Wednesday, September 24, 2014

Pete’s Room is Now Clean and Neat

I have written before in this blog about the technique known as a 5S event. The main goal of a 5S is to organize and standardize an area 5S stands for Sort, Set in order, Shine, Standardize and Sustain. A 5S is at the foundation of performance improvement for an organization.  Clutter clogs up physical and mental flow of material and information.  After all, if members of our hospital staff are working in a cluttered   area how can we expect them to improve service to patients and others? Evidence shows that when a 5S is done well, the workplace will: “talk” to you, control itself, will be refreshing, safe, predictable and reliable. The results of a 5S will shorten training for new employees and be welcoming to everyone including our workers and our visitors.

5S GOR Team

Jody Porter, DNP, RN, our Sr. Vice President, Patient Care Services & Chief Nursing Officer was the executive sponsor for the event. The team also included Neil Crockett (Facilitator), Courtney Hendon (Team Leader), CJ Marbley, RN (Perioperative Nursing Administrative Director), Denis Albaladejo, RN (GOR Nurse Manager), Steve Adams, B.A., RN., CRCST (Sterile Processing/Anesthesia Manager),  John Bisker, RN (GOR Clinical Partner), Tracy Lamb, CRNP (Perioperative Nurse Specialist), Nick Dinatale, RN (OR Team Lead), Dan Schaefer, (Sterile Processing Supervisor), Frank McDonald, (Supply & Equipment Specialist), Charles Williams, (Supply & Equipment Technician), Will Boone, (OR Support Assistant), Kendrick Wiggins, (Stores Supervisor), Alyssa Natoli (Student Intern) and Celeste Demalo (Student Intern).  The team had representation from all areas that make the GOR run smoothly, which is critical for the last S, “sustain.”  Peter Whipple (Surgical Laser Coordinator), Stephanie Mayoryk, RN (Infection Control Manager), Michelle Tauson (Safety Specialist), our Environmental Services and Facilities team also played a key part in the success of the event.

The original scope of the event included hallways outside of the breakout room (pic below), central sterile and the locker room.  Other areas added were the “Breakout Room” (also known as the vendor equipment room) and “Pete’s Room” (storage area). Throughout the week the scope expanded to include the following supply rooms: the Equipment Room (pic. below), the Ramp Room, the Ortho Room (pic. below) and the Sub-Sterile (Emergency Cart) Room.

These additional areas could be added because of the outstanding pre-work done before the event week. The objectives were to: train the team in 5S principles and implement those principles; target equipment areas to organize, standardize space for patient volume, staff workflow and the restocking process; determine the physical items and information needed in those areas; and to clear hallways to create a safer environment for both employees and patients.

Through this event the team “sorted,” “set in order,” “shined,” and “standardized” three hallways and six storage supply rooms. Results included the “crushing” and disposal of 100 unused items, the creation of 200 visual parking spots for equipment, the hanging of 120 visuals, the making of 400 parking spaces and equipment labels and the shining of 3,622 square feet in the GOR.  In addition six life safety violations were resolved.  The team also found obsolete equipment that was quoted for a resale of $12,550.

After the 5s event, the team plans to sustain the success of the event by using a 5S daily audit checklist, a follow-up newspaper and have a created a communication handout for stakeholders of the newly 5S’d areas.
What great work this Team did! Not only Pete’s Room, but many other spaces are now standardized and clean and will make it easier for our people to serve patients the way they want their own loved ones served. I am very grateful for the efforts of the GOR 5S Team. What do you think?

Thursday, September 11, 2014

Critical Care at GBMC: No Longer Relying on Hard Work and Good Intentions Alone

On January 1 of this year, GBMC began a new era in critical care. We have always had excellent physicians and nurses caring for our sickest patients in our ICU’s, but our care delivery model – the system our people worked in – was not state of the art. 

All of that is now in the past. Under the leadership of David Vitberg MD, all ICU patients are now covered by a new, high-intensity, hospital-based team.  From inception, this new team significantly increased the level of oversight and availability for our sickest patients by extending attending physician in-house coverage from 8-10 hours (on average) to sixteen hours per day.  Also from inception, the team took ownership of all surgical intensive care unit patients. Prior to this, the attending surgeon was responsible for the minute to minute changes often required in the SICU while continuing to do his or her other work in the office or in the operating room unless a consultation request was made.  Now, the GBMC surgeons that fill the SICU with patients and the dedicated nurses that staff this unit have an equally dedicated group of intensivist physicians that attend to this high acuity patient population around the clock. This is what you would want if the patient were your loved one.

During the past six months, six new physicians were recruited to the division – four of which split time between the intensive care units and the new pulmonary practice – Pulmonary Medicine at GBMC.  In addition, three supplemental attending physicians were recruited to provide extra coverage as needed.  Supporting these ten physicians, two physician assistants were hired and now provide coverage seven days per week between 0700 to 1900 hours.

