided an enjoyable forum for our providers to put names with faces and become more acquainted with others’ styles of practice. PCPs met with specialists who could provide further care for their patients and the specialists had the opportunity to meet the PCPs who could refer their patients.

Physicians had the chance to kick back, enjoy some great food under the big tent and not only meet their peers, but have an entertaining time doing so. It was a win-win event for all who attended and I think we all look forward to the next event!

A Peaceful End-of-Life Journey with the Help of Gilchrist Hospice Care

The first of our four aims is to be the healthcare system where everyone, every time, gets the very best possible health outcome.

And, while we are focused on restoring patients to health, we also recognize that sometimes this is not possible. When patients have life-ending illnesses, it’s comforting to know we have the experts at Gilchrist Hospice Care to guide them through and to be there to support their families.

November is National Hospice and Palliative Care Month and I’d like to recognize the excellent staff and volunteers at Gilchrist who are devoted to ensuring a peaceful and respectful end of life journey. Gilchrist Hospice Care is the largest hospice in Maryland and is repeatedly recognized nationally for its work. In fact, Gilchrist is often referred to as the platinum standard for hospice care.

To commemorate National Hospice and Palliative Care Month, I've asked Cathy Hamel, the Executive Director of Gilchrist Hospice Care, to talk about hospice and the vital role it plays in caring for patients:

Cathy says:

“Every day in the United States, 10,000 people turn 65. Seven out of every 10 Americans die from a chronic illness. A century ago, our ancestors, more often than not, died suddenly. But today, many of us have the good fortune to live longer thanks to the wonders of technology and advances in medical care.

We’re also more likely to suffer from one or more chronic illness at some point in our longer lives. As a result, we now have more choices in both life and death, and both studies and practice have shown that hospice is a wonderful alternative -- I would argue the best alternative -- for terminally-ill patients as they seek to balance quality of life vs. quantity of life. It is the former that is the focus of hospice.

If you ask most Americans to envision a "good death," they would tell you they prefer to die at home, surrounded by loved ones. Few wish to spend their last days in a hospital room, and even fewer in an intensive care unit, surrounded by machines. However, as a society, we tend to avoid conversations about death. We avoid planning for the day when we will need a feeding tube or assistance with breathing. We don't tell our family, our caregivers -- our doctors -- our wishes for care at the end of life. As a result, when those last weeks and days arrive, so many patients find themselves headed to the ICU, and more invasive, often futile treatment, against their better wishes.

Every November, during National Hospice and Palliative Care Month, we applaud those who have had what we call "courageous conversations" with their families and physicians and have created a game plan, of sorts, for their death. Every November, we encourage those individuals who haven't yet had these discussions to begin thinking and talking about their wishes for care when they are terminally ill. And every November, we recognize the teams of hospice workers -- physicians, nurses, social workers, chaplains, hospice aides, volunteers, bereavement counselors and support staff -- who are able to transform an emotionally-wrought time into a celebration of life for our families, and who are there to ensure that patients are able to approach the end of life in comfort and with dignity, surrounded by their loved ones.

At Gilchrist Hospice Care, our staff and volunteers understand that building relationships and memories with our patients and their loved ones is of the utmost importance. They understand that terminally-ill individuals still have life goals, even if time is fleeting, and they go above and beyond to help their patients achieve those goals. Gilchrist has earned its stellar reputation because of our commitment to providing individualized, compassionate care to each and every patient. The death of a loved one is a lifelong memory and we’re committed to making that memory as positive as we can.”

***
I sincerely thank Cathy and the entire team at Gilchrist Hospice Care for their devotion to making the end of life journey a peaceful and positive one for so many families throughout the years.  You can also read more about Hospice care and Cathy’s insights into end-of-life issues in The Gilchrist Blog.

Have you or a loved one been touched by the care of a hospice or palliative care team member? I’d love to hear your personal stories of exceptional care…

Change is a Learning Process

Winning organizations recognize the importance of learning. Companies that don’t learn new ideas don’t change to meet the demands of those they serve. When an organization doesn't change to meet new demands, it eventually fails. That is why we set aside time for learning.

Last Thursday, GBMC leadership had a marvelous day of learning with our teachers from Next Level Partners who taught us about focused problem solving to get better execution of meaningful change.

The former President of the Institute for Healthcare Improvement, Dr. Don Berwick, says there are three important factors required for improvement:
1. The will to change
2. Ideas
3. Execution

I have no doubt that at GBMC our people want to change. They embrace our vision of providing the care that we would want for our own loved ones to every patient, every time. We have the will to change.

I know that GBMC has a workforce made of many intelligent individuals with great ideas to improve our processes. I also know that with the Internet, many solutions are just a few clicks away. So, there is no lack of great ideas.

Our dilemma is number 3: execution. Healthcare in general has not been particularly good at executing change. Many healthcare service processes haven’t changed much since the mid twentieth century. Many companies have unwittingly instilled the notion into their people to hold on to the status quo, and to learn to deal with systems that don’t work, rather than getting them the idea that not only is it their right to fix broken systems – it is their duty.

We are implementing Lean Daily Management to change this. Since we started this technique last April, our senior team visits departments and units every day. On our daily walk, members of the unit and department teams tell us about the performance of key indicators from the day before. They tell us about the reasons why goals were missed and about their problem solving to improve the process.

