Earlier this week, I read an op-ed piece in The Baltimore Sun that focused on the life sciences industry in our state and the value that these companies bring to our economy. The author of the op-ed was making the case that regulations on the pharmaceutical industry are onerous and should be reduced.
As I was reading the article, I tried hard to keep an open mind. We should always be cautious in applying new rules or regulations to any industry to make sure that the benefit provided by the regulation outweighs any potential harm. We are well-served by the pharmaceutical industry in the U.S. in that we (usually) have a ready supply of high-quality drugs. But would the quality and efficacy of the drugs be so good without the manufacturing controls and tests required by the Food and Drug Administration? It is clear to me that the profit motive alone is insufficient to assure that we have the drugs we need. Recently, U.S. hospitals have had to scramble to acquire certain medications and intravenous solutions because they weren’t being manufactured due to low-profit margins.
GBMC works diligently to make sure that we are good stewards of the community’s resources. We are here to bring health, healing, and hope to those we serve and to do it as efficiently as possible. This year we are performing very well on our annual budget. We are serving many more patients than expected and our expenses are in line, with one big exception — we are overspending our pharmaceutical budget, especially in oncology drugs, by $3.2 million.
Why is this? Well, a small part of the overspend is because we are serving more patients, but the biggest reason is the dramatic increase in drug prices for both new and common drugs. A new report from The Health Care Cost Institute showed that the cost of insulin, which has been commercially available since the mid-twentieth century, has doubled between 2012 and 2016. By looking at health insurance claims, researchers also found that there was a 97% increase in the amount spent on insulin for people with Type 1 diabetes using employer-sponsored health insurance. Personal costs went from $2,900 in 2012 to $5,700 in 2016. For more on the report click here.
Recently, I heard a presentation from Aaron S. Kesselheim, MD, JD, MPH, Associate Professor of Medicine at Harvard Medical School and a faculty member in the Division of Pharmacoepidemiology and Pharmacoeconomics in the Department of Medicine at Brigham and Women’s Hospital. Dr. Kesselheim has made a career out of studying drug prices and he disputes the idea that new drugs are more expensive because of research and development (R&D) costs. Dr. Kesselheim’s work shows that only 10-15% of the cost of a drug comes from R&D and asserts that pharmaceutical companies are charging more to maximize their profits —sometimes more than one thousand times their cost of production. Dr. Kesselheim believes that this won’t change unless consumers and purchasers take action.
I think the American people need to first answer this question: “Is healthcare a right or a privilege?” If it is a privilege, then everyone must deal with the price of care in whatever way they can. If healthcare is a right, then we need a system with an oversight mechanism that checks the profit of individuals at the expense of the sick and the society at large. Pharmaceutical companies must make a profit but when is the profit too much?
The op-ed writer in The Baltimore Sun did not mention the protection afforded to pharmaceutical companies which block competition from generics for years after a drug comes to market. Nor did he mention their ability to maintain the protection significantly longer by creating minor changes to the drug formulation. Dr. Kesselheim explained government protected monopolies for drug manufacturers in his article in the Journal of the American Medical Association, which can be found here.
There is no simple solution to the dilemma of the cost of prescription drugs in the U.S., but it is time for citizens to learn the facts and weigh in. What do you think?
Bereavement Services for Our Employees
Over the last few weeks, I have highlighted various Gilchrist successes and initiatives, and this week I want to mention Gilchrist’s bereavement program led by Deb Jones, Bereavement Program Manager. The bereavement staff is well-trained in accompanying families through their grief journey.
The bereavement program is now open, not only to hospice families and friends, but also to GBMC and Gilchrist employees at no charge. The Gilchrist Grief Support Programs offer six-week and monthly support groups, workshops, and special events. For more information, please call 443-849-8251.
Friday, January 25, 2019
Friday, January 18, 2019
Moving Patients and Equipment Around Our Campus is a Very Complex System
Recently, I spoke with Anthony Anderson, GBMC’s newly appointed Director of the Service Response Center and Patient Transport.
Anthony, who worked at GBMC for three years as our Assistant Director of Food and Nutrition, now oversees daily transports and Service Response Center (SRC) calls. Anthony’s leadership team includes Destini Washington, Dominique Eaddy, and Gaurav Vasson.
Moving patients safely and efficiently requires standard processes and synchronization, which is the coordination of events to operate a system in unison. For example, when a patient needs to move from an inpatient unit to the radiology department for a study, the nursing staff must align its work to have the patient ready when transport arrives to move them. If either the patient or transport team is not ready on time, the system is “out of sync.” In a highly reliable hospital (one in which what should happen, happens, and what should not happen, doesn’t) patients are where they need to be when they need to be there.
This is a very complicated process because it’s impossible to predict exactly when and where patients will need to be moved at the beginning of the day. Anthony will be working closely with other leaders, especially our inpatient nurse managers, to make sure that we have standard work that is synchronized.
