The Quadruple Aim on Unit 36

I have the pleasure this year of being the GBMC Senior Team member who is assigned to Unit 36. Each of us on the Senior Team works with two units to narrow the gap between what the “front office” knows and what the “front line” knows.

Unit 36 is our Medicine/Psychiatric Unit. The Unit cares for people with mental illness who also have acute medical needs. The leadership dyad of Nancy Amann-Santos, RN, the unit manager, and Darin Lerner, MD, the medical director, are two of the most dedicated people I have ever met. Everyone who knows anything about healthcare knows how challenged our mental health system is. Nancy and Darin deal with this dysfunction everyday and they never lose sight of the reason why they and their Team are there…to deliver the care to their patients and families that they would want for their own loved ones.  But boy is it hard!

This morning I went to the Team huddle at change of shift at 7:15 AM. Nancy showed me the Team metric board that showed, among other things, recent hand hygiene audits that were at 100% compliance and many days of no patient falls with injury. I then listened while the staff debriefed on an incident where family members who were not associated with the same patient but who evidently knew each other, got into a verbal altercation on the Unit.

Trina Griffin, RN explained to the group how she had acted to deescalate the situation, avoid getting the patients upset, and get the visitors to act appropriately. The Team quickly brainstormed on other things that they could change to avoid this type of problem in the future. They then discussed two other patients: one who was admitted with a significant medical problem but who also had obsessive compulsive behaviors and the other who could not understand why it wasn’t safe for him to get out of bed by himself.

Working on an inpatient unit where the patients understand the care and are generally grateful is hard enough – dealing with the same issues in a population who does not always understand and who may take actions to harm themselves or others takes it to a whole new level. The Unit 36 Team comes to work every day to get to better health, and better care with less waste for their patients. You can feel their joy in knowing that what they do means so much to their patients and families, even if the patients….and sometimes the families…don’t always understand. I am very proud of them and very grateful for all that they do. 

It Should Be Easy to Move an Admitted Patient from the ED to a Floor Bed….Shouldn’t it?

This week a Team of GBMC people spent 5 days studying our system from when a patient is first seen by an Emergency Department physician until those that need to be admitted to the hospital are actually in an inpatient bed.

The Team was chartered because we identified this as a strategic opportunity for improvement when we created our operating plan for this fiscal year. We set a goal for ourselves to reduce the average time from when a patient arrives in the ED until they are in an inpatient bed from 8.5 to 6.8 hours… a reduction of 20 percent. 

GBMC HealthCare set this goal because our patients get very upset when they are still in the Emergency Department long after they have been told that they need to be admitted. This is no surprise. Almost every adult has accompanied at least one family member who has waited in some ED to be moved to an inpatient bed. If we don’t want this for our own loved one, no one should wait. Not to mention the cost to our system of extra staffing and foregone admissions when other people leave our ED and go somewhere else for care.

The Team included doctors and nurses from the ED, hospitalists and inpatient nurses, secretaries and people from many support services. Their mentor was Neil Crockett from Next Level Partners and they were aided by a number of our Performance Improvement Masters. After getting some training, the team set out to study the current processes. They went to the ED and the inpatient floors and watched them and documented the way they were doing things. The Team identified 89 sources of unnecessary variation and waste.

They were amazed that for almost every step that they studied, each person doing a task was doing it differently.  They then identified 56 actions that they could take to redesign the processes within the system.  The Team then divided these actions into things that they could change right away: “Just do it’s”, things that they could test immediately (trystorming), and more complicated things that could be changed over time. They immediately implemented the “just do it’s” and began implementing the things that seemed to work in the “trystorms”.

I went to the final Team report today and was amazed at how much they had accomplished. Every team member had a greater understanding of how the other team members were doing their job and how complex the system of admitting a patient from the ED actually is.

There is a lot of work to be done to redesign healthcare in our country and in the GBMC system. When we talk about delivering better health, better care, and lower cost, the uninitiated believe that this means more work for those providing the care. It is only when they develop the deeper knowledge of what is going on in our existing system that they see that a lot of what they are doing is not really benefiting anyone and if they do the work of redesign, they will accomplish better health and better care with less work.

It was really exciting to see that this was one of the learnings from the Team’s efforts this week. I am awed by what they accomplished and am more excited than ever about the transformation of the GBMC HealthCare system. 

Perfection

Our GBMC HealthCare system is working towards a vision of perfection. When we strive to give everyone the care that we would want for our own loved ones, every time, it is perfection that we are after. When I say this to people, I always add that we will never quite get to perfection because we are human and as good as we can make them - our systems will still be fallible.  There will always be at least a few holes in the “Swiss Cheese”. So when we do get to perfection, even if it is just for some subset of our patients on one parameter I am surprised and delighted!  

I am happy to report that Unit 58, our Joint and Spine Center inpatient unit, has achieved perfection in hand hygiene in January and for two of the last three months. The team, under the direction of nurse manager Conchetta Jackson, RN and medical director Lee Schmidt, MD are doing great things. In January, the secret auditor watched 45 separate incidents of a staff member walking in and out of a room and the individual cleansed his or her hands every single time! This is not easy! When people are busy it is very hard to not slip at least once in remembering to clean their hands so as to not spread germs from one patient to another…but they did it!

