Tuesday, October 29, 2013

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.

Tuesday, October 22, 2013

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.”


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?

Tuesday, October 15, 2013

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.


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.

Tuesday, October 8, 2013

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.

Tuesday, October 1, 2013

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 visionto 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.

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/.