Monday, January 25, 2016

Once Again, Our Staff Shows Their Commitment to Our Patients and Their Resiliency

Baltimore is now digging out from the largest recorded snowfall in its history. This past weekend, Team GBMC again demonstrated its commitment to its mission of health, healing and hope for the community. I witnessed the teamwork, camaraderie and “can do” attitude of our people first hand.

I am writing this late Monday morning. I have been on campus, along with many, many others since Friday night.

Stacey McGreevy, our incident commander, did a remarkable job coordinating everyone’s actions. Cate O’Connor-Devlin oversaw the complexity of 24-hour nurse staffing for over 200 patients. Michelle Tauson and Dan Tesch tirelessly exhibited their expertise in disaster management for the duration of our “code yellow” event. Dr. John Saunders, our Chief Medical Officer, was the administrator on-call and has also been on campus since Friday morning. This leadership team did a fantastic job to the point that a nurse told me that she had been with us for over 30 years but this was the best handled weather event in her tenure.

For sure, there are things that we have learned from this event…. our supply of cots, once numbering 500 is now too few for our needs – we will order more. We did a good job of telling people where to sleep, but, we need to generate a map of who will be where. But for the most part, things went smoothly and every patient got the care they needed.

Our environmental service and food service workers were extraordinary in their ability to keep GBMC clean and all of us fed (Dr. Saunders and I each gained a few pounds because we did not miss a meal.) Our grounds crew did their usual phenomenal job of clearing snow and our facilities team made sure that everything remained in working order.

Most of the nurses and nursing techs worked 36 hours in three days. Many physicians trudged on foot through snow to get here. After going to pick-up one of our essential physicians, who had walked a couple of miles to the interstate and dropping him off at the ED door, a patient asked me if I could give him a lift to the center of Towson. When I accommodated him, he was very grateful to not be among the stranded at our hospital. Our communications team, staff at Gilchrist Hospice Care and the pharmacy were exemplary.

All of our other clinicians, patient access reps, secretaries and other support staff did their jobs well and remained focused on our patients under trying circumstances.

Late Sunday night, we got a special treat when members (pic left) from the Chesed Fund/Project Ezra, Hatzalah, Shomrim and Chaveirim all brought us fresh bagels!

So, I am in awe of all of my GBMC colleagues. Thanks again for all you did for our patients! Is summer almost here?

Friday, January 22, 2016

Making Sure Our Patients Know What to Do When They Go Home

It is very hard for a patient to know precisely what they should do and what they should look out for when they are discharged from the hospital. I have spoken many times, in this blog, about the biggest failing of the U.S. health care system being its inability to efficiently coordinate care for those with chronic disease. Patients are often not sure what to do in the transition from inpatient to outpatient. (This morning, I learned of a patient who had prescriptions for 48 separate medications when she arrived at our hospital!)

To try to get U.S hospitals to fix the problem of poor coordination and other issues, the Center for Medicare and Medicaid Services (CMS) requires that hospitals participating in Medicare participate in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. The survey has 32 questions ( seven of them are demographic) that ask about things like care from nurses, care from doctors, cleanliness and communication. There are two questions that directly inquire about the discharge process for those not going to another health care facility. The questions are: “During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”

I encourage all blog readers to go to the Hospital Compare website and see how GBMC measures up against others on HCAHPS and other quality of care metrics:

Well, since our outstanding physicians, nurses and other staff members have been testing changes to better inform our patients when they are going home, like having the physician and nurse give the instructions together, we have made great progress! Just look at this run chart that combines the score on the two questions:
We are not at perfection yet…this work is difficult….but we have made great progress. Please join me in thanking our great clinicians for helping our patients to better understand what they need to know when they get home.

Our Housekeepers Are Preventing Infections!
We have now gone twenty-four days without a hospital-acquired Clostridium Difficile (C. diff.) infection. This is a fantastic accomplishment. C. diff. is a serious infection that causes abdominal pain and diarrhea that can be severe. Our Environmental Service team began a test of change recently where they are now sanitizing all rooms of discharged patients with bleach and it is working! Please thank our EVS staff when you see them. They are truly helping us treat everyone every time as it they were our own loved ones.

Friday, January 15, 2016

Celebrating the Accomplishments of our Nurses, Physicians and other Clinicians in Creating a Safer Hospital

Those of us who have been in health care for a while remember the days when we believed that infections that people acquired in the hospital were unavoidable. Because of this, we did not measure how often those in our care got a urinary tract infection because we had inserted a urinary catheter, as an example.  Now, we routinely measure hospital acquired infections (HAI’s) and we have been working hard to eliminate them.