A great example of excellent problem solving can be seen in the work done by both the Emergency Department and inpatient unit teams, including doctors, nurses and techs, with the help of housekeepers and transport aides, to move patients more quickly from the ED and into a hospital bed. We have reduced the time in the ED of patients admitted to the hospital by more than two hours.

So, our friends at Next Level Partners taught us more of the science of improvement to help us execute faster. It was a great day of learning for GBMC leaders. Such offsite trainings make us stronger as an organization and make our people more skilled. We all came back to work more inspired and better prepared to move us faster toward our vision.

Continuous Improvement – The Method that Will Get Us to Our Vision

GBMC HealthCare is using the management science that other excellent organizations use to provide ever-increasing value to those they serve. This way to manage, created by the likes of W. Edwards Deming and Walter Shewhart in the 20th Century, is what is helping us get closer to our vision every day. How are we doing at using this science? Well, we recently “took a test” when examiners from the Maryland Performance Excellence Awards program reviewed us. The examiners studied GBMC through the lens of the Malcolm Baldrige Performance Excellence criteria.

On October 15th, I attended the Maryland Performance Excellence Awards dinner with a group of my colleagues. GBMC received a silver award. Congress established the Baldrige Program in 1987 to recognize U.S. companies for their achievements in quality and business performance and to raise awareness about the importance of quality and performance excellence.

Forward thinking organizations like GBMC utilize the National Malcolm Baldrige Criteria for Performance Excellence to make themselves better, faster. This was GBMC’s first application for this distinction, and to be honored with the silver award recognizes the advances our organization has made in improving care to our patients. Our vision is a vision of perfection, and we won’t get there unless we use scientific management. We will apply for the award again next year, because it is a great way to learn and improve our management systems.

At the awards dinner, I had the opportunity to explain our vision to a large group of people assembled from other industries. I told them about our quadruple aim (Better Health, Better Care, with the Least Waste and the Most Joy for those providing the care) and I gave them some examples of the progress we were making. As I was speaking I realized how proud I was of everything that our people were accomplishing, but I also recognized how much work there still is to do to become even more patient-centered.

Our vision of perfection includes always delivering the correct medication at the correct dose to the correct patient. This is the definition of a highly reliable medication delivery system. Our Pharmacy team is using continuous improvement to build this highly reliable system. And, with this week being National Pharmacy Week, I asked our pharmacy team to explain their expanded role in patient care and safety.

Todd Jackson, Automation Systems Analyst, Pharmacy Informatics explains:

“In both the hospital and community setting, Pharmacists play an integral role in patient care by preventing medication errors, advising physicians on the best drug choices, safeguarding against medications allergies and drug interactions, and working with nurses to ensure that patients understand how to use their medications safely and effectively.

Several members of the Pharmacy team including (L-R):
Mahsa Mahmoudian, C.Ph.T, Nicole Garrison, R.Ph, Dana Hack, R.Ph.,
Heather Orach, C.Ph.T., Peter Furgiuele, R. Ph.
(Not pictured: Min Min Than, R.Ph., Pharmacy Director, and Todd Jackson)

Certified pharmacy technicians play an equally important role in the healthcare continuum. Incorporating a high level of multitasking ability, they are involved in compounding medications, packaging and labeling, and delivering medications.

Pharmacists and certified technicians have taken on enhanced patient care roles through the use of special technologies including DoseEdge, Medex, RobotRX, as well as the Acudose and Anesthesia RX stations.  Here at GBMC, technology is utilized at many points in the pharmacy workflow. 

Computers also help pharmacists monitor every patient’s medication therapy and provide quality checks to detect and prevent harmful drug interactions, reactions, or mistakes. But, it still takes a human being to evaluate what the computer says and to know what to do to prevent adverse medication events.”

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To move toward our vision of perfection: “To every patient, every time, we will provide the care that we would want for our own loved ones,” we must continue to have outstanding professionals who continually improve our systems. I thank teams throughout GBMC, such as our Pharmacy team, for holding themselves accountable for the attainment of our vision.

What are your teams doing to redesign systems and improve quality in your departments?

Important Insights for Breast Cancer Awareness

You may have noticed that the world looks a little more “pink” in October. This is because October is national breast cancer awareness month and to recognize the important strides GBMC’s Comprehensive Breast Care Center has made in diagnostics, treatment and overall care for our patients, I’ve asked Dr. Lauren Schnaper, Director of the GBMC Sandra and Malcolm Berman Comprehensive Breast Care Center, to be a guest blogger this week. Dr. Schnaper is nationally recognized for her breast cancer expertise and patient care and has been active in a number of national clinical trials. She was named one of Maryland’s Top 100 Women in 2010 and is passionate about sharing lifesaving information with women. I hope readers of this blog will find Dr. Schnaper’s observations on breast cancer screening and biases as enlightening as I did:

Dr. Lauren Schnaper

Dr. Schnaper writes…

The first mammograms were performed in Europe, as early as 1913.  They were not the high tech digital films we know today and did not catch on for many decades because surgeons treated all breast tumors, no matter the size or the behavior, with radical surgery.  Finding smaller tumors that might be treated with more limited procedures was a concept foreign to physicians. They believed, erroneously, that removal of as much tissue as possible was the only way of keeping breast cancer from “coming back.” That is a tenacious concept, still believed by many people.

By the early 1960s, when surgeons began to question radical mastectomy dogma, mammography was resurrected and the first screening trials began. Screening mammography was not widely performed until the 1980s.