In addition, 5 different “disciplines” also had a perfect score in January. They were: Nutrition/Food Services, OT/PT, Phlebotomy, Radiology, and Volunteers. My hat is off to these colleagues who are doing great things to keep our patients safe.

Purple Baltimore

While I am congratulating folks, I would be remiss if I didn’t congratulate Ray Lewis, Joe Flacco, Anquan Boldin and the rest of the Ravens. It was a great game and although I would have preferred the game to have ended at halftime, I was delighted with the final score. I felt sorry for the people operating the Superdome, we at GBMC know what it is like  to deal with power outages!

Standardizing The Work Of Rounding

Humans do things in batches to make the most efficient use of their time. Years ago before I paid my bills on-line, I would put them in a pile on my desk at home and then write the checks all at once towards the end of the month rather than getting the checkbook out every day when each bill came in. This made sense if my goal was the efficient use of my time. However, “batching” is a huge problem in large complex systems because the “downstream” process is often idle, waiting for the batch to be run.

“Batching” is a big problem in healthcare. (See: “Getting Better at Getting Better” and “Using Technology and Standardized Work to Make Care Easier and More Reliable”)  I remember when I was a practicing pediatrician and was caring for inner city children with high environmental exposures to lead. I would see a child on a Wednesday and have to wait a week for the blood lead level because the test was only done on Tuesdays. Occasionally, we would find out that a child had very high levels of lead 7 days after I should have admitted him to the hospital for treatment for acute lead toxicity. The tests were all done on one day because it made sense for the lab….but it didn’t make sense for the system that was trying to take care of the children.  The system would have been better served by the tests being done one at a time as they were needed by the physician to make the decision to help the patient.

At GBMC, we too have problems created by batching. One that we have committed to fix in this fiscal year is the problem of admitted patients in the Emergency Department waiting to go to an inpatient bed. The rate of arrivals of patients to the ED starts picking up around 8 in the morning. By late morning, there are a significant number of patients who have been identified for admission at GBMC as in most hospitals in our country.  But in almost every hospital in our country, few admissions actually leave the ED until late in the afternoon or early evening. Why do they wait? Well, there are a number of reasons but the most common is that they are waiting for a discharged patient to leave a bed in order for the bed to be made ready for the next patient. Why are the patients not leaving sooner? Well, again there are a number of reasons, but the single biggest reason is that the doctors, nurses, and other clinicians have not yet done the work of discharge.

Late last year, we did a value stream analysis of the work required to discharge a patient and physician rounding was identified as a significant opportunity for improvement. The long wait time for a patient waiting to go home is nothing more than a characteristic of the system that we have designed to discharge them. Our doctors and nurses are working very, very, hard. It is not about them, it is about the system. 

If you were waiting to drive your mother home from the hospital and you were told early in the morning that she was ready to go but that it was going to take until the late afternoon before the team could do the work required to discharge her, you would not be happy. We owe it to our patients and their families to redesign our systems when they are not meeting our needs. Our vision is “to every patient every time we will provide that care that we would want for our own loved ones.” And, we don’t want our patients waiting unnecessarily.

I’m excited to report that last week we did a weeklong Kaizen event (a review by staff to reduce waste and improve efficiency) on physician rounding. A team spent a week studying physician work on the medicine hospitalist service and the medicine resident service and they mapped all of the daily work and then started testing changes to that workflow.  Team members were Jeff Biedronski, Michael Finegan, Lisa Griffee, Stephanie Mayoryk, Dr. Fred Chan, Dr. Ezza Khan, Dr. Rekha Motagi, Dr. Eugene Obah, Dr. Sajeet Sohi, Kathy Bull, Keith Jackson, Deb McCaffrey, Cate O'Connor, George Bayless, and Dr. John Saunders. The Team began with the evidence- the data on when physicians write the discharge order (peaking at 2 PM) and when patients actually leave (peaking at around 4 PM).

Their work included trying to plan the evening before who would be ready to leave the following morning; improving the signout from physicians going home in the morning to those coming in; and planning discharges to do a few each hour rather than all at once.

This work is very exciting because it “smoothes” or “load levels” the amount of work across the daylight hours, so if a patient is ready to go home early in the morning, they can, rather than have everyone go home in the afternoon. This effort is another example of GBMC learning to utilize engineering concepts as we standardize our work toward our goals.  It’s not about relying on hard work and good intentions alone, nor about telling doctors and nurses to work harder and faster. I am so excited to show you the same graphs as above on the second day after the team implemented some changes!

Our goal is not for everyone to go home in the morning, rather the goal is for everyone to home as soon as possible after they no longer need to be in the hospital.  We look forward to making this goal a reality in 2013.

Welcome to the GBMC Family
We have some very exciting news to share!  We recently received commitments from two local outstanding physicians to join the GBMC Medical Staff. Drs. Michael Sellman and James Bernheimer will join the Department of Medicine as employed members of GBMA and will be leading our Division of Neurology and nationally-accredited Stroke program beginning July 1.  This is an exciting and important event for GBMC as we build a strong hospital-based neurology practice.

Go Ravens!
One final thought for the week – Go Ravens!  The GBMC family wishes the best of luck to our Baltimore Ravens in this weekend’s Super Bowl XLVII.  Hopefully many staff, patients and visitors have enjoyed the lights, banners and other “Purple Fever” activities throughout the GBMC HealthCare system this week and I look forward to celebrating a victory for the Ravens on Sunday night!