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.