Evidence of an Improved Culture of Safety

A marvelous thing happened on Lean Daily Management rounds today. My LDM Team is “Team A.”  Deloris Tuggle and I are the senior leaders on this team. Deloris was away today, so Kevin Creaby, our Manager of Benefits, was standing in for Deloris and we were accompanied on the walk by Ishmel Fulton, our new Lean Facilitator. We were on our way to the PACU board, rounding the corner, passing the family waiting room desk for the General Operating Room, when we heard: “Gentlemen, stop! You must clean your hands before entering the PACU!” I turned to see that this message had been delivered by one of our superb volunteers. She and a colleague were looking at us with smiles on their faces, but, they were not kidding. We thanked them for the reminder, cleaned our hands, and proceeded into the PACU.

Readers of the blog may remember my posting: A Just Culture Fosters a Safer Culture (Dec. 11, 2013) http://ahealthydialogue.blogspot.com/2013/12/a-just-culture-fosters-safer-culture.html. In that blog post, I spoke about the Tenerife crash, the worst disaster in the history of commercial aviation, where the belief is that the two co-pilots could have prevented the event, but they were afraid to say anything that might upset the captain. The unwillingness of “subordinates,” people lower down in the organizational hierarchy, to speak up is a detriment to safety and a sign of a poor safety culture. So, as we were entering the PACU after having cleaned our hands, I was really delighted that volunteers felt comfortable speaking up to the President and CEO of the organization. I was very proud of them and happy that we are making progress towards our vision!

Continually Improving Lean Daily Management

Lean Daily Management (LDM) has been a huge success for GBMC HealthCare. But there is always room for improvement. The Senior Team has been studying the groups that make the most improvement to find ways to help others. When the local manager and his or her team understand that LDM is about problem solving, much more improvement happens as opposed to groups that act as if telling the story of “red” or “green” is the end. We on the Senior Team now see that in our zeal to “help” by asking questions about the specific problem, we may actually be slowing down the problem solving.

On the LDM walk, some teams are celebrating when a metric is “green” even though they have not changed anything since it was last “red” and they apologize when the performance is “red.” We frequently have to remind them that if something is “green” but nothing in the process was changed that it is likely to return to “red.”

I have written before in this blog (http://ahealthydialogue.blogspot.com/2014/04/red-is-not-badge-of-dishonor.html) about how “red” should not be looked upon as being bad – it is merely an opportunity to problem solve so there is no need to say that they are sorry or feel that they have to defend themselves.

The job of the Senior Team is to hold managers accountable and ask questions to generate problem solving, NOT to offer advice to fix the specific problem.  The Senior Team must make sure that the manager and the unit or department have what they need to get the job done and then say thank you.

So, we on the Senior Team have committed to ask questions like “What have you learned?” and “What are you going to try next and when?” and not get involved in suggesting fixes. This should help us get more out of a tool that has already been immensely helpful! What do you think? I would love to hear your thoughts.

It Takes The Whole Team to Meet Our Patients’ Needs

I recently had an experience with a loved one in a hospital in another state that really bothered me. I went to visit my family member who was a very sick inpatient, and he told me that earlier in the day he had had a very acute need. He had pushed his call button to get help, but unfortunately, no one came to his aid for more than an hour.

It wasn’t that the staff in that hospital didn’t care. My relative’s nurses were very polite and hard working, but, they were also very busy. It was clear to me that there was no real sense of collaboration. The unit secretaries, housekeepers, nursing support technicians, other nurses and even the occasional administrator who came to the unit did not see responding to the call light as part of their job descriptions. I also got the sense that there was no attempt to anticipate my relative’s needs. When someone came into his room, they had one thing in mind. They did that one thing and that one thing only, and then left the room. In that hospital, my loved one did not get the care that I wanted him to get.

I wondered if this could happen at GBMC? I know how hard our nurses and support technicians work and that our patients – especially the very sick and elderly – have many needs. I asked myself the question, “Did I always go to answer a call light when I was a practicing physician on the unit if the staff was busy doing other things?” The answer was clearly that I did not.

I was very happy to hear of the rollout this week of the GBMC “NO PASS ZONE” (NPZ), a new hospital policy regarding how our clinical and non-clinical staff respond to our patients in need. If an alarm goes off or a call bell light is seen and/or heard, someone – even a nonclinical employee – will respond immediately. The concept of an NPZ has helped prevent falls and aid workers in responding more quickly to patients in need when it has been implemented elsewhere.

How does the NO PASS ZONE work? If you see a call light on, you CAN do the following for a patient:

• Reposition the call light, telephone, bedside table, chairs, trash can, tissues or other personal items within reach.
• Assist with making phone calls or answering the telephone.
• Change TV channels or turn the TV on or off.
• Turn the lights on or off.
• Obtain personal items such as blankets, pillows, towels, washcloths, toiletries, pens, pencils, books, magazines, etc.
• Reduce clutter.
• Perform and encourage hand hygiene.
• Alert the clinical staff for all clinical needs.

We should always use AIDET communication standards (Acknowledge, Introduction, Duration, Explanation, Thank You) upon entering the patient’s room. If you need a reminder about the AIDET communication standards, they are listed and explained on the small Service Excellence and AIDET card behind your GBMC badge.When entering an isolation room, we must also follow the proper personal protective equipment (PPE) requirements which will be displayed outside of the room.  If you do not have an AIDET badge please contact Courtney Hendon in Service Excellence.  She would be more than glad to provide you with one.

