Meeting With a Man on a Mission

Last week I had the pleasure of spending some time with Dr. Samuel Ross, the CEO of Bon Secours Hospital in West Baltimore. Sam and I have been comparing notes about necessary changes in our national healthcare system. He visited GBMC a few weeks ago and I made a trip to see his operation.

Bon Secours serves a community with a very high unemployment rate and a median household income of $23,070. While the infant mortality rate in Maryland is 7.9 per 1,000 live births, it is 18 per 1,000 births for the population served by Bon Secours. The mortality rate for cancer is 50% higher than in the rest of Maryland and the mortality rate for heart disease is almost double what it is in the rest of the State.

Dr. Ross took me on a tour of Bon Secours. Every member of his team that I met, from the guard at the entrance to the nurses in the ICU, were upbeat. It looked to me like they were all following their leader and they were on a mission. They appeared ignorant of the fact that the odds were stacked against them – they were determined to beat those odds and lessen the burden of disease in their community. No one lamented the age of the facility…but they were very proud of their robot that allows them to use telemedicine to improve care in the intensive care unit. Dr. Ross showed me the “COWS”- computers on wheels -  that are connected to the new single database electronic record that they are about to roll out. He explained to me that they would not have been able to purchase this system without the help of the Bon Secours system.

I reflected on how lucky I was to not have the same burden of poverty and rate of chronic illness in the community served by GBMC. Sam and I spent some time thinking about how we could learn from each other and we committed to looking for areas in which we could collaborate – I think it would be fantastic if we could help Dr. Ross bring advanced primary care to the Bon Secours neighborhood. There are many hurdles to get over but we will look for ways to make this happen. Sam and his team are on a mission, and I am betting on them.  

I Like Swiss Cheese…But Not in My Work

I remember being a 22-year old in Italy and not worldly-wise. I was trying to buy “Swiss cheese” and was asking a friend to help me find it in a supermarket and translated it literally. My friend pointed out to me that Switzerland was known for its cheeses and there were many kinds of “Swiss cheese.” I explained to him that it was the one “with the holes in it,” and he then told me that the cheese was called Emmental.  

Many years later, when I was learning about safety, human error, and complex systems, I got introduced to the “Swiss Cheese Model of Error,” the work of Professor James Reason of Manchester University, in England. Professor Reason created the model to help his students understand the relationship between the thoughts and actions of humans in a complex system and how these thoughts and actions can either contribute to the creation of bad outcomes and in some cases, catastrophes, or help prevent them.

Reason knew that humans understand at some level that they are fallible, so that they build protective walls to “block” errors from resulting in bad outcomes. An example of this is in the system for protecting patients from medication ordering errors.  Physicians can and do occasionally make errors of ordering the wrong drug, the wrong dose, or the wrong route. The first wall of defense to block one of these errors is called pharmacist verification. Every time a doctor orders a medication on a patient in the hospital, the pharmacist checks it to make sure that it is safe for the patient. But pharmacists also occasionally make mistakes. So the pharmacy verification wall has holes in it, too. The next wall of defense is called nurse check. Nurses also make mistakes so this wall is also imperfect. If you line up all of the walls what does it look like? You guessed it…Swiss cheese.

                                                                                                                                                                   
Reason calls the holes in the cheese latent failures. Latent means hidden or present in an unexpressed form. These latent failures can be grouped into a number of categories. One of the categories is failures at the managerial level. This occurs when a manager knows that a design is not being followed that could cause a bad outcome but the manager allows the design to not be followed. An example would be if a manager knew that the doctors and nurses were not doing the timeout correctly before a procedure but let the procedure go on anyway.

A second type of latent failure is called a psychological precursor. Psychological precursors can be thought of as beliefs held by those involved in a complex system that lead to people not following the design. An example of this would be if doctors and nurses did not do the timeout properly because they believed the timeout was “stupid” and “not necessary and a waste of time.” A psychological precursor that is rampant in healthcare is: “I do it whatever way I have to, to get whatever my patient needs.” This psychological precursor is the end result of clinicians working in broken systems. They come to believe that they don’t have to do it the way it is designed because the design never works anyway. This psychological precursor is the opposite of what people in other high risk industries like commercial aviation or nuclear power believe: “I follow the design because it is not safe to do otherwise.”

Other holes in the walls may be due to less pervasive problems or one- time events. These latent errors are called: local triggers, intrinsic defects, or atypical conditions. An example of an atypical condition is when a clinician is dealing with a patient that does not speak his or her language. We know that the opportunity for error increases when our patients can’t participate fully in their care or in protecting themselves from harm.

Bad outcomes may start with an unsafe act where an individual does not follow a procedure as designed or does not follow the standard work.  

Let me tell a story about an employee injury at GBMC using the Swiss cheese model. 

Our colleague falls and injures her arm.
An employee took an office grade bag of trash that had a lot of liquid in it out of a break room garbage can. The employee placed it on the floor in the hallway where it leaked onto the floor. (The designed procedure is to place the bag immediately in a cart.) The employee then realized that the bag had leaked, and retrieved a mop and cleaned it up. The employee did not put a wet floor sign down and a nurse turned the corner and slipped, falling to the floor and injuring her wrist.

So applying the model we see that one latent error in our system is that we use trash bags that are not designed for liquid in trash cans that may receive liquid. Although it is not absolutely clear it appears that at least someone may have the psychological precursor of “any trash bag will do” in using the bag that is not designed for liquid.  A second psychological precursor may have been, “I don’t need to follow the rule, it won’t leak, I’ll just put it on the floor.” The actual unsafe act was putting the bag on the floor. A last unsafe act was not putting the wet floor sign up.

