Thank You to All Who are Helping GBMC Transform to be Even Better

On the last day of 2013, it is once again time to reflect and take account of our progress toward our vision. How much farther have we progressed in becoming truly patient-centered? What have we done to treat every patient, every time, the way that we want our own loved ones treated?

Aim #1: Better Health

Since the opening of Greater Baltimore Medical Center some 48 years ago, our system has been blessed with very talented physicians, nurses, and other clinicians who work very hard to maximize the health of those we serve. Over the last few years, we have gotten better at measuring and at getting in action to change things that we used to take for granted. In fiscal year 2011, we had 20 serious safety events. Through the first six months of fiscal 2014, thanks to the hard work of those very same talented clinicians and others in creating standard work and making us more reliable - we have seen three. Zero is the only ethical stopping point but we have come a long way. In 2010, we did not have a robust system for people to report minor events and near misses. Now, we have over 1500 incidents reported monthly so that we can learn from them and redesign our systems to plug “the holes in the Swiss cheese” so that they don’t align to create bad outcomes. In fiscal ‘11, we had 216 hospital acquired infections and we did not count all of them. Through the first six months of fiscal 2014, we have less than 50 total incidents of patient harm (central line associated blood stream infections, catheter associated urinary tract infections, surgical site infections of the hip and knee, falls with Injury and pressure ulcers)! We had 10 pressure ulcers alone in fiscal 2013. This year to date we have had zero! GBMC nurses and nursing technicians deserve a huge THANK YOU for this!

And we have begun moving upstream on measurably improving health. In 2013, Greater Baltimore Health Alliance made its first ever quality report to the Centers for Medicare and Medicaid Services under the Medicare Shared Savings program. We now know exactly how our diabetics are doing, for example, in getting evidence-based care and we know how many of our patients are hypertensive. Our Patient-Centered Medical Homes are in action improving these outcomes before patients require hospitalization.

Aim #2: Better Care

In 2013, we made significant progress at making continuous improvement in our culture. In April, we rolled out Lean Daily Management (LDM). LDM has helped us improve clinical outcomes, but perhaps the aim that it has had the biggest effect on is Better Care. A huge example of this is our success in moving admitted patients out of the Emergency Department to a floor bed faster. Units 35 and 38 have led the charge here by creating a pull system and measuring their success daily. The median time that an admitted patient spent in the ED in fiscal 2013 was 395 minutes. We have reduced this time to 305 minutes – a 23% reduction. The score on our patient survey question regarding waiting time to be admitted has reached an all-time high showing that the patients are truly feeling the effect of this work. In 2013, Greater Baltimore Medical Associates (GBMA) began seeing patients on Saturdays and their overall patient satisfaction scores reached all-time highs. And as I reported recently in this blog, GBMA has embarked in 2013 on the physical design of a new patient-centered medical home to minimize waits and delays and waste of all kinds. Gilchrist Hospice Care, already functioning at award winning levels in so many areas, redesigned communication with families and significantly improved the families understanding of the dying process and their feeling competent to deal with the impending death of their loved one.

Aim #3: Least Waste

Our nurses work very, very hard. A great example in 2013 of lessening their burden a bit has been achieved in the reduction of the number of “missing” medications. Nurses have enough to do in providing care for their patients without searching for things that should be there! Through the hard work of our pharmacy team collaborating with our nurses, we have reduced missing medications by 30% in 2013. Unit 45 has worked with materials management and has drastically reduced missing supplies. What used to be a major waste of nursing time has now become an uncommon event. There are many other examples of waste being driven out throughout the GBMC HealthCare system.

We finished fiscal 2013 a bit ahead of budget and we raised more money in Philanthropy than we had in many years. We are on track to break that record in this fiscal year.

Aim #4: More Joy

Our work in creating a hierarchy that engages and empowers our physician leaders through our service line model has had a positive effect in our physician engagement scores. Our overall physician satisfaction score increased significantly in 2013. We still have a lot of work to do in making all of our doctors believe that they have a voice and that it is heard. On a local level, our nursing staff has begun working on things like assuring that everyone gets an uninterrupted meal break and that they can get their work done and get home without having to do overtime. We have committed to reducing employee injuries at work and we are making great progress. In fiscal year 2013 we had 327 injuries on the job and half-way through this year we are at less than 100! In 2013, we changed vendors on our employee satisfaction survey so the results were difficult to interpret. We will continue to work at a senior team level on things like benefits and providing career growth opportunities and at a local level to bring more joy and to make the GBMC system an even better place to work in 2014.