The definition of a screening test for a population or an individual means that they are asymptomatic (no lumps or bumps, skin changes, nipple abnormality, etc).  The screening criteria also may not apply to individuals who are considered to be at high risk (strong family history or genetic mutation carrier, previous breast cancer).  The benefits (reduction in the risk of dying from breast cancer) must be weighed against the financial and non-financial costs (radiation exposure, additional tests and biopsies, anxiety, money per test).

There are two major problems with screening:  Underdiagnosis means that the mammogram failed to find a cancer that will eventually be discovered when it becomes a lump or presents with some other symptom. Overdiagnosis means: (1) that an abnormality is found that is not a cancer but is evaluated with multiple procedures as if it was a cancer or (2) a true cancer is found but one that would never become clinically significant during the indivdual’s life-time and would not influence how they are treated, how they live or die.

In America, we have trouble with the concept of costs vs. benefit.  We believe that if a million women need to be screened to save one life, then so be it.  We picture ourselves or our loved ones as that one life saved.

The non-financial costs of screening are influenced by several biases:

Lead time bias means two women develop a deadly breast cancer on the same day.  They die of that cancer on exactly the same day, five years after diagnosis.  They both have treatment but no treatment that they receive will change the behavior of their cancers or save their lives but they are not aware of that fact.  The first woman’s cancer is picked up on a mammogram in year #1 after the cancer is born.  She and her family believe that mammography has benefited her because she has had four additional years of life following her diagnosis.  The second woman never had a mammogram.  Her cancer is picked up as a lump in year #4.  Her survival appears to be shorter than that of the first woman, even though it is identical to the first woman’s.  To be effective, screening must decrease mortality from the disease, not just give the appearance of doing so.

Length time bias speaks also to the variable behavior of cancer.  More poorly behaved fast growing tumors do not lend themselves to screening as they often occur in between the screening test interval and have already spread before they are detectable.  Slow growing tumors are amenable to screening because they might hang around for a long time before doing any damage.

The concept of “early detection” is a simplistic view of a disease that has numerous and complex behaviors; no two cancers are the same.  In the extreme, a few are deadly from the day they are born but most require treatment and are ultimately curable.

Herein lies the controversy that waxes and wanes in the popular press.  Who should be screened and how often?  The United States Preventive Services Task Force (USPSTF) has reviewed screening mammography studies in 2002 and 2009.  The members took many factors into account.  In 2002, they recommended that the screening interval be changed to one to two years.  In 2009, they changed their recommendation to every two years because they saw the same decrease in the death rate in the annually screened groups as in the longer screening interval groups.  They also found that there was no difference in the chances of detecting an aggressive cancer between the one year and the two year screening interval.

The risk of developing breast cancer increases with age.  The “readability” of mammograms gets better after menopause when breast tissue goes away and is replaced by fat.  The average age of menopause in America is 52. The behavior of breast cancer is also less aggressive in older women.  The USPSTF recommend screening every two years between 50 and 74 and individualized screening for women over 74.

In women who are still menstruating, there is a lot of breast tissue which is referred to as “breast density” on mammogram – as if this is an abnormality or a disease.  It is not. The breast is a round object, compressed by the mammogram plate to be a flat picture.  The overlapping shadows of the tissue are white on the film.  Because all of the abnormalities – good or bad – are also white, they may not be seen if transposed on a white background.  Digital mammography has more contrast and is more sensitive to changes in mammograms of menstruating women or those on exogenous hormone therapy.  Again, the USPSTF recommends individualized screening decisions for women in their forties but at a two year, rather than a one year, interval.

It should be noted that the American College of Radiology, the National Comprehensive Cancer Network, and the American Cancer Society continue to recommend annual screening for all women over 40.  They do not offer an opinion as to at what age mammography screening should stop.

The National Cancer Institute advises screening every one to two years beginning at age 40.  The American College of Physicians, every one to two years age 50-74 with individualized recommendations ages 40-49.  The American College of Ob/Gyn recommends every one to two years from 40-49 and annually thereafter, with no stopping recommendation.

Interestingly, the United Kingdom National Health Service recommends screening every three years from age 47-73.

NO organization recommends a baseline mammogram at age 35.

In order for a screening test to be adopted or changed it must improve on all of the parameters already discussed.  Touted as the new era in breast imaging is Tomosynthesis or 3D Mammography.  It is a digital mammogram, that instead of taking a flat top-to-bottom and side-to-side picture, the machine swings around the breast, taking as many as 60 thin “slices” through the tissue.  This may benefit women with dense breasts on imaging as it does away with overlapping tissue shadows so that white lesions can be separated from the white tissue background.  Another advantage is that there will be fewer call-backs for additional films to evaluate vague areas of density.

Although some say there is less pain during a 3D mammogram, this is not true.  Compression is the same. Other disadvantages:  Although 3D mammography has FDA approval, there may be additional out-of-pocket expense to the patient because there is no insurance reimbursement at this time.  There is increased radiation exposure, approximately that of the old analog films, because both 2D and 3D mammograms are performed at the screening visit.  The 2D films will probably not be needed after the technology for creating a 2D picture out of the 3D slices is improved.  Radiologists have to be trained in new reading techniques and interpreting the films takes about twice as long as for the 2D films alone.  In terms of increasing ability to detect cancer or decreasing mortality from breast cancer, studies are underway.

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I thank Dr. Schnaper for her insights and continued work on behalf of all the patients who turn to GBMC for superior breast care.