The 7 full time members of the physician critical care/pulmonary group are:

As of September 1st, all of the members of this new team are on board. But much progress has already been made to improve the quality and safety of Critical Care Medicine at GBMC.  An overriding principle in developing this new division was to elevate the delivery of Critical Care Medicine and build an environment and group of clinicians that would deliver this care in a safe, efficient, evidence-based, and compassionate manner that would defy the ‘low intensity’ label typically attributed to a community intensive care unit.  The following key initiatives highlight the division’s dedication to rapidly creating a safer and more cutting edge critical care system at GBMC.

1. Therapeutic Hypothermia for heart attack patients
Therapeutic hypothermia after return of spontaneous circulation in survivors of cardiac arrest has been shown to improve neurologic outcomes.  Between 2002-2004 many local hospitals around the beltway developed and started using therapeutic hypothermia protocols.  GBMC created an order set for this therapy but did not design a robust system to use it.  Within weeks of launching our new Critical Care program in January, an updated therapeutic hypothermia protocol was written and equipment required to delivery this therapy was acquired (Arctic Sun Temperature Management System).  The policy and procedures for cooling patients was updated to reflect best evidence, and cutting edge technology like BIS monitoring (Bispectral Index continuous processed EEG) was incorporated into the protocol. to limit potential awareness under paralysis and improve patient safety, and the related Neuromuscular Blockade policy was overhauled and fully updated. This modality is now available for use on patients who will benefit from it.

2. Critical Care Infusions: Improving patient safety and standardizing care delivery
Realizing the risk associated with different physicians ordering the same titrateable medications in different ways (and the confusion this created for our nurses), Dr. Vitberg and his team identified every titrateable infusion commonly used in all critical care areas and standardized all five fields required to order these medications.  The ‘Medication Guideline – Critical Care Adult Titrateable Infusion’ policy was approved by the Medical Board in May.  Our MIS/IT staff is completing an update in Meditech which mirrors this paper policy.  This will undoubtedly lead to more appropriate utilization of these high-risk medications, increased standardization in our practice of critical care medicine, and provide a safer experience for our patients. 

3. The ICU Transfer Checklist: Ensuring no missed hand-offs and reinforcing direct attending to attending physician communication
One of the highest risk times during a patient’s hospitalization is the time at which they transfer out of the intensive care units to lower levels of care.  To ensure that the handoff to the receiving physician happens reliably, the new group created an ICU Transfer Checklist.  A patient cannot be moved out of the unit or transferred to another facility without the sending critical care attending talking to the receiving medical attending or surgeon, the residents giving sign-out to each other (when they are involved in patient care), and the nurses giving sign-out to each other.  Since the checklist was implemented, our Team has achieved a near 100% compliance with hand-offs over the past few months.
4. Creating standard work and  organizing critical care interventions to improve patient outcomes
Many interventions in critical care are time sensitive. Implementation of protocol-based care empowers nurse and respiratory therapists to begin therapy quickly for critically ill patients and engages all members of the critical care team.  Implementation of evidence-based protocols, many of which contain bundled care items recommended by organizations like the Institute for Healthcare Improvement, improve care reliability and patient outcomes.

5. CHARMS Committee: Taking a closer look at how we screen for and treat sepsis
The CHARMS Committee (Community Hospital Action plan to Reduce Mortality from Sepsis) was organized in June 2014.  The committee is made up of MICU and SICU nurses, ED physicians and nurses, intensivists, residents, and a faculty physician representative from the Department of Medicine charged with quality improvement.  The focus of the committee is to review every aspect of sepsis care at GBMC, decompartmentalize the delivery of sepsis care across all patient care areas (i.e. ED to ICU to floor), ensure evidence-based best practices are being utilized, and improve clinical outcomes for these patients.
Goals of the CHARMS committee include:

• Develop a house-wide screening tool for sepsis (build on the existing screening tool already utilized in our ED)
• Update all sepsis order sets to reflect best practice, evidence-based medicine
• Ensure sepsis treatments are ordered and delivered in consistent fashion across all patient care areas (decompartmentalization of care: EMS-ED-ICU-floor-discharge)
• Develop a standard approach to determining need for central venous access
• Meet regularly to monitor clinical outcomes via review of data from Crimson

6. Code / Rapid Response Committee (RRT): Improving our response to emergencies around the GBMC campus
The division has worked hand in hand with the Code / RRT Committee to improve our response to cardiac arrests and rapid responses on the GBMC campus.  A recurring problem at code responses has been overcrowding.  In July, code team huddles were launched.  Every day at 0745 hours, all members of the code team meet in Unit 57, hand-off badges which indicate pre-assigned roles in a code response, and receive 5-10 minutes of educational ‘pearls’ from the ICU attending physician regarding resuscitation.  The names of the code team members are recorded on a dedicated board in the center of Unit 57.  This board contains educational material which reminds team members of their responsibilities at a code response, the educational ‘pearls’ for the day are posted, and any important announcements like QA/QI initiatives or equipment issues can be posted.  As ‘badged’ code team members arrive at the patient’s side, they replace initial responders that have started the resuscitation.  Security personnel and the admission coordinators have been trained to limit responders at the bedside to only those that are wearing a code badge.