So I think the evidence is clear. GBMC HealthCare made great progress towards our vision in 2013! We have many, many people to thank for this. Our doctors, our nurses, other clinicians, our administrators and all of our non-clinical employees have done a fabulous job. We must thank our phenomenal Volunteer Auxiliary, who in 2013 celebrated 50 years of service to GBMC! We also need to thank all of our donors who gave of their treasure. And lastly, we must thank our patients – you are the reason we do what we do and you will make us do it even better in 2014!

Please click on the video link above to be thanked!

Peace on Earth

This week I did what most Americans do during the holiday season….I went shopping. I think I am the stereotypical male in that I really don’t like shopping, but I do it to try and find gifts for the people I love. I remember when I lived in Rome in the 1970’s seeing how the Italians celebrated the holidays. It was much less about gifts and more about gatherings and joyous meals together.

Tuesday I went on our Lean Daily Management walk and realized how wonderful our staff is and how not just on Christmas Eve, but every day, they give so much to our patients and their families. It’s like most of them have the spirit of giving all year round. After rounds, I had three patients and families I wanted to see. One was a phenomenal volunteer who gives so much to GBMC. One was quite an accomplished gentleman who I did not know personally, but I knew of him, and was asked to visit him by a mutual friend. The third patient was a woman who had just delivered her first baby and her husband. They were so glad to have this new, wonderful gift in their lives. Making all three visits really got me thinking about what the season is all about, so I gathered my things and went home to be with my family.

I am writing this next to our Christmas tree listening to holiday music and looking at the ornaments that we have collected over the past 30 years. My favorite ornament sits atop our tree. It’s a paper angel that my son Mike made in Kindergarten and it has a photo of Mike’s face at age five glued on the body of the angel. It reminds me of how lucky I am. I wish that everyone in the world could stop during this season and reflect on what is really important.

I wish everyone a peaceful and joyous holiday season and for those who celebrate it – Merry Christmas!

Patient Safety and the Man-Machine Interface

We know that humans make errors and we also know that we can eliminate some of those errors through the appropriate use of technology. For example, the computerized order entry system (CPOE) has just about eliminated medication errors due to misinterpreted handwriting or the use of dangerous abbreviations.  
However, machines don’t fix everything and computerization creates new opportunities for error at what is known as the man-machine interface.

An example of a catastrophe created at this interface was the crash of American Airlines Flight 965. The aircraft was a Boeing 757, and it was on a scheduled flight from Miami International Airport to Cali, Colombia, when it crashed into a mountain in Buga, Colombia on December 20, 1995, killing 151 passengers and 8 crew members.

Cali's approach uses several radio beacons to guide pilots around the mountains and canyons that surround the city. The airplane's flight management system already had these beacons programmed in, and could have told the pilots exactly where to turn, climb, and descend, all the way from Miami to the terminal in Cali. Essentially, once the pilots had programmed the computer, the plane could have taken off and landed itself successfully.

Cali's controllers asked the pilots if they wanted to fly a straight-in approach to runway 19 rather than coming around to runway 01. The pilots agreed, hoping to make up some time. The pilots then erroneously cleared the approach waypoints from their navigation computer. When the controller asked the pilots to check back in over Tuluá, north of Cali, it was no longer programmed into the computer, and so they had to pull out their maps to find it.