I know that some of my non-clinical colleagues are nervous about assisting a patient, but there is no expectation that a non-clinical person do anything clinical. Everyone can help meet the patient’s other needs or get help from a clinician if the problem is clinical. It takes the whole team to work together to get the job done. Thanks in advance for making NPZ work!

Gray and Son Construction and GBHA – A New Partnership for the Quadruple Aim

The United States has one of the most complex health insurance systems in the world. An individual could be covered through a governmental program like Medicare, Medicaid or the Veterans Administration; they could be covered because their employer buys a health insurance plan for them or they could buy their own health insurance policy. In addition, many of us are covered because our employer pays our healthcare bills directly. I get coverage through GBMC. GBMC does not actually buy health insurance for its employees….it pays the bills for care as they come in. We contract with a company that handles the payment and we buy what is called “stop loss” insurance for very large claims. So we are able to say that GBMC is “self-insured”. We are not alone in this practice. Most larger companies are self-insured.

It is in the interest of the self-insured company to get the most value for the healthcare dollar spent. But until now, most companies didn’t pay much attention to what they were paying for a service. It was almost as if the employer was assuming that all services were the same, no matter who the provider was and that the costs were about the same. Well we know that this is not true. Some providers of care can charge as much as 60% more for the same service and the quality of the care received is not always the same.

So a few weeks ago I was very happy to meet with many of the employees of Gray and Son Construction.   Gray and Son is a leading contractor in the Baltimore area for both private and public projects, specializing in paving, excavating, utilities, and soil stabilization. It is a family-owned business steeped in tradition that dates back to 1908. I learned that the company intends to remain independent and looks out for its people. I realized that GBMC HealthCare and Gray and Son had a lot in common-both are local, independent- and relatively small, giving both companies an agility that makes it easier to get the job done and provide greater value to those that they serve.

Gray and Son saw the value that the Greater Baltimore Health Alliance could provide. They understood that advanced primary care with a team of caregivers led by a physician that was available and accountable could help them with prevention and the management of chronic disease. They knew of the great specialists at GBMC and that our outstanding hospital is lower cost than most in the area. Gray and Son learned of GBMC’s success in keeping the healthcare of its employees within the GBMC family while lowering out-of-pocket costs to its employees and they decided to do the same. So, Gray and Son employees will now have a “GBMC tier.”  If they use GBMC doctors and GBMC facilities, they will pay less. We will deliver improved clinical outcomes and better care experiences, showing them that we believe providing healthcare is a joyful pursuit.

Please join me in welcoming the people of Gray and Son into this partnership for better health and better care with the least waste and the most joy for those providing the care….our quadruple aim!

THANK YOU TO OUR SOCIAL WORKERS!!!
March is Professional Social Work month and I want to thank our dedicated group of social workers (pic below) who serve GBMC.  I am constantly impressed and humbled by the creativity and determination of this group. Our social workers carefully arrange for care of patients after they leave the hospital. Our social workers and care managers have helped GBMC reach the lowest readmission rate in the state and have designed a system that assures that our patients with advanced illness receive the continued support they need after they leave our hospital. Please take the time to say “thank you” for all they do.

How did our checkup go?

GBMC recently underwent its triennial survey by The Joint Commission (TJC), an independent, not-for-profit organization that accredits health care organizations.

GBMC is working towards its vision of perfection: treating every patient, every time the way we would want our own loved ones treated. For this reason, we don’t dread the unannounced arrival of the surveyors. Having outside experts check to see if the processes are all in place to deliver perfect care is very helpful. Outsiders might see things that we miss. As a learning organization, we welcome the identification of defects so that we might fix them.

The five-member survey team visited our inpatient units, procedural areas, and outpatient settings providing a thorough and comprehensive assessment of our policies and procedures, documentation, and environment of care. They rated us on the national patient safety goals, our leadership and governance oversight.

We did very well on our checkup. The surveyors applauded us for our quality improvement work, especially Lean Daily Management. They told us that we were well on our way to becoming a high reliability organization. The surveyors did find areas where we need to improve. In an area where we have had no infections, they found that our standard disinfection work was not following best practice to assure sterility. Changes were made on the basis of this learning before the surveyors left GBMC and a team will be returning in 30 to 45 days post survey to assure that our new designs are firmly in place.

Throughout the process TJC surveyors commented on our staff’s professionalism and engagement and their commitment to do what is best for their patients and their families. The surveyors also praised the overall cleanliness of the hospital environment.  At the final session, surveyors recognized GBMC as an organization to which they would confidently send their own loved ones!

So, congratulations and thank you to all for an excellent checkup!

GBMC concluded the celebration of Black History Month. During February we had a number of events that incorporated decorating the display case on the 5th floor to highlight excerpts from famous speeches and poems by African Americans, daily physician trivia, our annual Sweet Potato Pie Bake-Off (Congrats to Marcia Tepper for winning this year’s contest!) and the canned food drive for the Bea Gaddy Shelter in Baltimore.

Our celebration culminated with a visit from Dr.  Raymond A. Winbush, Director of the Institute for Urban Research at Morgan State University, and entertainment from the Cristo Rey Student Steppers (pic right). Dr. Winbush gave a passionate speech on how GBMC over the last 50 years has progressed from its humble beginnings to a jewel of the community it serves.  Dr. Winbush emphasized our long history of treating patients well regardless of race or gender. This rich history is something that we, as GBMC employees, should be proud of.  I would be remiss if I didn’t mention the great work of the Cristo Rey Student Steppers (pic right).  It is very important that we take time at least annually to recognize the contributions made to our country by our African-American brothers and sisters.