Thanks to the outstanding collaborative improvement work of our nurses, physicians, and other clinicians, many of our units have gone months, and in some cases, years without any of the prevalent HAIs!  This accomplishment is truly a great cause for celebration because if it was your loved one, you wouldn’t want them to get an infection because they are sick and in the hospital.  The goal of coming to the hospital is to get better not to get a new problem.

Below is a list of the respective Units and their HAI Prevention Milestones:

Central Line Associated Bloodstream Infection (CLABSI):  
Without incident since 2008:  Unit 39 and Unit 54
Three-plus years without incident:  Unit 58 
Two-plus years without incident:  Unit 34, Unit 36 and Unit 59
One-plus year without incident:  Unit 38, NICU and Unit 48
Less than one-year without incident:  Unit 35 (six months), Unit 45 (seven months) and Unit 57 (10 months)

Catheter Associated Urinary Tract Infection (CAUTI):
Without incident since 2012:  Unit 39 and Unit 54
Three-plus years without incident:  Unit 36, Unit 38, Unit 45
Two-plus years without incident:  Unit 35, Unit 48 and Unit 58
One-plus year without incident:  Unit 34
Less than one-year without incident:  Unit 57 (10 months) and Unit 59 (three months)

One of the major reasons that we are much less likely to have HAI’s is because we have a 95 percent Hand Hygiene Compliance rate house-wide! Our remarkable hand hygiene rate plays an integral role in the prevention of all infections, not just CLABSIs and CAUTIs.  Maintaining the standard work of “washing in” and “washing out” is critical to our success!

Again this is great cause for celebration of the hard work of our nurses, doctors and other clinicians but especially to our nurses and nursing support technicians who maintain the catheters and lines, turn the patients to avoid bedsores and who make sure that the ventilator bundle is followed to prevent ventilator associated pneumonia.

Great job everyone and thank you!

Thursday, January 7, 2016

Reducing Missing Medications By Studying The Incidents As They Happen

I remember one of our first visits to Unit 38, during Lean Daily Management (LDM) rounds, in April of 2013. The clinical unit coordinator reported that there had been 35 missing medications the previous day. This meant that 35 separate times, within a 24-hour period, a nurse went to give a patient his or her medication and it was not present. This report really bothered me. The nurses on that unit work incredibly hard. The beds are always full and the patients are very sick. There was nothing odd about that day…nurses were looking for meds that were not there about that many times every day! There had been an acceptance that this was just the way things were and nothing could be done about it.

Reliability means that what should happen happens and what should not happen … doesn’t. A highly reliable medication delivery system would have all of the medications present for the nurse as they were needed. Our nurses found themselves in a very unreliable medication delivery system.

The “old” way to fix this problem was to find out who made the mistake. There must have been someone in the pharmacy who didn’t know what they were doing or didn’t care or both. But nothing could have been farther from the truth.

GBMC has always had outstanding pharmacists and technicians who really care and work as hard as the nurses. The real problem is that moving thousands of doses of medications from the pharmacy to the nursing units in the correct doses, and always on time, as patients are being discharged and new patients are arriving is a really, really complex problem. Our processes were not reliable enough to get the job done.

We have made phenomenal strides in reducing missing medications over the past three years. The missing meds team, which includes nurse managers and pharmacy staff, began working with individual units, like Unit 38, to study the causes of missing medications and test system changes to reduce them.

Over the past year, under the leadership of Pharmacy Director Cherryl Peterson and Lead Clinical Pharmacist Vaishali Khushalani, the team has been studying individual missing doses as soon as they happen to heighten the learning and find more specific process improvements to test. The Pharmacy has worked with SICU, under the direction of its nurse manager Jen McDonnell, and they have made incredible progress toward 100 percent reliability. The SICU, which added ‘missing meds’ to its LDM board in June 2015, started with a monthly average of 28 missing meds. A pharmacist began conducting a real-time assessment to find the cause of the defect. Representatives of the SICU team and pharmacy began meeting with the missing meds team weekly to share the previous week’s learning.  This has helped identify unit-specific and house-wide issues and solutions. One of the earliest interventions was the addition of an extra tower to the SICU’s Acudose machine, housing electrolytes and other IV medications that would often be missing.  Another recurring issue was that of missing medications on transfer from the ED or GOR PACU.  The Pharmacy developed a process to ensure delivery of medications to the appropriate unit after such transfers by getting an hourly transfer report. There were only 11 missing medications in the SICU in the entire month of December. What great improvement!
Let me particularly thank all of the staff of our pharmacy and the clinical unit coordinators of the SICU for their great work in making our processes more reliable to drive out wasted steps, improve our care, and make GBMC a better place to work!