“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.

Talent, Hard Work, and Laudable Goals

Time away from work gives us the opportunity to explore the facets of life that are not immediately related to our work. Last Thursday night, I saw Terence Blanchard in concert at the Blues Alley in DC. It wasn’t the first time that I had seen him and he did not disappoint me. Mr. Blanchard and the other members of his quintet mesmerized the crowd with their hauntingly beautiful numbers mostly from their new CD, Magnetic. http://www.youtube.com/watch?v=uMTjt7EcGtU

I really enjoy Jazz music and I am in awe of the masters of this genre. In May, Wynton Marsalis gave the keynote address at the graduation ceremonies of the University of Vermont. http://www.youtube.com/watch?v=JIYKfyDVzxg. Mr. Marsalis’ son, Simeon, was among those getting their bachelor’s degrees as was my son, Patrick. I knew Wynton as a virtuoso of the trumpet, but I did not realize that he was also a gifted public speaker. He had me, and most of the other parents in the crowd choking back tears as he brought himself to tears in giving the best commencement address that I have ever heard. Mr. Marsalis addressed us from the heart of a proud father and his words really connected with me. I was amazed at how such a talented musician could relay such a powerful message through the spoken word as well. He is truly multi-talented. It is clear that both Terence Blanchard and Wynton Marsalis put in many, many hours of practice to take advantage of their talents. Talent and hard work are unbeatable.

At GBMC we are blessed with many, many talented people who work very hard. From our dedicated Board members who give so much of their time to assure the community that we stay true to our mission and move towards our vision; to our senior team and our tremendously talented and hard working physicians, nurses, therapists, social workers, care managers, hospice aides, medical technicians, secretaries, food service workers, environmental services workers, billers, finance analysts, and every other member of Team GBMC, we are all united in our quest-that everyone gets the care we want for our own loved ones. United around this laudable goal and with the hard work and talent of our people, the GBMC HealthCare System is unbeatable.

Do you have a story about a GBMC team member going the extra mile to deliver excellent care? Let us know in the comments below.

Which Hospital is the Best?

The last few weeks have seen the release of the annual U.S.News & World Report hospital rankings and the Consumer Reports rankings. The releases triggered discussion in the news media that is long overdue.

How should the consumer decide which hospital is best?

Most would agree that the best hospital is the one that provides the best possible health outcome. Given similar health outcomes, most would also agree that the hospital that provides the best care experience should be judged to be better than hospitals with lower patient satisfaction.

But what about cost?

Most rational thinkers would be willing to pay more if their health outcome would be better and most would probably pay a bit more for friendlier, more comfortable and more timely care. Value = Quality/Cost. Where do patients get the best value for their dollar (or their employer’s dollar, or the taxpayer’s dollar)?

Well, it turns out that the truth is very hard to find. I believe that this has been the classical “chicken vs. egg” conversation. The data needed to decide which hospital is best are not available because historically no one has looked for the data. The news media has recently done stories that are beginning to awaken health consumerism, however. The stories asking why a CAT scan at one hospital costs X and a CAT scan at a hospital a few miles away costs 2X have begun the conversation. Now the uproar regarding the ‘Best Hospitals’ report is continuing.

There are now some unbiased places to go to get good comparative data. The Department of Health and Human Services (www.hospitalcompare.gov) is one such place. Here, a consumer can find good comparative data on patient satisfaction scores, mortality rates, and a number of process measures of care and some outcome data beyond mortality rates for certain disease states. Unfortunately, the data here are generally nine months old because of the complexity of collecting the data from all of the nation’s hospitals.

Earlier this year, we at GBMC began publishing many of our quality measures monthly at www.gbmc.org. However, we are the only local system doing this and very few others do it nationally. When we began publishing this information, we knew that very few patients would look at the data before making a decision of which hospital or health system to use, but we also knew that the organizations that made their data visible to the outside world got better, faster.  So that is why our HealthCare Board authorized us to show the data…good, better, excellent and not-so-good.

It is my sincere hope that the citizens of the U.S. will become more demanding of the evidence of who is truly the best and ignore rankings based on “reputation” without substance. If it were your loved one seeking the answer to the “who is the best” question, you would want him or her to be able to find the true answer.

Update on Dr. Ted Houk

Dr. Ted Houk, the member of the GBMC medical staff who was struck by a car and seriously injured while jogging on March 28th, continues to recuperate and improve with an eye on returning to the practice of medicine in the future. Members of the GBMC family and the community can keep up with his rehabilitation on his Caring Bridge page at http://www.caringbridge.org/visit/tedhouk/journal.

Dr. Houk’s family is also in need of support during this time of recovery. Those who wish to help Dr. Houk and his family should consider donating to his recovery fund. Information can be found at his GiveForward site at https://www.giveforward.com/fundraiser/3pc2/tedhouk.

Thank you for your support and well wishes for Dr. Houk.