Friday, January 27, 2017

A Hospital with Everything in its Place

I am so proud of my colleagues in the GBMC HealthCare system for all the progress we have made towards high reliability (what should happen always happens and what should never happen doesn’t happen). An example of this progress, that we have discussed previously, is our reduction of catheter-associated urinary tract infections (CAUTI’s). Back in 2011, CAUTI’s happened a few times a month at GBMC. Since then, because of the creation of standard methods for deciding who will really benefit from a catheter and standard methods for maintaining the catheter once it is put in, these hospital-acquired infections are now rare. But we still have work to do.

We are still prone to want to do things the way it feels comfortable to us in the moment. This is especially true of people like me who have been in health care quite a while and can remember when nothing was standardized. Back in the “good old days” almost everything was happening by chance and almost nothing was happening by design. We had workarounds for everything. When I was a resident back in Massachusetts in the 1980’s we didn’t trust the lab to get us results in a timely fashion, so we ordered almost every lab test “stat.” We didn’t realize that once every test was ordered stat, nothing was truly stat. Our work-around corrupted the system and actually made things worse. It is very hard to get people to understand that when they drift, cut corners and do not follow the design, it just creates problems for themselves or others although it may not be apparent to them in the moment.

Last week, I was having a discussion with a colleague about a broken bed being left in a narrow corridor on a nursing unit. I was concerned that this bed was blocking the egress of our patients if there was ever a fire. My colleagues on the unit, who were all outstanding doctors, nurses and techs and who were all working very hard, had come to accept the fact that beds would occasionally be blocking the corridor. They knew that the system for expeditiously removing unneeded beds was unreliable. What they didn’t understand was that their “tolerance” of the beds not being where they belonged was actually making the problem worse.

Since it's so hard in a large complex organization to get everyone to follow a disciplined and standard process, most improvement experts believe that leaders should start with the technique known as 6S, that we have discussed in this blog a number of times before.

1. Sort: eliminating everything not required for the work being performed.
2. Separate: efficiently placing and arranging equipment and material.
3. Shine: tidying and cleaning.
4. Standardize: standardizing and continually improving the previous three.
5. Sustain: establishing discipline in sustaining workplace organization.
6. Safety: creating a safe work environment.

6S is seen as part of our foundation because the daily practice of making sure that your workspace is clean and organized takes discipline and the effects are easy for all to see. When the senior team goes on LDM rounds, we all look for litter on the floor and we pick it up and dispose of it when we find it. We are also intolerant of clutter and we are in action to get everything in its place. Here is a photo of a linen cart that was left in a corridor right next to a sign (an “affordance”, a reminder that is visible in the moment, also known as level two mistake proofing) that says “No equipment storage allowed in this area.”

Why do you think one of our colleagues left the linen cart there? Of course I don’t know but I suspect that the person was working hard and needed to go and do something else and decided in the moment that it was ok and probably did not think of the downstream effect of leaving it there. It was not blocking an egress but what if a few hours later a colleague needed a cart and couldn’t find it? What if a patient’s family member saw it and thought less of GBMC because of the clutter?

We have set cleanliness as an annual individual goal for all GBMC employees in this fiscal year. We each need to own 6S in our workspace wherever that is. What can we do to make this happen? Please let me know your thoughts.

GBMC United Way 2017

Finally, I encourage all GBMC HealthCare employees to consider participating in our United Way campaign which started this past Monday and runs through Sunday, Feb. 5th   Each year we partner with the United Way to give back to those who need our help the most, whether it be contributing to your favorite GBMC program or giving to the community and helping families stay in their homes and out of shelters, for example.

This year's campaign will feature a raffle, special Jeans Days, and a "ski-off" competition between various groups within our system.

Click here to view instructions on how you can make an ePledge today.

With your help, we can reach more people than ever! Thank You.

Friday, January 20, 2017

Do we ask the patient: “What matters to you?”

Recently, I was having a conversation with a friend about the care of his elderly relative. My friend was a bit annoyed that his relative was not following all of the advice of his physicians. My friend obviously loved his family member and was really concerned about his health. He told me that he had had a frank conversation with this loved one and that if he did not follow all of the advice of the physicians, that he “was done.” By this, my friend meant that he would not be as attentive when his loved one called for help.

I asked my friend if he had asked his relative what mattered to him. My friend looked perplexed at my question. People are used to following their doctors’ recommendations, as they should be, but is following every well-intentioned recommendation really the “bottom line?” Shouldn’t we start any conversation about a plan for people with chronic disease, especially those towards the end of life, by asking “What matters to you?”

In my friend’s example, he was most annoyed by his loved ones’ dietary indiscretions. Well, the loved one was already frail and eating his favorite things was one of the few pleasures he had left. So eating what he liked, meant more to him than possibly shortening his life by a few days or hours.

Maureen Bisognano, the former president of the Institute for Healthcare Improvement (IHI), first began encouraging clinicians to change the question to the patient from “what is the matter with you?” to “what matters to you?” The ultimate decision about diagnostic tests or therapies lies with the patient, not the physician. The role of the physician, or advanced practitioner, is to lay out the choices along with the evidence as to their efficacy. Knowing matters most to the patient will help guide the dialogue between the provider and the patient and has a better chance of resulting in a plan that the patient will actually adhere to.