For anyone who isn’t familiar with GBMC’s program, the Comprehensive Breast Care Program and its affiliated Advanced Radiology Breast Imaging Center have received national accreditation as Centers of Excellence, which speaks to the integrated and superior care our patients receive. From the Breast Cancer Risk Assessment Program to GBMC’s Rapid Diagnostics Program, our patients truly benefit from the expertise of our physicians and care providers and the advanced technology available for diagnosis and treatment of breast cancer. But, most importantly, our team of specialists takes to heart GBMC’s vision of treating every patient, every time, the way they would want their own loved ones to be treated.

Finally, GBMC is currently offering 3D Tomosynthesis Mammography at the Breast Care Center. You can call 443-279-9639  for more information or to make an appointment or visit the Comprehensive Breast Care Center page on GBMC’s website to learn more.

The GBMC System is Prepared for Maryland’s New Medicare waiver

We in Maryland are fortunate to live in a state that is willing to experiment with novel healthcare payment systems. Maryland is the only state where the standard federal Medicare hospital payment program doesn't apply, and this is because, since the mid-1970s, Maryland has had a waiver from Medicare rules that brings more than $1 billion extra Medicare dollars to the state annually. This waiver is for a demonstration project with the Federal government to test the idea that an all-payer rate setting commission in Maryland, working with hospitals, could keep the rate of increase of Medicare inpatient payments below the average rate of increase in Medicare inpatient payments in the other 49 states.

Maryland is, in fact, the only state where hospitals don’t negotiate rates with individual insurance companies. The Maryland Health Services Cost Review Commission (HSCRC) sets hospital rates. So, whether a patient is on Medicare or Medicaid, or has Blue Cross or some other private insurance, or is uninsured and comes to GBMC for care, our hospital is paid the same amount.  The HSCRC pays different rates to different hospitals.  Since the 1970’s, the federal government has been calculating the increase in Medicare inpatient costs in Maryland and comparing that to the average increase in inpatient Medicare costs in the other states and Maryland has kept its rate of increase lower. But recently, we have gotten dangerously close to exceeding the national rate of increase and have put ourselves at risk of “failing the waiver test.”

However, the 40-year-old “waiver” test is out of date.

In order for Maryland to not fail the test, in recent years the HSCRC has been increasing hospital rates in the outpatient area and holding inpatient rates fairly constant. The net effect of this, however, is to increase overall costs to Medicare. The Centers for Medicare and Medicaid (CMS) are not happy that overall Medicare costs are getting significantly higher in Maryland. This, coupled with the fact that everyone knows that our national healthcare costs are unsustainable, has made CMS believe that the current waiver test is no longer a good idea. CMS welcomed an application from Maryland for a new demonstration. So, Maryland began negotiating with the Federal government for a new waiver where Maryland would continue to have an all payer system hospital rate setting, but now, the test would be more designed to reduce all-payer hospital spending, both inpatient and outpatient and reduce Medicare costs. The Affordable Care Act created the Centers for Medicare and Medicaid Innovation (CMMI) and this agency within CMS has been negotiating with Maryland to get a new waiver that would drive towards the triple aim of better health, better care and lower cost.

The overall objectives for the new waiver are:

• To CHANGE the way we pay for and provide health care
• To BUILD on the system we have that allows hospitals in Maryland to be paid for the care of the uninsured and make it even better (e.g. more affordable, safer and to create a healthier Maryland)
• To provide the opportunity for Maryland to be a NATIONAL LEADER in health care

So, with the support of the Maryland Hospital Association (MHA), a new application is being submitted to the Federal government through the partnership of Maryland hospitals, the State and insurance companies for a new, five-year demonstration project.  The MHA has more information on this “waiver” on its website, for anyone who wants to read more about this. 

This new test will look at how we can:

1. Work together to slow growth in spending for hospital care
2. Continue Maryland’s unique way of setting hospital prices
3. Change how hospitals are paid to reward the right things (such as reducing waste and services that don’t get hospitals to a goal of better health for patients)

With this new waiver test, growth in all-payer Maryland spending per capita cannot exceed Maryland’s rate of increase in Gross Domestic Product which is projected to be 3.58% over the next 10 years. In addition, Maryland must generate Medicare savings of $330 million over five years.

Is GBMC ready for this new waiver?

For GBMC, we've been working for three years to get ready for this new payment system. We've already started transforming our company away from hospital-centric fee-for-service to patient-centric fee-for-health.

The way I see it, the only people who can truly lead the charge in this change are physicians. This is why, over the past few years, we have been working toward building a legitimate physician leadership hierarchy within our hospital, as well as establishing the Greater Baltimore Health Alliance (GBHA), our accountable care organization that is already participating in the Medicare Shared Savings program and which is made up of both employed and private practicing doctors. Following the idea that physicians must lead the change, GBHA’s Board of Directors is comprised of 75% doctors - the physicians have to, and are, redesigning the way care is delivered.

This new waiver will ultimately change how hospitals are paid to reward value over volumes. A simple way to look at this is rather than wait for the patient to get really sick and then pay the hospital to fix the problem, the new system will pay to keep the well healthy and to better manage chronic disease.

Opportunities and Benefits

The new waiver will incentivize all to do what we have begun to do over the last three years.  It will give our state, our hospitals and our communities a number of opportunities, from the ability to continue our unique hospital rate-setting system and provide more equitable care for low income and uninsured people to putting a statewide focus on quality and safety and hopefully slow the growth in insurance premiums. The drive toward less waste and lower cost will lessen the burden on employers who want to continue to provide insurance for their workers and lessen the Medicaid strain on the State budget.

