We Need To Act More Like Engineers

All improvement requires change, but, not every change results in improvement. Engineers are taught this. Medical education and nursing education have only recently begun to include systems thinking in their curricula. I was speaking with one of my most trusted colleagues, Dave Hynson, our Chief Information Officer, and he was reminding me how we are pushing to shorten the time to action. We want to move faster towards our vision, but, we have to be careful when we create change so that it actually leads to improvement. Dave and I were talking about some recent examples of changes that went well and others where we may have skipped some steps and moved too soon to implementation.

I have spoken in this blog before about Walter Shewhart http://ahealthydialogue.blogspot.com/2013/10/continuous-improvement-method-that-will.html, a giant in the history of the application of science to industrial quality. Walter was a physicist, engineer and statistician. He worked at Bell Laboratories in the early 20th Century and was responsible for many early telephone improvements. He is also known for the famous Shewhart or PDSA cycle: plan, do, study, act. He taught many industries how to apply the scientific process to the creation of a product. Prior to his work, many business owners thought that poor quality was always due to lack of effort by the workers.

Today, we know, especially in health care, that we have an incredibly smart, dedicated, well-trained and hard- working staff.  We are desperate to deliver on the quadruple aim and we know we need to change and people like me want the improvements to have happened “yesterday”. Because of this, some of our people are doing plan-do, plan-do, plan-do. Dr. Shewhart, being an engineer knew that not all changes result in improvement and that is why the cycle is plan-do-study and only then – act.

We are a bit too quick to create a change that we think will help and roll it out. We are much better off if we declare our aim first and then ask ourselves “how will we know if a change is an improvement?” and only then begin thinking about what we could change. Once we have an idea we must test it on a small scale to see if it will work. After we test it, we should study our results and then based on how it went, either implement our change or do the next test.

When we push things out into use without testing them first, we are less likely to have a smooth implementation that achieves our original aim. Bell telephones were the world-wide standard for telecommunications’ excellence in the 20th century thanks to the work of Shewhart and his colleagues. Let’s become the same for healthcare excellence in the 21st century using his methodology.

Acts of Kindness and Smiles

This week, and for the first time ever, GBMC celebrated "Random Acts of Kindness Week.”  Our Marketing and Communications, Philanthropy and Human Resources Departments collaborated to bring this initiative to life. The goals were to thank our staff, our patients and their families and our donors for all that they do for the GBMC HealthCare System and to bring smiles to their faces. In addition, we conducted a canned food drive to give back to our community by supporting the Bea Gaddy Family Center.  One alarming statistic shows that one out of eight Maryland residents struggle with hunger. The Bea Gaddy Family Center provides food to needy families throughout the greater Baltimore metropolitan area and throughout Maryland.

We didn’t come up with the idea on our own. Random Acts of Kindness (RAK) Week, which started on Sunday, Feb. 14, is a national observance to encourage people in spreading kindness with “pay –it forward” actions.  At GBMC these actions were spearheaded by the BeKind Brigade, comprised of GBMC staff from various departments, who randomly choose a certain hour on a selected date, to walk around the medical center and conduct random acts of goodwill.  Others took initiative by conducting their own acts of kindness. For example, the care manager at our Perry Hall primary care practice, Lisa Anglin, surprised her colleagues with breakfast (pictured above)! What a great way to show her colleagues how much she cared about them. 

On Tuesday, we distributed meal vouchers for the cafeteria to staff and patients and families. On Wednesday, we distributed parking vouchers to patients and family members. The patients that I gave vouchers to were stunned to be stopped in the hallway and receive this gift. Each person had a big smile on their face when I walked away.  

We kicked off the festivities by distributing KIND bars to employees at GBMC and satellite locations while encouraging them to sign up for the Blood Drive.  A total of 100 meal vouchers and on Thursday 100 free coffee vouchers were given to community members and employees.  

Please remember that even though RAK week ends this coming Saturday, our canned food drive will continue until Monday, Feb. 29.  Please consider dropping off non-perishable food items to one of our various 14 drop-off locations in the main hospital or at all GBMC primary care offices.  We often see food drives being held around the holidays, but many of our local families are in need of food year round.

  

The GBMC staff always rises to the occasion to help people. Imagine how much better our society would be if the culture of “spreading kindness” took place every day, not just here at GBMC, but everywhere.  I know that the GBMC family is up to this challenge to embrace showing kindness always.

Thanks to everyone who made this first Random Acts of Kindness Week at GBMC so successful.