By the time they found Tuluá's coordinates, they had already passed over it. In response to this, they attempted to program the navigation computer for the next approach waypoint, Rozo. However, Rozo was identified as R on their charts. Colombia had duplicated the identifier for the Romeo waypoint near Bogotá, and the computer's list of stored waypoints did not include the Rozo waypoint as "R," but only under its full name "ROZO." In cases where a country allowed duplicate identifiers, it often listed them with the largest city first. By picking the first "R" from the list, the captain caused the autopilot to start flying a course to Bogotá, resulting in the airplane turning east in a wide semicircle. By the time the error was detected, the aircraft was in a valley running roughly north-south parallel to the one they should have been in. The pilots had put the aircraft on a collision course with a 3,000-meter (9,800 feet) mountain. They realized their error too late and the plane crashed into the mountain. A system designed to make flight safer had been misused by the humans flying the plane and this had resulted in 159 deaths.

Recently, at GBMC, we had a near miss from a human error at the man machine interface. An ED doctor was trying to order a CT scan of the head and neck on a patient and inadvertently clicked on the next name in the list and ordered the CT on the wrong patient. In the old system, the doctor would have taken an order sheet and stamped the patient’s name on it, but in the computerized world, this type of new opportunity for error presented itself.

The wrong patient did not get the scan because our design for safety has a check that worked that day. Jana Sanders, the C.T. technician who was working reviewed the patient’s record and questioned the orders because there was no mention of a fall or head/neck pain. Jana called the physician to make sure he wanted these exams on the patient before doing the scans. At that point, the physician realized the error, thanked Jana for catching it, and put the order in for the correct patient.
 
It is said that in highly reliable systems, operators have a preoccupation with failure. Operators, like Jana, have a questioning attitude because they know that humans make errors, so they follow the design for safety and do the check to make sure they have the right patient. They also realize that computerization prevents many types of errors but creates some new ones at the man-machine interface. Our hats are off to Jana on a job well done!

What opportunities for error do you see in your work at the man-machine interface?

A Just Culture Fosters a Safer Culture

When I was a medical student I had the opportunity to scrub on a bowel resection surgery for a patient with colon cancer along with a second year resident and the attending surgeon. I was holding a retractor and watching the case up close, watching as the surgeon sewed one end of the anastomosis (reconnection of the two pieces of bowel) to the other. But then, I watched as he started cutting right through the bowel he had just meticulously stitched. I knew this was wrong and I was scared. Could it be that this surgeon was actually cutting through the bowel section he had just stitched or was I not seeing this correctly?  I thought, ‘I’m just the med student,’ and I stayed quiet. As he was almost finished with the procedure, he stopped and looked at me and the resident and said, “Why didn't you say anything?” He realized that he was cutting through the anastomosis he just stitched. Not speaking up because of the hierarchy and the fear of retribution is very dangerous in any high risk industry, and especially in healthcare.

One of the problems in healthcare is that our field is very paternalistic and hierarchical. We must make it safe for people to speak up in order to make the care safer.

No one questions that the doctor is the captain of the team by training and by law, but to get it right it takes the whole team. For the team members to perform at maximum capacity there has to be a culture of respect and openness to full participation by all.

The Just Culture is a concept where individuals are consoled if they make a human error. They’re coached if they are drifting into at-risk or risky behaviors and they are only punished if they are involved in reckless behavior or knowingly put someone in harm’s way by violating the established rules.

Let me give you some examples of this:

A busy hospitalist physician inadvertently clicks on the wrong patient in the order entry system and orders insulin on the wrong patient. The pharmacist, not seeing the diagnosis of diabetes in the patient’s record, calls the physician who realizes her error and apologizes, feeling terrible for her mistake. The pharmacist consoles her.

A nurse later draws up the insulin but gets distracted by her phone ringing and draws up the wrong dose. Because insulin is a high-risk medication and patients can be harmed by receiving too much or too little insulin, we have a double check on insulin delivery – one nurse draws up the insulin, checks it against the physician order and then hands the syringe to a second nurse who must double check the dose against the written order to make certain it is the correct amount. In this case, the second nurse, also feeling pressed for time to give care to his patients looks at the syringe but does not check it against the actual order. The first nurse then gives the incorrect dose to the patient.

These two nurses are drifting from the design for safety – they did the second check but did not do it the designed way. In this case, their behavior is risky and they need to be coached on why the second check is done and why it is critical to do it correctly.