This will be a challenging but very exciting next chapter in healthcare in Maryland! And, GBMC is proud to be out in front as we continue to achieve our four aims, and move closer to our vision.

The Health Insurance Exchanges of the Affordable Care Act Open Today

The lead up to the government shutdown and today’s opening of the health insurance exchanges have once again brought about a lot of talk about the Affordable Care Act (e.g. Obamacare).  Many Americans are confused about what the Act has brought and what it will bring.

It is a fact that the United States is the only developed country in the world where all citizens do not have health insurance. And, it is clear that some Americans are afraid of the Affordable Care Act in part because of the positions taken by many elected officials.

What people should understand is that several parts of the Affordable Care Act have already gone into effect:

1. The children of workers who have employer sponsored health insurance can now stay on their parent’s plan until age 26. 
2. As of January 1, 2014, insurance companies will no longer be able to deny an individual coverage because of preexisting health conditions. Until now, if you were born with or acquired a disease that would cause you to use your insurance to pay for care, the insurance company could refuse to insure you as an individual. If you were part of an employer sponsored plan or had Medicare or Medicaid, this did not apply to you and you were covered. What many people don’t understand about this part of the Act is, for insurance companies to be able to cover the cost of sick people with preexisting health conditions, there must also be healthy people in the mix. This is called community rating. As a result, the Affordable Care Act requires that everyone have health insurance – either through the government, a private employer or through purchasing individual coverage through the new healthcare exchange. This is called the individual mandate. 

Which brings us to today, October 1, the date the health care exchanges open for everyone who does not have health insurance to purchase individual coverage that will take effect on January 1, 2014. 

Mitt Romney created the idea of these healthcare exchanges when he was Governor of Massachusetts. Governor Romney thought that it was wrong that so many working people did not have health insurance and he also knew that Massachusetts hospitals had huge amounts of bad debt from individuals who got sick and couldn't pay their bills. The State of Massachusetts wound up covering this debt. Governor Romney was also concerned with the cost of health insurance for business owners who were already covering their employees and he wanted to create a true market where insurers would compete for customers and drive costs down. He also recognized that once you start requiring individuals or small employers to buy insurance, you must help them by creating a true market. President Obama’s people later recognized that the notion of health insurance exchanges was a good idea, which is why it is part of the Affordable Care Act. And again, individuals with preexisting conditions will not be excluded (which is great).

One of the big misconceptions of this law is that it contains “government run” healthcare. There is NO provision in the law for the government to provide care. 

Our government already purchases care for everyone over age 65, which is called Medicare. It purchases healthcare for many of the poor and disabled along with the States through Medicaid. Our government purchases care for federal employees. It is true that our federal government already provides care directly to our veterans through the Veteran’s Administration (VA). In fact, the VA, the military medical systems, and the National Institutes of Health are the only organizations where government employees provide care. There is NO new government run healthcare within the Affordable Care Act.

Additionally, one of the major portions of this act that has already taken effect is the Medicare Shared Savings Program. The GBMC Healthcare System is participating in this program through the Greater Baltimore Health Alliance (GBHA) which we created in 2011. The Board of GBHA is over 75% physicians with Dr. Anthony Riley, head of geriatric medicine at GBMC, as the Chairman of this board.

The incentive here is for doctors to work towards the triple aim for those with Medicare:

1. Better health and health outcomes for the Medicare beneficiaries
2. A better care experience for Medicare beneficiaries
3. Lower costs for beneficiaries and the Federal government

Early first year results for GBHA’s participation in the Medicare Shared Savings Program shows that we have saved about 7% per beneficiary. If we improve our quality parameters and save money, some of the savings are then shared back with the doctors participating in GBHA and GBMC.

This is another part of the law that I think is good for Americans. It’s driving value in healthcare. Notice that there is no money given back to the providers unless the quality and patient satisfaction goals are achieved and money is saved. Most people believe this is good because if we don’t drive Medicare costs down, we could bankrupt the country.

Every American has the right to dissent – it’s one of the wonderful things about our country. But every American also has the duty to review the facts before they make up their minds.

So, regardless of what happens (although it does not appear there will be changes to the Affordable Care Act) GBMC will not deviate from its vision – to treat every patient, every time the way we would want our own loved ones to be treated. And we will continue to measure our progress towards our four (or quadruple) aims: better health, better care, with the least waste, and the most joy for those providing the care.

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Babies small and grown who were born at GBMC and parents of GBMC babies 

Finally, this past Saturday, GBMC’s Foundation held its 13th annual Legacy Chase at Shawan Downs. It was a fine fall day in the sun celebrating our vision and commitment to families and the community. Through the 2013 Legacy Chase event we have raised more than $1 million in commitments toward the Endowed Chair in Pediatrics. Close to 8,000 people came out to support this great event which also included several special reunions. This year marked the second year of our annual NICU reunion to celebrate the milestones of our smallest patients and GBMC’s volunteer auxiliary also celebrated its 50th anniversary! And, we had a wonderful group photo taken of babies born at GBMC (above) where several generations made this reunion truly special.

I thank all those who attended and all those who donated time or treasure. Kudos to the GBMC Foundation for another successful, fun-filled event. There’s still time to support the cause by visiting http://foundationevents.gbmc.org/.