7. Limited Bedside Ultrasonography: a core feature of any cutting-edge ICU
Limited bedside ultrasonography has evolved into an extension of the physical examination for critically ill patients.  All critical care fellowships now teach this skill to improve patient assessment, for procedural guidance, and to help guide resuscitation.  Ultrasound is typically used to rapidly answer binary questions in the ICU setting: is a pneumothorax present or absent?  Is there cardiac activity?  Is there free fluid in the abdomen? Is the vena cava empty or full?  Ultrasound must be used whenever possible to guide needles during invasive procedures.
So, you can see what happens when a new leader grasps the concept that hard work and good intentions by themselves are not enough to move closer to flawless care. It takes a team to design better systems and then carry them out! I am absolutely amazed at what Dr. Vitberg and his Team have done in a very short period of time. I can’t wait to see the improved health outcomes and care experience along with the reduced waste and greater joy that adding them to our existing team of outstanding nurses and other clinicians will bring.

Wednesday, September 3, 2014

Assuming and Speculating vs. Observing and Learning

Throughout the GBMC HealthCare System, excellent improvement work is being done to move us closer to our four Aims and our Vision. Where our teams have made the most progress is in letting go of behavior that proud people like me have a hard time getting rid of. We “learned professionals” have studied hard and have been trained to voice our opinion when confronted with a problem. We hear a few facts and quickly give our belief on a cause without really knowing. We assume many factors and then speculate on how these have contributed to the problem.

Engineers, as a group, do things differently. They are trained to observe things in action, to take things apart and to see how things really work or don’t work. Engineers are taught how to investigate; to get as deep as possible an understanding of an element or a process before thinking that they have a solution. When they believe that they have thoroughly studied a process only then do they test changes, one at a time, so they can see if their change is responsible for an improvement.

Engineers know that the best incident investigation is done immediately after the event with the people actually involved so that the steps can be recreated with as much fidelity to the true story as possible. Getting as deep an understanding of what happened by asking a series of “why’s” is the best way to generate tests of change to prevent the incident from happening again.

On a bad day in healthcare when we ask someone how defective care occurred (like a nurse going to give a medicine to a patient only to find that the medicine is not available to give) we get responses that begin with “Well, usually….” or “Sometimes….” Beginning the response with these words shows that the speaker has not investigated the occurrence, but, is merely speculating on the basis of his or her personal assumptions.

At GBMC, we are making great progress as our people work to investigate defects in close to real time to better come up with improvements. The learning from studying individual cases deeply is much more helpful than a perfunctory review of many cases. We leaders must give our people the time and resource to investigate defects as they occur. I look forward to hearing your thoughts on this.

I want to congratulate both Clair Francomano, M.D., Director of Adult Genetics at the Harvey Institute of Human Genetics and Janet S. Sunness, M.D., Medical Director of the Richard E. Hoover Low Vision Rehabilitation Services for their recent achievements.

Last month, we celebrated a monumental event, attended by Ehlers-Danlos Syndrome (EDS) patients and families from throughout the U.S., members of The Ehlers-Danlos National Foundation (EDNF) and GBMC leadership, to announce the official opening of The EDNF Center for Clinical Care and Research.  The major goals of the EDNF center are to expand treatment options for patients diagnosed with Ehlers-Danlos Syndrome (EDS), an inherited condition, which negatively affects the connective tissue that binds together skin, ligaments and bone.  EDS affects one in approximately 5,000 people in the US. Ours is the first center anywhere or at any time dedicated to helping EDS patients.  The center is being funded by EDNF which will give $250,000 a year over the next five years.  The funding will go toward providing comprehensive clinical care for patients, professional education , and cutting-edge research.  Dr.  Francomano will serve as the center’s Director.

Dr. Sunness has been selected to receive the 2014 Envision Award in Low Vision Research.  She is being recognized for her expert work and as a prolific clinician-researcher in the area of maculopathy and for her significant contributions, most specifically in the understanding of and defining the parameters in clinical trials for the “dry” form of advanced age related macular degeneration.  The Envision Oculus Award is presented to individuals or organizations whose efforts in professional collaboration, advocacy, research or education have had a significant national or international impact on people who are blind or have low vision.  The Envision Award in Low Vision Research recipient is chosen by peers and selected from among nominations submitted by the Envision Research Peer Review Committee.