Anthony and his team also have the added complexity of moving equipment (stretchers, beds, wheelchairs, etc.). Our transporters are key players in keeping our facility clutter free and assuring that everything is in its place so that our staff will have what they need when they need it. They follow our 6S principles: sort, separate, shine, standardize, sustain, and safety. When things are not where they belong, it is hard to get them to the people who need them and clutter in the hallways is a safety hazard. Imagine if we had to move a patient quickly but the corridor was obstructed by a stretcher!
Anthony has created a new initiative with his people that we should all be following. It’s called “if you see something, say something.” It is everyone’s responsibility not to ignore something that is not in a 6S condition. For example, if a transporter sees trash overflowing, a stretcher in the hallway, or a wheelchair that is not in its proper place, he or she will rectify the situation or call ext. 6800. The transport team is trained to say something when they see something. If they see a stretcher, they will ask the unit if they need the stretcher. If they don’t, the transport team will ask them to log the equipment, run it in Epic, and take the stretcher to its proper destination.
Anthony told me that he and his team believe building relationships with leaders throughout GBMC will build the trust that patient transport will arrive on time. This will encourage others to do their part in making sure the patient is ready when the transporter arrives.
Please join me in welcoming Anthony to his new role and committing to help him create an even more reliable transport system. I would also like to thank Stacey McGreevy and David Brierley for their leadership in this area.
Kudos to our cleft lip and palate team!
Our cleft lip and palate team recently received approval by the American Cleft Palate-Craniofacial Association (ACPA). This recognition makes us one of four hospitals in the state to receive this endorsement.
The ACPA is an international nonprofit association of more than 2,500 healthcare professionals who are involved in the treatment and research of cleft lip, cleft palate, and other craniofacial abnormalities. The ACPA sets industry standards and optimizes the interdisciplinary care of persons affected by craniofacial abnormalities.
This approval is only given to teams with the highest level of training. The ACPA approval is a well-deserved recognition for Dr. Tonie Kline and the rest of the team. It is also recognition of the leadership and hard work of our recently deceased medical director of the program, Dr. Randy Capone. Congratulations to all!
Remembering Dr. Martin Luther King, Jr.
On Wednesday, we hosted our 4th annual Martin Luther King, Jr. Day celebration, which commemorated Dr. King’s life and vision. This year’s program, titled “Songs of Our Soul – We Shall Overcome,” featured our keynote presenter Richard Maurice Smith, Ph.D., associate professor of Sociology at McDaniel College and Lead Pastor of The Movement Church in Howard County, along with live music from the City Neighbors High School Choir.
I am grateful to Jennifer Marana, Ph.D., our Director of Diversity and Inclusion, and my colleagues on the Diversity and Inclusion Council for their hard work on this event and helping to bring us closer together. I also want to thank Dr. Smith, members of the City Neighbors High School Choir, and our Black History Month committee that put together this year’s magnificent celebration!
I encourage you all to send in your nominations for our GBMC Spirit of King Award. This award recognizes an individual who embodies the spirit and life's work of the late Rev. Dr. Martin Luther King, Jr. and who is dedicated to serving their local community, place of worship, child's school, etc. All nominations must be submitted no later than Thursday, January 31. The winner will be announced at the Black History Month celebration in February. Click here for more.
Anthony, who worked at GBMC for three years as our Assistant Director of Food and Nutrition, now oversees daily transports and Service Response Center (SRC) calls. Anthony’s leadership team includes Destini Washington, Dominique Eaddy, and Gaurav Vasson.
Moving patients safely and efficiently requires standard processes and synchronization, which is the coordination of events to operate a system in unison. For example, when a patient needs to move from an inpatient unit to the radiology department for a study, the nursing staff must align its work to have the patient ready when transport arrives to move them. If either the patient or transport team is not ready on time, the system is “out of sync.” In a highly reliable hospital (one in which what should happen, happens, and what should not happen, doesn’t) patients are where they need to be when they need to be there.
This is a very complicated process because it’s impossible to predict exactly when and where patients will need to be moved at the beginning of the day. Anthony will be working closely with other leaders, especially our inpatient nurse managers, to make sure that we have standard work that is synchronized.
Anthony and his team also have the added complexity of moving equipment (stretchers, beds, wheelchairs, etc.). Our transporters are key players in keeping our facility clutter free and assuring that everything is in its place so that our staff will have what they need when they need it. They follow our 6S principles: sort, separate, shine, standardize, sustain, and safety. When things are not where they belong, it is hard to get them to the people who need them and clutter in the hallways is a safety hazard. Imagine if we had to move a patient quickly but the corridor was obstructed by a stretcher!
Anthony has created a new initiative with his people that we should all be following. It’s called “if you see something, say something.” It is everyone’s responsibility not to ignore something that is not in a 6S condition. For example, if a transporter sees trash overflowing, a stretcher in the hallway, or a wheelchair that is not in its proper place, he or she will rectify the situation or call ext. 6800. The transport team is trained to say something when they see something. If they see a stretcher, they will ask the unit if they need the stretcher. If they don’t, the transport team will ask them to log the equipment, run it in Epic, and take the stretcher to its proper destination.