Perfecting the Hand-Off – to Better Coordinate Care

Our vision is to treat everyone as we want our own loved ones treated. Most of us have had loved ones with some chronic disease where our loved one was caught between providers of care and we had to try to bridge the gap. I often get calls from family members asking me to help resolve differences of opinion between providers. I have told the story of a woman who was admitted to the medical intensive care unit at GBMC with diabetic ketoacidosis because her insulin plan was wrong. Our physicians and nurses got her back on her feet and discharged her to the care of her doctor. Unfortunately, her doctor put her back on her previous plan and she ended up back in the Emergency Department. It seems that her doctor did not get the message about her new plan at the time of her discharge. A clear lack of coordination.

How do we fix this? 

Well, the improvement has to start with someone being willing to coordinate the care. This is why the GBMC HealthCare system has embraced the concept of the patient-centered medical home (PCMH) because the physician-led team knows that it is accountable to provide the coordination 24 hours a day, 365 days of the year, and actually has the capability to do that! Also, the other members of the healthcare system must work with the primary care teams at the time of handoff, like when a hospitalist is discharging a patient from GBMC back to the primary care physician.

The Head of the GBMC hospitalist group, Rekha Motagi, MD, and her team have been working tirelessly to improve the handoff back to the primary care doctor. You can imagine that communicating to literally hundreds of different doctors and offices can be quite a challenge. Rekha and her colleagues have been redesigning their communication process and measuring its performance as a measure on their Lean Daily Management board. Every day on our management rounds, Rekha or one of her hospitalist colleagues and members of our two internal medicine resident teams, report on the percentage of the previous day’s discharges where they have had a high quality communication with the primary care physician or his or her office staff. As a result of their work, they rarely miss a handoff with a GBMA PCMH practice and we are seeing improvement with our non-GBMA practice colleagues as well.

I’ve asked Dr. Motagi to explain the obstacles that have been identified and the improvements that have been made in the transition of care since the team started testing changes:

Rekha Motagi, MD

Dr. Motagi explains: 

The hospitalist group has always made it a priority to communicate with a patient's primary care physician to provide verbal hand-off when patients are discharged from the hospital. This is a very important aspect of the transition of care. Reviewing a patient’s hospital course, medication changes, test results and pending tests during this hand-off is also an important patient safety measure.

Previously, we were not sure how consistently this hand-off communication was occurring in our large group and the reasons we were not always successful. But since we started the lean daily management process, where one of our metrics is for each physician to note if they have been able to reach the PCP for discharge hand-off, we have identified several areas for improvement.  

About 90% of the time, our doctors have made an attempt to reach the patient’s PCP; but we've only connected with them from 50-70% of the time due to various reasons including:

• Offices were closed or the front office did not want to interrupt the PCP. In these instances, we left a message but were not sure if the PCP received it (This becomes much more challenging on weekends/holidays.)
• We have been put on hold for 10 minutes or more; in many instances, our doctors have had to hang up because they needed to respond to other calls
• The PCP was on vacation, so there was no way to ensure they received the message
• There is no attempt made to call when there is no PCP or if the patient is going to be transferred to a facility and no provider in the facility has been identified

Since we started Lean Daily Management, the physicians relations office (Mary Ely, Ann Veltre and Bonnie Longerbeam) has been working to reach out to several physician groups to obtain their feedback on the best ways to accomplish a successful transition of care. What we've found is that there are some PCPs who are very involved in their patient's hospital stay. Some are interested in receiving the call from the hospitalist, but only call back if they have questions. From this outreach, we've been able to make improvements and design a more effective system for coordinating the transition of care, including:

• Obtaining back-office telephone numbers for PCPs (and in some cases cell phone numbers) which provides us with faster access to some of the PCPs
• Updating incorrect physician office numbers in our database 
• Identifying physician offices that have care co-coordinators (RNs) who will take the patient’s information, relay it to the PCP and contact patients to arrange follow-up

We are now working with all primary care providers to further standardize this process. Our group is also committed to making sure the written communication (discharge summary) is completed within 48 hours of a patient being discharged. Currently, we are over 95% compliant with this effort and we are working to get this rate to 100% so that the information is there for the PCP to use in follow-up.

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I want to thank Dr. Motagi, our hospitalists, our internal medicine residents, the physician relations group and our PCPs for their commitment to creating a more reliable system for patient hand off. Continuous improvement requires a focus on who it is that we are serving, system design, measurement, teamwork, and empowerment. Lean daily management appears to be helping us speed up the implementation of all of the above!

Honoring, Remembering One of GBMC’s Founders, Mrs. Jeanne H. Baetjer

Last week, GBMC lost an inspiring and visionary leader. Mrs. Jeanne H. Baetjer, one of GBMC’s founders, passed away at the age of 91 years. What a legacy she left behind. Mrs. Baetjer was a true leader in every sense of the word. Her strong sense of community was quite evident in her life’s work, which included her vision for the development of a community hospital in Towson.

In 1958, while serving as President of the Hospital of the Women of Maryland, of Baltimore City, Mrs. Baetjer and other community leaders saw the need for a hospital in this area and set out to work on making this vision a reality. This was no small feat as the creation of GBMC entailed combining The Hospital for the Women of Maryland, of Baltimore City (Women’s Hospital) with the Presbyterian Eye, Ear, and Throat Charity Hospital. But, her tenacity and dedication to filling a greater community need paved the way for the establishment of our hospital, and from 1962 to 1965, while building was underway, Mrs. Baetjer oversaw the massive project. Her commitment to GBMC spanned five decades and she served in various roles in our history including the very first President of the Board of Trustees.