At GBMC we have learned a lot through our study of people who leave our hospital “against medical advice,” in other words leaving when we think they need to stay for some diagnostic procedure or therapy. We have met patients who leave rather than get fired from their job and patients who leave rather than miss a family celebration. Knowing what matters most to the patient may not change our primary recommendation, but it may get us to a common ground that ends up in a better plan.

So, let’s work to make the conversation about “What matters to you?” to be part of our standard work with people with chronic disease. What do you think about this? Please give me your thoughts.
Helpful links to IHI and “what matters to you?”

Friday, January 13, 2017

Remembering a Man of Peaceful Discourse, Learning and Reflection

Earlier today, GBMC hosted its 3rd annual Martin Luther King Jr. Day celebration which commemorated Dr. King’s life and vision. This year’s program, titled “Hear My Voice, Engage My Soul,” featured a keynote presentation by the Rev. Dr. Tim Tooten, who is also the education reporter at WBAL-TV, along with live music from the Cristo Rey Choir. I would like to begin my blog post with my introductory remarks from the celebration.

Have you watched television talk shows recently where the participants take turns shouting over each other? This is why they are called talk shows. Have you heard of television shows that are called “hear” shows or “listen” shows? I have not. We may only have talk shows because our society is full of people who “know” and want to “tell”.

I believe that our difficulty listening to and hearing others is one of the main reasons why we have such huge divides between groups of people today whether the line of demarcation is race, religion, income level, or rural vs urban habitat. Those who would divide us continue to talk without hearing.

Men and Women of good will must stop listening to their own voices and hear the voice of others. This is a message of Dr. King that we must take time to listen to what others are saying in order to understand and engage them to improve their lives and our own and improve our communities. We at GBMC must work hard to assure that all of our voices are heard, that we engage everyone and that everyone feels included.

I am grateful to Jennifer Marana, our new Director of Diversity and Inclusion and all of my colleagues on the Diversity and Inclusion Council for helping to drive us closer together. United, we can achieve our vision of being the healthcare system where everyone, every time is treated the way we want our own loved ones treated. If we don’t hear each other and engage each other we have no hope of achieving this lofty goal.

I want to thank Dr. Tooten, members of the Cristo Rey Choir and our Black History Month committee that put together today’s magnificent celebration!

How much can anyone “know” if they are only listening to their own voice?  Dr. King was a well-read man who knew the importance of gathering information and reflecting on it prior to speaking and of the importance of hearing the voice of others. Let us all remember this as we move towards our vision at GBMC and we move into the next chapter in the leadership of our country.

Friday, January 6, 2017

A New Year’s Resolution

No reader of this blog will be surprised to hear that I have been a bit concerned lately about maintaining the gains that we, in the GBMC HealthCare System, and others across our nation have made towards the national triple aim of better health, better care, and lower costs.

Since the passage of the Affordable Care Act (ACA), also affectionately known as Obamacare, our nations’ hospitals, physicians, nurses and the rest of the healthcare team have generated significant improvements in our care. Medicare has seen the smallest annual cost increases in its history. Employers, like GBMC, have also seen annual health care cost increases barely above the rate of inflation in the overall economy. Much of this has been stimulated by the ACA and the agency it created: The Centers for Medicare and Medicaid Innovation. Millions of Americans who did not have insurance before passage of the ACA now do and people who have significant illness, so-called “pre-existing conditions” can now get insurance when before they could not. Adult children can stay on their parent’s insurance plans, until the age of 26, when before they could not be covered after the age of 22. Insurance companies must spend at least 85 cents of the premium dollar on care and limiting the administrative costs and profit to 15 percent when before there was no such requirement. Now, if they spend on administration or have as profit more than 15 percent, they must return the difference it to the purchaser of the insurance. The concern that the ACA would be a “job killer” has proven not to be true. The unemployment rate is now much lower than it was at the time of the passage of the ACA.

It is sad that the part of the ACA that is not working well, the sale of individual policies to people who don’t qualify for the government subsidies, is the only part that is getting much “air time.” The price of these policies has gone up significantly because the “individual mandate” is not working. Too many healthy people are not buying the coverage leaving only the sick people in the pool thereby driving the cost up and making it likely that more people will stop buying the coverage.

The wonderful thing about the triple aim is that it transcends politics. I have not met anyone, Republican, Democrat or Independent that does not want better health and better care at lower cost. So, we in the GBMC HealthCare System must put the rhetoric aside, ignore the distractions and redouble our efforts towards our vision phrase: to every patient, every time, we will provide the care we would want for our own loved ones. What we want for our own loved ones is: we want them to get better; we want them to have the best care experience; we don’t want their resources wasted and we want them to know that we get it that it is a gift to serve them and this is a joyful pursuit.

So please join me in a resolution for 2017: The GBMC HealthCare Family resolves, in the New Year, to rise above all distractions and bring more joy to each other and our patients as we move faster towards the national triple aim.

If you would like to share your personal new year’s resolution, or goal, that you’ve set aside for this year, please go to to share.