Notice that if any one of these latent errors had been “fixed,” the hole would have been blocked and our colleague would not have been injured. If the correct bag was used, or if the person emptying the trash had put it directly in a cart or if he or she had put up the wet floor sign, our colleague would not have been injured. But, if only one had been fixed, the other latent errors would still have been present waiting to align for the next bad outcome or catastrophe.

We cannot wait until the holes in the Swiss cheese align to create a catastrophe; we must fix the holes when we find them. This is what our near miss (Quantros) reporting system helps us to do.

What latent errors have you found and are working to fix in our healthcare system?

Enrolling Others in Change

There are nearly 4,000 of us who work in the GBMC HealthCare System as employees, volunteers or physicians in private practice. When I think of all the improvements that we have made on our way to our vision, I am amazed at how many of them started with only one or two of our people in action and then spread to many more people. A fantastic example of this is the work that has been done by our nurses at reducing pressure ulcers.

It has now been more than seven months since the last pressure ulcer at GBMC! Those of us who don’t have to turn debilitated patients every two hours to prevent these can only imagine how hard our nurses and nursing technicians have been working to prevent them. Our people have always understood that they needed to help patients avoid pressure ulcers but only after a few folks started the movement to guarantee standard work in assessing who was at risk for skin breakdown and then delivering the measures shown to prevent it reliably, have we improved our performance.

Why is it that some change initiatives achieve great results and others don’t? There are a number of reasons but I think the single biggest reason is failed enrollment. We often hear: “People don’t like change.” Doug Krug, the author of the book Enlightened Leadership, makes the point that this is not true. Krug says that people change all the time; just think of all of the people that got rid of their flip phones and Blackberries to get iPhones, for example. The true statement according to Krug is: “People don’t like to be changed.”  We humans need to see and accept the need for the change and we need to feel that we have played a part in the design of the change or at least have chosen to make the change and have not had it forced upon us.

We have achieved zero pressure ulcers at GBMC because the overwhelming majority of our nurses and nursing technicians have been enrolled in the change. They understand the reason for the standard work, they now know what the work is and they have accepted that it must be done to prevent harm to their patients.

It is hard to get everyone enrolled in any change initiative in a large complex organization. The GBMC System is not presently making the same degree of progress on some of our other goals. From me on down the line we need to do a better job of enrolling others to achieve these goals. The enrollment starts with a conversation about the need for the change – what we are trying to accomplish. It continues with a discussion of what is expected of the person being enrolled. Then the enrollee must have some time to ask questions, voice any concerns, and be heard. Finally, the person doing the enrolling needs to hear from the enrollee that they have understood and that they are in!

I am very grateful for everyone’s hard work and particularly for everyone that enrolls others in change.

Finally, I'd like to congratulate two of GBMC's nurse leaders on recent accomplishments: Jody Porter, RN, DNP, Senior Vice President, Patient Care Services and GBMC’s Chief Nursing Officer, has been re-elected to the board of directors position of Treasurer of the Maryland Organization of Nurse Executives and CJ Marbley, RN, has been named to the same organization’s board of directors as a Member-at-Large. These individuals are certainly enrolled in creating positive change right here at GBMC and throughout the nursing community. Thank you for your commitment to excellence!

Looking Ahead to a New Year

While we just turned the page of our calendars to a new year, GBMC is actually half way through its fiscal year. In 2014, we have much to look forward to as we stay in action on change with an operating plan that moves us toward our vision and the achievement of our four aims.

In the second half of our fiscal year, we will continue to build the patient-centered medical home. I am excited to see this really come alive this year as we begin construction on the new Family Care Associates office – the first office specifically designed as a patient-centered medical home. Our patients can also expect to see us continue to expand office hours in many of our primary care practices to better serve our patients.

Here’s what else we can look forward to in the coming months at GBMC:

• We will build on our success in 2013 and continue the strengthening of our outstanding surgical services at GBMC. We are delighted that Orthopedic Specialists of Maryland have now joined Greater Baltimore Medical Associates!
• Greater Baltimore Health Alliance will be reflecting on how healthy our patients are by disease state through the development of patient registries for chronic conditions such as asthma, hypertension, diabetes and obesity. These patient registries will help our practices better coordinate and manage the care of patients with chronic diseases.
• We are gearing up our employee wellness initiative to make it easier for our employees to get healthier, and stay healthy.
• We will be working to develop tighter and richer connections with other care providers such as our partners at Johns Hopkins Healthcare to give GBMC’s Accountable Care Organization - GBHA- the ability to provide even better, more coordinated care to our patients.
• We will be taking GBHA to the next level as a contracting entity beyond just the Medicare Shared Savings Program in 2014. We will be inviting specialist physicians on our medical staff to formally join GBHA so we can contract for them.
• We are excited about hosting a special breakfast meeting in March to introduce GBMC’s transformation as a healthcare system to business owners in Baltimore County.
• We are also excited about completing our negotiations with the Health Services Cost Review Commission (HSCRC) on their new payment model that will pay us on a global budget. This provides us with the opportunity to deploy resources where people need it most, coordinate patient’s care, keep people healthier and keep people out of the hospital when this is possible.

As we begin a new calendar year and continue to forge ahead with this fiscal year, there’s much to be excited about as we work even harder toward achieving our vision.

What do you look forward to from the GBMC system in 2014?