Monday, January 26, 2015

Delivering on a Promise to the Community

Last Thursday, I traveled to Annapolis to address the Senate Finance and Budget and Taxation Committees. I was part of a panel from the Maryland Hospital Association (MHA) that was asked to give the Senators an update on how hospitals are transforming themselves in order to meet the four requirements of the new waiver: to keep hospital cost increases no higher than the rate of increase in the general economy, to improve the quality of inpatient care, to reduce re-admissions and to save money for Medicare.

At the hearing, there were two panels. In the first panel, the Senators heard from John Colmers, the Chairman of the Health Services Cost Review Commission, the body that sets hospital rates and must assure that the State complies with the waiver mandates, and Donna Kinzer, the Executive Director of the Commission. These two leaders did an excellent job of educating the lawmakers on the basic tenets of the waiver and how the State was performing so far.

The Committees then heard from David Horrocks, the Executive Director of CRISP (Chesapeake Regional Information Sharing for our Patients network), our regional health information sharing network. Mr. Horrocks told them of the work of CRISP in sharing patient information across hospitals.

The Chairman of the Finance Committee, Senator Mac Middleton, then invited the hospital panel to address the senators. Carmela Coyle, the President of the MHA, told them that the hospitals had embraced the notion of global revenue budgets as a means to begin converting towards higher value health care and that significant progress had been made in a short period of time. Carmela referenced the waiver “dashboard” ( that the MHA was updating monthly.

Then it was my turn. I had been invited because of all of our accomplishments to date in building a system of care through the eyes of the patient – a system that can achieve our four aims of the best health outcome with the best care experience with the least waste of resources and the most joy for those providing the care, in other words, the care that you would want for your own loved one. I told the senators a bit about our hospital, our hospice, our excellent physicians and nurses, and our outstanding acute care capability, especially in surgery. I then told them of our vision, our 100+ primary care providers practicing in the patient-centered medical home working with embedded care managers, our extended hours of operation, and our daily use of CRISP to assure that our teams were not missing important information about our patients. I concluded with a few examples of our results so far and I informed them that GBMC has the lowest readmission rate in the State among non-rural hospitals. I had a huge sense of pride as I was speaking. We are delivering on our promise to the community. While I knew that the legislators did not understand everything that I was saying, I also knew that they were grateful for the work of the GBMC family. We were not asking for more money or lamenting our lot in life and telling them how hard our work was (even though it is!) – We were transforming into a company that can deliver better outcomes at lower cost and we had data to prove it. I want to thank all of my GBMC HealthCare System colleagues for being in action on change for the better!

Friday, January 16, 2015

Improvement Across Departments Requires “Boundary Spanners”

The GBMC HealthCare System is making great progress in improving care. Every morning on Lean Daily Management rounds I hear of tests of change that have led to better outcomes under our four aims. We are making performance improvement the way we run our organization.

Dr. Deming taught us the importance of deep process knowledge. Without knowing how the work is actually happening, we have no hope of generating better designs. We must go to the workplace, or as the Japanese call it the “gemba” and observe the process to find the opportunities to make it better.  It is clear to me that when the work is totally within the control of a given unit or department, we make progress quickly. There are many examples of this at in our system of care, but one that I spoke about in this blog is the work of Charlene Mahoney, RN, Lewis Hogge, MD, and their team in the GOR PACU. They quickly identified a design change and got to 100% completion of the final check by the Anesthesiologist before the patient leaves the PACU.

In a complex system, like a hospital, it is much more difficult to improve performance when the process involves more than one unit or group. This is because no one “sees” the whole process. People know the part of the process that they are involved in and are quick to assume what is happening in the rest of the process. An example of this is in our process for medication delivery from the pharmacy to inpatient units. I remember in April 2013, at the Unit 38 LDM board, it was reported that there had been over 30 missing doses of medication the day before. This means that when a nurse went to give a patient a prescribed medication, it was not there at the time it was due. Through the hard work of our nurses, technicians and pharmacists, the rate of missing medications is much lower but we are still not at perfection. It is hard to fix the remaining defects because it requires direct study of each defect across the departments and units involved.

In this blog, I have been talking about mindfulness and the tenets of high reliability and referring to the work of Drs. Karl Weick and Kathleen Sutcliffe. Last week, I commented on the commitment to resilience, or the enhanced ability of high reliability organizations to deal with and overcome the unexpected. Another tenet of mindfulness is the reluctance to simplify.  Weick and Sutcliffe point out that high reliability organizations do not jump to conclusions and they do not allow people who haven’t seen and studied the entire process to suggest changes to the process. They suggest that organizations have “boundary spanners” or people that go from one department to see the part of the process that they don’t know in another department. This is the same concept as going to the “gemba” in Lean terms.

Boundary spanning is hard because we generally don’t have people who have created time in their schedule to do it. Instead, they are put in the position of spending their time fixing the same problem every day like in the movie Groundhog Day. In the medication delivery example, we need to do the hard work of studying the few remaining missing doses to come up with the improvements required to eliminate them. We need boundary spanning and we need to be reluctant to simplify and assume why things are not going well to avoid making the situation worse.

Do you have an example of boundary spanning or going to see the work in another department that has resulted in better care?

Friday, January 9, 2015


In the GBMC HealthCare System, we are students of high reliability. We have to be if we are working towards our vision of patient-centeredness and treating everyone, every time, the way we want our own loved ones treated. The defining characteristic of high reliability organizations, according to Dr. Karl Weick, the internationally recognized expert in this field, is “mindfulness.” You can think of mindfulness as a heightened awareness of what is going on around you coupled with an unwillingness to believe that since everything is going along smoothly, things will continue to progress smoothly. Highly reliable organizations have robust processes (standard work) that can be relied upon, but they also anticipate and become aware of the unexpected faster so that they can deal with it.

In previous blogs I have discussed one of the fundamental underlying concepts of mindfulness - preoccupation with failure. This week, because of the outstanding work that our people have done in dealing with the influenza epidemic, it occurs to me that I should write about another of the concepts – a commitment to resilience. Dr. Weick points out that highly reliable organizations develop better capabilities to detect, contain, and bounce back from unexpected events. They learn from things that don’t go well and refine their processes. They try and plan to be ready for whatever might come their way, but still they can get caught unprepared for a rare event or for the magnitude of a less rare event. Such is the case with our current influenza epidemic.

Over the last 3 winters, we have not had huge increases in demand due to the flu.  One day last week, our emergency department saw 238 patients in a 24 hour period. Our normal average number of patients is around 150 per day. Imagine any business that needs to serve over 50% more customers than the usual! The ED nurses, physicians, nurse practitioners and physician assistants came in early, stayed late, and came in on their days off in order to serve those in need.  

And clearly all of the extra work has not been limited to the Emergency Department. Our hospitalists have also had huge increases in workload. Our hospitalists normally cover around 70 patients per day and they peaked earlier this week at 98. Our inpatient nurses and nursing technicians have also been tirelessly caring for a higher number of patients than usual. We opened Unit 37 to care for more acutely ill patients, and the intensivists and critical care nurses made it work.  All of our other clinicians, from therapists and phlebotomists to lab and radiology technicians, have all dealt admirably with the influx of patients. Of course our environmental services and food services teams have also had to rise to the occasion and cover the increased demand. Every member of the GBMC team has pitched in at some level to get the job done.   

I am very grateful to all of my colleagues for their expertise, hard work, and resiliency. Our patients and our community are so much better off because of their efforts.