Reckless behaviors, on the other hand, need to be punished. Take, for example, the medical technician who was sentenced to 39 years in prison for infecting more than 45 patients with Hepatitis C after he stole syringes filled with narcotics intended for the patients, injected himself with the drug, refilled the syringes with saline and then used the syringes on patients knowing he had hepatitis C. This is reckless and dangerous behavior and in a just culture, should be, and is, punishable by law.

To err is human

Commercial aviation had to make dramatic changes to its culture because of the worst airline disaster in history - the Tenerife crash of 1977 where two 747s crashed into each other.  The co-pilot of the one plane on the runway was aware that they hadn't been cleared for take-off but feared speaking up to the pilot who was the most distinguished captain in the KLM fleet at that time. The co-pilot failed to speak up to this pilot and they died, along with 500+ other people. After this disaster, commercial aviation began to work on removing the barriers to open communication in the cockpit and everyone who travels on planes benefits from this today. Building a just culture is a step towards making our care safer.
 
Humans make mistakes; this is a simple fact. But without a just culture, people who make human errors may be punished, thereby decreasing the likelihood that they will report errors that lead to harm. When errors and near misses are not reported, we miss the opportunity to learn from these events and design systems to catch the errors.

Last week, our physicians of Greater Baltimore Medical Associates spent some time learning about the Just Culture and studying examples of its application. I am very grateful for their engagement in making our care even safer than it already is.

What would your ideal primary care office look like?

I have been both a provider of care and a patient in many primary care offices. As a provider, I often thought that the way things were laid out could be improved to make us more efficient. As a patient, I have often reflected how similar all physician offices are – front desk, with or without a glass window, relatively large waiting room and exam rooms arranged along corridors.  I can remember as a physician, coming out of a room and walking down the long corridors to find another member of our team, to ask for help with something. As a patient, I was once “forgotten” in an exam room over the lunch hour (I didn't complain too much because I had back pain and lying on my side on the exam table felt comfortable).

GBMC has embraced the patient-centered medical home concept. We have taken our existing primary care offices and have used them in a new way. On a recent visit to our Hunt Valley site at mid-afternoon I noticed that the waiting room was empty….the way we want it to be because we don’t want people waiting….and I realized that the waiting room was now just a lot of wasted space.

So I am very excited to tell you about a 3P going on this week on the ground floor of the North Pavilion on the GBMC campus. A team, led by Sarah Whiteford MD, and Ben Hand MD are designing the new home of Family Care Associates, one of our GBMA practices! Drs. Whiteford and Hand spent some time last month in Seattle at the Virginia Mason Institute, part of the Virginia  Mason Health System. Virginia Mason is a national leader in patient centered care and one of the first healthcare companies in the country to fully adopt Lean as a business model. A consultant from the Institute is guiding our team’s work this week.

Dr. Sarah Whiteford (left), Bryan Niles, construction project manager (center),
 and Dr. Ben Hand (right) work at designing a more efficient office that
 will not only enhance the patient experience but create more joy for the staff. 

Do you remember what a 3P is? We discussed the concept in What’s a 3P, the blog installment of October 26, 2012, when we talked about the process for designing our new inpatient pharmacy.

3P is a lean tool that stands for production, preparation, and process. The tool helps us invent new designs that follow lean principles and drive out waste. In this case, waste is defined as anything that the customer would not pay for. Most patients will pay for time discussing their problems with their doctors but are not excited about paying for waiting rooms or filling out forms.

Most physician offices use “batch” processing and move the patient from point A to point B to point C throughout the process. You come in and you wait. You are called to register and you wait. You are then called to have your vital signs and height and weight taken, you are brought to a room and you wait. Your physician or nurse practitioner comes in and deals with you and you wait to then be checked out of the office. The time waiting is nothing more than a characteristic of the design for patient flow.

If you were going to design the process that would be used for you as the patient how would you design it? I would like to arrive, be welcomed, brought to a room, my vital signs taken if necessary and then have my physician begin the visit with me. When he or she was done, I would like to leave with my instructions for the future.

Drs. Whiteford and Hand, along with medical assistants, care managers, and other members of their team now have the wonderful opportunity of designing a space that is better able to deliver care with less waste of time, effort and resources for all - I will be excited to see what they come up with! Stay tuned.