Following the Design and Doing Standard Work….It’s a Mindset Change

Getting every patient what he or she needs requires a large, complex system. In complex systems, the actions of one individual can have dramatic effects elsewhere in the system but since those effects are often not seen, the individual has no idea what they caused. As an example, when a nurse takes a medication from another patient’s bin because the medication is not in his patient’s bin and it is time for his patient to get that medicine, it seems like the appropriate thing to do. The move is well-intentioned. His patient needs the medication and the nurse is “doing whatever he needs to do to get whatever his patient needs.” What the nurse does not see is the effect, a few shifts later, when the second patient doesn't have the medicine in his bin and the pharmacy believes that he does. In unreliable systems, people begin gaming the system to get what they need, thereby making the system even worse.

In a hospital, the notion of moving toward a system of standard work and following a design is so important to making the work easier and ultimately the care of patients better.

It is time to change our mindset.

In our LEAN daily management rounds, we visit a number of units and departments to learn how those units did in the preceding 24 hours. These rounds show us just how hard all of our people are working to get the job done. Unfortunately, a lot of time is spent in working around broken systems. Through the LEAN rounds I have learned that on average, units are searching for a medication that should be there but isn't on the order about 15 to 18 times per day. This is not right. Our nurses should have the medicine they need every time. Rather than having them spend their time in the daily workarounds of broken systems, we need to get them energized about problem solving and redesigning those broken systems.

It is hard to get clinicians, especially doctors and nurses, to believe that following the design and doing work in a standard way will actually improve things. This is the reason why it is so difficult to change the mindset from “I do it whatever way feels right to me,” to “I do it according to the designed system.” They don’t trust that following the design will make it easier for them because the systems have not been reliable enough for them in the past. They believe that following the design will make their work harder. It’s a Catch 22 of sorts.

This is not about working even harder, it’s about working differently. 

We have some great examples of problem solving and change. This move toward standard work has already been successfully implemented on a number of our inpatient units and departments. One of those units is Unit 38. Clinical Partner Kim Vohrer and Administrative Director Justine Kellar have led their team to dramatic improvements in the availability of devices for patients at high risk of falls. These two leaders have really done well at helping their people become problem solvers and to redesign systems to make the work easier and get to better results. Kim and Justine also understand that the mindset change of standard work is hard and that managers need to check back to see that the design is actually being followed.  It’s not realistic to expect people to get into this high reliability mindset from the get-go. Kim and Justine have realized that the verification step is critical - so they now do spot checks of the standard work on their unit. And when they see that the design isn't working, they coach their team, or learn from others about how to improve the design.

Similarly, I’m incredibly impressed with Kathy Bull and her team on unit 35 for implementing the standard work of calling the Emergency Department within 15 minutes of the patient being ready to move to “pull” the patient to their Unit. This new design is having excellent results in reducing the time that an admitted patient waits in the ED.

I believe that if we work differently, we’ll realize that we’re not working harder, but more effectively. This is the power of a designed system where everyone does the standard work. It can be done. We’re seeing the positive effects on Units 35 and 38.

Think of moving from a bunch of smart people working very hard but each doing things their own way toward the new model of standard work as going up a very steep hill; right now, we’re half way up this hill, and if we can just get the courage to forge forward, we’ll make it to the top instead of sliding back down to where we began. Thanks to everyone for helping us on this journey towards higher reliability.

Moving Upstream in the Fight Against Disease While Improving the Health of Our Community’s Children

As we continue to build our system of care it is important for us to begin to focus on prevention. The  GBMC system has taken an important step to reduce the rate of childhood obesity by partnering with West Towson Elementary School in an exciting initiative.

This all started over a year ago when GBMC was invited to participate in the Baltimore County Healthcare Coalition. As part of the Affordable Care Act, all states began creating plans to improve the health of their people.  Maryland turned to the counties to conduct an assessment of the health of the county and roll out a plan for improvement. So the Baltimore County Healthcare Coalition was formed and began work on three important health initiatives

1. Tobacco cessation
2.  Reducing childhood obesity
3.  Reducing low birth weight

As a member of the committee to reduce childhood obesity, I realized how important it was to roll up our sleeves to do something tangible. So when the time came, we jumped at the opportunity to work with Baltimore County Schools and to partner with West Towson Elementary School, and their wonderful school nurse, Lisa Vanderwal. You see, they had a significant need. They had run an afterschool fitness program last year for girls, but did not have enough resources for the boys too. So, GBMC committed to running a fitness program for girls and boys at risk for childhood obesity. 