Since GBMC first opened its doors to the community in 1965, we have cared for countless individuals and we are forever grateful for Mrs. Baetjer’s vision and dedication. Her impact on GBMC and the community is immeasurable and far reaching. To this day, GBMC embraces her guiding principle that the patient always comes first– through our current Vision of “to every patient, every time, we will provide the care that we would want for our own loved ones.”

Please join me in honoring her life and legacy by sharing your memories and thoughts about Mrs. Baetjer with our blog community.

What can we do to make GBMC safer for our people?

Our fourth or “quadruple” aim is more joy for those providing the care. All of us in our healthcare system should derive joy from serving those in need. But how can work be joyful if it is not safe? Safety on the job is surely relative. There are many jobs that have higher risk of injury than working in healthcare. Nonetheless, it is unethical to not be working toward zero injuries among our people.

The run chart below shows the monthly number of injuries reported to employee health. 

In fiscal year 2013, which ended on June 30th, we had 327 injuries. That number is an improvement of 12% from fiscal 2012’s 370 injuries. We have set a goal of no more than 294 injuries in fiscal 14, a further 10% reduction. Our Senior Executive Team receives a daily report of the number of employee injuries in the preceding 24 hours and measures this on our Lean Daily Management board. We are driving toward a goal of zero injuries.

The injuries can be grouped into a number of large categories. The most dangerous of the injury groups is the needle stick/body fluid splash category. Being injected with hepatitis C or HIV contaminated blood can lead to a lifetime of therapy and/or long term morbidity. These injuries can be prevented by using the appropriate safety devices like needle-less systems, needles with protective sheaths and protective eyewear. A respiratory therapist was recently exposed when the therapist did not use protective eyewear when inducing cough in a patient.

System design is also important. Standard work in the passing of sharps in the operating room is critical to reducing needle stick injuries. Recently, a resident physician stuck himself with a contaminated needle because he used his fingers rather than pickups to reposition a needle on a needle driver.

Another category of injury among workers at GBMC is sprains and strains, usually from lifting. With the national epidemic of obesity, it is very important that we use the appropriate lifting devices to avoid musculoskeletal injuries. Slips and falls is a category of injury that usually occurs from spills that go unnoticed or from workplace clutter. An employee recently fell after tripping on an exposed electrical wire. Our IT Team has recently been doing environmental rounds to make sure that computer and printer electrical cords are not creating tripping hazards on our units.

Our last major category of injuries is those due to workplace violence. We have made some progress in this area by implementing training for employees in high risk areas like the Emergency Department and also by stationing a security guard on Unit 36. There are other injuries that don’t fit into common categories like the employee who was recently harmed when a swinging door came off its hinge.

So what can we do to drive towards zero workplace injuries? First, we can make sure that we are following safe practices and using protective devices when appropriate. Secondly, we can report all injuries and participate in the learning from injuries to make our systems even safer. Thanks very much for sharing your ideas on how we can reduce employee injuries in the GBMC HealthCare system.

A Day of Remembrance

Finally, tomorrow is a somber day for our nation as we remember those we lost on September 11, 2001. It’s hard to believe it has been 12 years since that tragic day in our country’s history. We should all take some time out of our daily lives to reflect on the sacrifices made by our first responders and every day citizens. Instead of focusing on the inhumanity and the horror of the day, let us focus on the many stories of hope and humanity that we witnessed as people came together to help others in any way possible. It’s the examples of humanity that keep us strong and we hope that by remembering incidences of the past, we can grow and change to create a better future. My thoughts are with everyone touched by this tragedy as we remember and hope for a more peaceful tomorrow.

A Reflection on the Meaning of Labor Day

As our country celebrated the hard work of the American people during the Labor Day holiday on Monday, many of us enjoyed the three-day weekend which has also come to symbolize the unofficial end of summer. But, Labor Day is also an opportunity for us to reflect on what we have accomplished and will continue to achieve, and to thank the people that make our health system and our country strong because they go to work every day and put their best efforts toward serving a need. At GBMC, we are fortunate to be able to meet the important need of helping others by delivering to everyone the care that we want for our own loved ones.

And as I reflected on the true meaning of the Labor Day holiday, I realized how thankful I was for the efforts of the entire GBMC staff - from the doctors, nurses, and technicians to our food services workers, environmental service staff and parking attendants.  Every individual at GBMC is an important part of the collective team and I see the great efforts our team puts forth to provide the very best care to patients every day.

I also reflected on what it means to have a job, especially with the way our economy has been over the past six years or so. Now that I have four children who have graduated from college, I see how hard it is to find a good job that you love. I am grateful for my job, which I competed for and was delighted to get. GBMC is a great organization with a great vision and a great future. I know what it means to love what you do and I am honored to work with such dedicated individuals.

I have been talking a lot about standard work, processes and systems, but as we celebrate Labor Day and look ahead I need to remind myself that what makes a healthcare system truly outstanding is not the technology or the facilities, but the people.

“I Think They Forgot to Reset the Bed Alarm.”

Recently, a man and his daughter came to see me in my office. They were upset because their wife and mother had fallen and broken her hip while an inpatient at GBMC. She had come in for an elective surgical procedure and was a bit disoriented post-operatively. A unit staff member had helped the patient out of bed in the middle of the night and had then assisted her back into the bed. Sometime later, the patient tried to get out of bed again to visit the bathroom and fell, fracturing her hip. It seems that the staff member who helped the patient out of bed had forgotten to reset the bed alarm so that when the patient got up on her own, the alarm did not sound and the staff was not alerted to the impending danger. The staff had correctly identified this patient as high risk for falls and had the appropriate equipment for fall prevention in the room.