Speaking of kindness, I also want to ask that you please join me in helping sexual assault victims in our community, as GBMC will be hosting Walk a Mile in Her Shoes®:  The International Men’s March to Stop Rape, Sexual Assault & Gender Violence.  The one-mile walk event, in which men (wearing heels) and women (wearing tennis shoes), is taking place as a way to educate the community and support our SAFE and domestic violence program.  We encourage men and women to register for the event, slated for Saturday, Apr. 16 from 11 AM to 1 PM, by visiting: https://www.eventbrite.com/e/walk-a-mile-in-her-shoes-tickets-20458939238 or if you can’t participate, but, want to financially support a registered participant, please visit: https://www.crowdrise.com/walkamileinhershoes5/fundraiser/

The Support of a Leader to Help Redesign the Maryland Mental Health Care System

Earlier this week, I had the privilege to participate in a roundtable discussion, spearheaded by U.S. Senator Ben Cardin (D-Md.), that dealt with the challenges of mental health care in the United States. Joining me in representing GBMC were JoAnn Z. Ioannou, DNP, MBA, RN, NEA-BC, our Senior Vice President of Patient Care and Chief Nursing Officer, Robbin Motter-Mast, DO our Chair of Family Medicine and Jeffrey P. Sternlicht, MD, FACEP, Chair of our Department of Emergency Medicine.

The roundtable consisted of many physicians, hospital administrators, community mental health care advocates and providers that discussed ways to improve our mental health care system. The lack of adequate inpatient psychiatric beds and a well-functioning crisis intervention system has gotten the attention of many. Every day in the GBMC Emergency Department, for example, we house 5-12 people who are living there waiting for a psychiatric bed.  The panel’s discussion was led by Dr. Steven Sharfstein, the President and CEO of the Sheppard Pratt Healthcare System. The group discussed the nature of the problem and  potential ways to overcome the many hurdles to delivering the best possible care in cases of mental illness and substance abuse in Maryland and across the nation.

I applaud Sen Cardin’s dedication to reforming mental health care and for treating this as an unwavering priority for our nation.  I look forward to helping the Senator make sure that Americans who require mental health care services have access to them.

Recognition for 10 Years of Great Education
Many years ago, the Executive Director for our Center for Spiritual Support Training, The Rev. Joseph Hart, M.Div., BCC, along with a few of his colleagues, gathered around to examine the issue of ministry preparedness, and its future, in a changing world.  Joe and his group started to look at ways they could impact the larger community and how as a community medical center we could respond not only to the spiritual needs of those who come to us for care, but also to those in need of a clinically challenging educational program, but for whom Clinical Pastoral Education (CPE) programs were not an option.  Well, Joe and his group came up with a new option and that alternative is now approaching a major milestone…its 10th anniversary.

I congratulate Joe and his group in celebrating our Center for Spiritual Training program’s longevity and success.  When it first started it was a 10 week, 40-hour curriculum and it has always received overwhelmingly positive feedback from students. Students have come from a variety of faith traditions as well as vocations, both lay and ordained.  In 2015, the Episcopal Diocese of Maryland approached the Center to explore the possibility that our program could serve as an alternative to CPE for Diaconal Candidates.  In response to their idea, Joe and his team expanded the classes from 10 weeks to 30 and included a broader range of topics. With the approval of the Bishop, we welcomed 5 individuals in the fall of 2014 and they graduated last spring.  Again, lets congratulate Joe, his team and program graduates not only for their 10 years of valuable service and successes, but, for being such a model educational program!

High Reliability: It’s Hard to Get to Zero

By now, most people in health care understand that safety is a system characteristic and that we owe it to our patients to not create harm when they come to us for care. Many people now understand that we operate in a large, complex system and that the system is full of “latent” errors like not knowing what the evidence says is the best care or not following protocols when we do.  When these latent errors align….a patient gets hurt. What those of us who work on this every day now know is that it’s really hard to drive out all of the latent errors in the system. It is really hard to get to zero injuries to patients!

So, when we do get to zero in some area of harm, it's really a cause for celebration. GBMC, our beloved medical center, has now gone 6 months without a single central-line associated blood stream infection! This is phenomenal news. Some hospitals only measure this for central lines in patients in intensive care. We measure this for all patients on all units. As the run chart below shows, as recently as August of 2014, we had a rate of 3.5 infections for every 1,000 patient days with a line in place.

We did not get to this outstanding performance by wishing or hoping. We got there by making a commitment to get to zero and by filling the holes in the “Swiss cheese” - that is, by making sure that we found the weaknesses in our defenses against the central line seeding bacteria into the bloodstream. We have always had excellent doctors, nurses and other clinicians and they really cared and worked hard but we were not always acting according to the evidence on how to avoid these infections. So, we created standard evidence-based work for inserting a line and we audited our performance to make sure the standard work was being followed. We created standard work for how the lines were used and maintained on a daily basis and we checked to see that this work was being followed as well. We also developed standard rules for assuring that the line came out as soon as it was no longer needed. Every time we had an infection, we studied the events to see if we could find the cause to root it out so that it could not cause a future infection.

Will we ever have another central line infection? We probably will because our systems are much better but they are not perfect and we still have humans working in health care. Our people are very smart and work very hard but they are sometimes distracted. There are also uncommon “special causes” that arise that are beyond our control – like the rare patient with mental illness who was purposefully contaminating a line. But I am so proud of our team for the outstanding accomplishment of 6 months without a CLABSI. Zero – 100% reliability - is hard but it is not impossible.

Our patients do not usually thank us for not harming them (when was the last time you thanked a pilot for not crashing your plane when it landed) but let me thank all of our clinicians for getting us closer to our vision.