Thanks to two of GBMC’s nurse leaders - Cate O’Connor-Devlin and CJ Marbley – and GBMC employees who volunteered to help including Laura Mitchell, RN and her 16-year old daughter, GBMC kicked off the Westy’s afterschool fitness program, PlayFit, on May 8. The program is designed to attract the kids at risk for childhood obesity. The children are all fourth graders and out of 98 children, approximately 30 are participating in PlayFit. One parent of a student participating in the program commented in an email to Ms. Vanderwal, “I wanted to let you know that D really enjoyed Wednesday's PlayFit – and he was really reluctant! Thank you so much!”

They are off and running, literally, and our staff and the kids alike are having a great time while getting fit and healthy. We also sponsored Westy’sWalk on May 19^th at Loyola-Blakefield which further encouraged fitness and fun.

And, best of all, this six-week fitness program will culminate with the kids walking in GBMC’s 25^th annual Father’s Day 5K  event on June 16^th . At the event, we’ll be sure to draw special attention to the kids and all they have accomplished – go Westy’s!

This effort goes to show that GBMC as a system of care has become involved in prevention of disease – childhood obesity for starters. We heard what some of the County’s issues were and took a step to enact a healthy change. We’re certainly proud of our partnership with the Westy’s and in our work with the coalition.

And speaking of the Father’s Day 5K and 1 Mile Fun Run – it’s the 25^th anniversary of this special event that raises much needed funds for GBMC’s Neonatal Intensive Care Unit and premature, sick babies. The event is on Sunday, June 16^th and there’s still time to register and donate. Click here for all the information.  

In other news, I am very pleased to announce that GBMC Healthcare has come to an agreement on a new one-year contract with 1199 Service Employees International Union United Healthcare Workers East (SEIU). GBMC has about 480 employees who work in bargaining-unit eligible positions. I thank the many GBMC and union leaders who worked tirelessly together for months to come to a mutually agreeable settlement that will no doubt benefit our union employees.

And finally, I am truly proud of another exceptional accomplishment by our dedicated oncology services team. As a result of hard work and a commitment to ongoing quality and excellence, the Sandra & Malcolm Berman Cancer Institute at GBMC has received a three-year QOPI certification. For those who don’t know, the QOPI Certification Program recognizes medical oncology and hematology/oncology practices that are committed to delivering high quality cancer care including high safety standards. Our team, led by Dawn Stefanik, put many hours of work into this achievement  and I personally thank them for their extraordinary efforts!

And now, I’m off to get in a run so I can keep up with those Westy’s kids at the Father’s Day 5K!

A Milestone….or Two

If you were an inpatient at GBMC during fiscal year 2010, which ended on June 30, 2010, you had a 50-50 chance of having someone wash their hands when they walked into your room or when they walked out of your room. In July of 2010, the percentage was 54% and in August of that year, it was 52%....equivalent to a coin toss.

Not anymore. In April of 2013, we achieved a score of 92%! This is a phenomenal accomplishment. In April, all 10 of the measured units achieved at least our annual goal of 83%. Two units, Unit 45 (Oncology) and Unit 57 (Medical Intensive Care Unit) were at 100% when the “secret shoppers” came by!

How did we accomplish this? I’d like to say that it was easy but we all know that it was not. I believe that the improvement started with a recognition that we are washing our hands because the patient deserves that. We now formally reflect on how we would want it to be if it were our loved one in the bed. Our leaders remind us at regular intervals.

Some units are doing daily spot audits and discussing the results at morning and evening huddles. We celebrate the measurements and make the statistics readily available. Handwashing has become much more reliable and our patients are benefiting. We are achieving lower rates of all of our measured hospital-acquired infections.

We should be proud of our work but we should not stop until we hit 100% and then we must maintain our vigilance.  


If it was your mother entering hospice?

Readers of this blog know that the people of our fantastic hospice company, Gilchrist Hospice Care, decided that the Medicare requirement that a patient entering hospice be comfortable within 48 hours was too low a bar. They asked themselves if 48 hours in pain would be ok if the patient was their loved one and answered with a resounding “no”.

In 2010 they also understood how hard it was to get to pain relief for a newly admitted patient with all of the steps required so they started redesigning their systems. Since that time, Gilchrist has had an afternoon phone call to check in among other things on all of the patients admitted in the previous 24 hours and to learn why any of them were not comfortable. They have kept score monthly since then (see the run chart below).

In April, Gilchrist achieved perfection on this measure. 100% of newly admitted patients were comfortable within 24 hours! Another phenomenal accomplishment. It did require hard work and good intentions but I am so proud of their problem-solving abilities that led to redesign and  continual improvement. Wonderful work. Thank you.