Reliability means what should happen, happens, and what should not happen, doesn't. In this case, a woman under our care fell and sustained a serious injury. This should not happen. But why did it happen and what should we do to make sure it doesn't happen again?

Our Falls Team has dramatically reduced the number of falls at GBMC. Preventing falls in the hospital, especially among the physically compromised, is very difficult. It requires vigilance among the staff, and standard work using evidence-based care to do this. One miss, as in this case, can cause serious injury. Until a few months ago, we had high defect rates in the use of all of the important safety devices (alarms, socks, wrist bands, and signage) on some days on some floors. Now, it is very unlikely that a high fall risk patient doesn't have all of the equipment in place. But even with the equipment in the room, most of our beds have alarms with a design flaw: to take a patient out of bed safely you first shut off the alarm, and when you put the patient back in the bed you have to remember to turn the alarm back on.

These bed alarms are examples of active safety devices. The problem with such devices is that they require an action on the part of a human to operate correctly. But humans are not perfect and they sometimes forget, especially when busy caring for many patients at once. If our nurses care for 80 patients a day with bed alarms, and the patient gets out of bed five or six times a day, that’s almost 500 times a day the staff must remember to reset a bed alarm. Our nurses and technicians work so hard it is easy to see how one of them could get distracted and forget to reset the alarm. But if we get it right 499 times out of 500, and the one time we miss results in a patient injury, we still have to find a way to get to perfection.

In the old days, our reaction here would have probably been to reeducate the staff on the importance of resetting the alarm. This action is silly at best. When our staff gets something right 99% or more of the time, is it that they don’t know that they should reset the alarm? Of course not, it’s that they forgot, so education is not likely to fix the problem.

High reliability organizations search for passive safety devices – ones that don’t require human action and therefore are much less likely to fail. As a pediatrician who has treated a number of drowning victims, I recall when gates in fences around pools used to require an adult to remember to pull the gate shut to keep young children from wandering into the pool area unattended. Now, most pool gates have a spring that pulls the gate back into the closed position and a self-catching lock…the gate shuts itself after someone enters. Our falls team recognized that even the smartest, hardest-working staff member will eventually forget to reset the bed alarm. GBMC is now beginning the replacement of our beds and purchasing new beds that have alarms that reset automatically. We now have a number of these beds already in place. In the interim, the Falls Team continues to test ways to “catch” that someone has forgotten to reset the alarm.

To err is certainly human; but as humans and as healthcare leaders, we have the ability to redesign our systems so that common human errors are blocked or mitigated before they cause harm. We must study every event and find new ways to make our GBMC HealthCare system safer every day.

Let me thank everyone in the GBMC family for helping us get to higher reliability and closer to our vision.

GBMC’s Annual Goals – How We Know If We are Getting Closer to Our Vision

The GBMC HealthCare System has a vision of perfection. Our vision is to deliver the care that we want for our own loved ones to everyone, every time. Since we are human and our designs are created by humans, we know that we will never truly get to perfection, but we accept that we must keep getting better. So, how do we know if we are getting better? We see where we are at the end of every fiscal year, we set goals for ourselves, and we then measure our performance on a regular basis (at least monthly) - and we keep score!

At GBMC, we work throughout the year to improve in our four Aims (the areas that best describe the care that we want):
1. Best health outcomes
2. Best satisfaction
3. Least waste
4. Most joy for those providing the care

As we begin this new fiscal year this summer, it’s a good time to look back over the last couple of years to see how far we have come. I am happy to report that year over year, GBMC has seen improvement in most of our aims, but not for every measure, and we still have a lot of work to do:

GBMC annual goals-  Click image to enlarge

Under the Aim of “Best Health Outcomes,” we saw significant improvement in the number of “good catches” and reported events that allow us to ensure patient safety and implement important safety measures. We also reduced total incidents of harm from 190 incidents in FY’ 12 to 96 in FY’ 13, and our plan is to decrease the number of incidents even further in FY’ 14. Again, this reduction is due in large part to the safety processes and redesigned systems put in place by our team members.

If you look at the aim of “Most Joy,” we are focusing efforts not only on reducing employee injuries but also improving our employee and physician satisfaction. We know that when our employees and physicians are satisfied and happy with their work and work environment, our patients truly benefit. We’re still waiting for FY’13 actual scores, but I’m confident that we will meet our goals in this area.

Meeting our annual goals, and in some cases exceeding them, is a result of the hard work and dedication of our staff as well as new processes and redesigned systems that have enabled us to work more efficiently and effectively for our patients. The results show that new initiatives and redesigned systems help us ensure better health outcomes, while improving patient satisfaction, reducing waste throughout the system, and increasing the joy our staff experience delivering the high level of care.

I thank all GBMC employees for doing their part to help ensure we keep moving toward our vision, and ask that everyone continue to work toward even better results in FY’14.

Finally, I’d like to welcome to the GBMC team, Tanya Townsend, who recently joined us as Vice President and Chief Information Officer. She comes to us from Wisconsin where she was the Chief Information Officer at the Eastern Wisconsin Division of the Hospital Sisters Health System in Green Bay. Tanya’s background as a leader in healthcare IT and her experience with standardizing systems will surely benefit our organization. Please join me in welcoming Tanya to the GBMC family.