Annual Employee Wellness and Information Fair / Open Enrollment

Approximately 500 employees, physicians, and volunteers attended yet another successful Employee Wellness and Information Fair last week, learning from more than 40 vendors how they can be "Healthy.Wealthy.and Wise" by improving health and by taking advantage of the resources that are available at GBMC. On a related note, Open Enrollment for health benefits started this week and runs through Friday, May 24. The Open Enrollment guides are located on www.gbmcbenefits.com and on the InfoWeb under HR/Benefits/Benefits Material.  Be sure also to check the list on the InfoWeb of when Information Sessions are being held if you have questions about benefits.

Celebrating National Nurses Week

Celebrating National Nurses Week

This week we take time to reflect on the profession of nursing and what our nurses mean to our national healthcare system and specifically to GBMC. Nursing requires selflessness and commitment. Nurses work long hours and their work is hard. Caring for patients with many needs requires physical and mental stamina. It is not a profession for people who have difficulty focusing on others. Commitment to helping others is a key trait that defines nursing.

But long ago nursing became a profession where commitment was not the only requirement. Now, nurses must put in many hours of preparation in the biological sciences to be able to do their work well with all of the complexities of medical care. Nursing is one of the few professions where both a strong scientific educational background is required along with the ability to do many consecutive hours of physically taxing work.

I often write in this blog of all of the things that we are working to fix in our national healthcare system but nursing is not one of them – the United States has the best prepared and hardest working nurses in the world. We in the GBMC HealthCare system are blessed to have phenomenal nurses in our inpatient units, in our operating suites, in our outpatient areas, our physician practices, and in our hospice. And we have outstanding nurse leaders. I am very proud of all of them and honored to call them my colleagues. 

But most of all, I am grateful for all that they do for our patients. Our nurses move us closer to our vision every day. Please especially take a moment to thank them this week as we recognize National Nurses Week, celebrated annually from May 6, also known as National Nurses Day, through May 12, the birthday of Florence Nightingale, the founder of modern nursing. 

Stacey Williams, RN, PEDS ED nurse, explains her Clinical

Ladder project at a Nurse's Week reception.

We are also celebrating National Hospital Week. Our system is so fortunate to have a great hospital. What makes our hospital great is not our beautiful campus, or our outstanding technology and clinical tools. What makes our medical center great is our people. Physicians, nurses, technicians, therapists, other clinicians, environmental services workers, administrators, transporters, food service workers, supply technicians, librarians, volunteers, groundskeepers, fundraisers, human resource experts, telephone operators, Information technologists, maintenance and facilities workers, and everyone else. When this big team works together….it is a thing of beauty….we call it GBMC…let’s celebrate it this week!

GBMC Activities

As part of national celebrations for Nurses Week & Hospital Week, GBMC will be holding several activities starting May 7th.  Many events will be taking place during this week, keep checking the InfoWeb for details. Below are just some of the events.

• GBMC Employee Healthy Recipe – all recipes should be submitted by Thursday, May 9, 2013.  All participants will be submitted in a drawing.  Please submit your recipe via email to HR Broadcast News.

• GBMC Bag giveaway – each employee will receive a GBMC totebag this week as a token of our appreciation.  Managers will receive an email with pickup locations so that they can pickup totebags for employees.

• Ice Cream Social Event for all GBMC staff and volunteers (Wednesday, May 8)
• 12 pm -2pm in ED Entrance and Civiletti Conference Center
• 6 pm - 7pm in ED Entrance Only
• 11 pm - 12am in ED Entrance Only

• Employee Health Fair (Thursday, May 9, 11 am – 3 pm in Civiletti Conference Center for all employees, volunteers and physicians 

Learn how you can be "Healthy.Wealthy.and Wise" by improving your health and by taking advantage of the resources that are available at GBMC!

Complimentary:  Massage therapy, glucose and cholesterol testing, blood pressure screening, BMI screening, hearing screening, vision screening, osteoporosis screening, Dermascan sun damage analysis…. and lots of free giveaways! 

A GBMC staff member receives a relaxing massage
at a prior  year's Employee Health Fair.

All attendees who fill out an evaluation form will be entered into a raffle for free prizes including gift cards, gym memberships, movie passes, and much, much more!

Two of Our Own are in Maryland’s Top 100 Women

On Monday night I put on my tux and went to the Meyerhoff Symphony Hall to celebrate the annual naming of Maryland’s Top 100 Women. The GBMC HealthCare System is the Circle of Excellence sponsor for the event, so after a video clip about our transformation into a true system of care was shown, I got to go up on the stage to salute the Circle of Excellence winners. 

This year’s event was special for us because Barbara Messing, the Administrative Director of the Milton J. Dance Center, and Bonnie Stein, the Chair of our GBMC HealthCare Board Quality Committee, were among the Top 100 honorees. 

Congratulations Barb and Bonnie, we are very proud of you!