Anthony told me that he and his team believe building relationships with leaders throughout GBMC will build the trust that patient transport will arrive on time. This will encourage others to do their part in making sure the patient is ready when the transporter arrives.
Please join me in welcoming Anthony to his new role and committing to help him create an even more reliable transport system. I would also like to thank Stacey McGreevy and David Brierley for their leadership in this area.
Our cleft lip and palate team recently received approval by the American Cleft Palate-Craniofacial Association (ACPA). This recognition makes us one of four hospitals in the state to receive this endorsement.
The ACPA is an international nonprofit association of more than 2,500 healthcare professionals who are involved in the treatment and research of cleft lip, cleft palate, and other craniofacial abnormalities. The ACPA sets industry standards and optimizes the interdisciplinary care of persons affected by craniofacial abnormalities.
This approval is only given to teams with the highest level of training. The ACPA approval is a well-deserved recognition for Dr. Tonie Kline and the rest of the team. It is also recognition of the leadership and hard work of our recently deceased medical director of the program, Dr. Randy Capone. Congratulations to all!
On Wednesday, we hosted our 4th annual Martin Luther King, Jr. Day celebration, which commemorated Dr. King’s life and vision. This year’s program, titled “Songs of Our Soul – We Shall Overcome,” featured our keynote presenter Richard Maurice Smith, Ph.D., associate professor of Sociology at McDaniel College and Lead Pastor of The Movement Church in Howard County, along with live music from the City Neighbors High School Choir.
I am grateful to Jennifer Marana, Ph.D., our Director of Diversity and Inclusion, and my colleagues on the Diversity and Inclusion Council for their hard work on this event and helping to bring us closer together. I also want to thank Dr. Smith, members of the City Neighbors High School Choir, and our Black History Month committee that put together this year’s magnificent celebration!
I encourage you all to send in your nominations for our GBMC Spirit of King Award. This award recognizes an individual who embodies the spirit and life's work of the late Rev. Dr. Martin Luther King, Jr. and who is dedicated to serving their local community, place of worship, child's school, etc. All nominations must be submitted no later than Thursday, January 31. The winner will be announced at the Black History Month celebration in February. Click here for more.
Friday, January 11, 2019
Missing Medications Revisited
It’s been a while since we discussed “missing” medications in this blog. When a nurse goes to administer an ordered and verified medication to a patient and it is not there on the unit, we have a system that is not 100% reliable (reliability = what should happen, happens and what should not happen, doesn’t). Physicians and advanced practitioners order medications and pharmacists verify the order. The verification step is a protection that the medication is of the correct dose, that the patient is not allergic to it or has contraindications to its use, and that it will fit in with the other medications the patient is taking without untoward drug interactions.
We have made huge progress in reducing “missing” medications since 2013, when we first started studying the causes and testing changes to our delivery system. The pharmacy has a two-hour window from the time a medication is ordered to verify the order and deliver the medication to the unit if it is not already stored there. We saw considerable changes once we began studying one unit at a time and looking at each case of missing doses in real time. It’s difficult to tell what happened when looking back in time at an event. It is much easier to do the 5 Whys as soon as a miss occurs. Remember, the 5 Whys process is asking the “why” question FIVE times before you get to the fixable cause of a defect.
Prior to working on improving our system, busy Medicine units could have 30 or more missing medications per day. This has been reduced to 0-3 per day. The most recent work between our pharmacists and units 34 and 35 has resulted in many days with zero missing medications! This is a great achievement.
There are several Pharmacy leaders who oversee this work: Julia West, Assistant Director of Pharmacy, Julia McDonnell, Pharmacy Operations Manager, and Vaishali Khushalani, Pharmacy Medication Safety Officer. The Pharmacy Lean Daily Management (LDM) lead team also communicates with Pharmacy Director, Yuliya Klopouh, and the observations from LDM are used to make practical improvements in the pharmacy. These leaders are also in close communication with the nurse managers to study the defects and, when necessary, change the standard work.
A recent example of improvement involves the transfer of medications between the Emergency Department and inpatient units. The previous process was to send all the patients’ medications with them on transfer. The Pharmacy team worked with Emergency Department Manager, Mark Fisher, Assistant Nursing Director for the ED, Monica Goetz, and Unit 35 Manager, Temitope Oseromi, to create a better process for expanding the stock of medications on the inpatient units and in the Emergency Department. This allows for fewer medication transfers and improves access to and visibility of patient-specific bins. After this change, medication tracking became significantly easier and there was higher accountability between emergency and inpatient units. Now, there are fewer medications missing during the transfer process.
An added benefit of the daily improvement work is the better relationship and collegiality between pharmacists and nurses!
Congratulations Gilchrist!
Gilchrist Care Choices (GCC) is a national test program which allows qualified Medicare beneficiaries who qualify for hospice to continue receiving curative treatment simultaneously. This is being tested under the belief that many people forego hospice fearing their providers will “give up” on them. The idea of the program is that allowing patients to continue curative treatment will allay their fears and encourage many people to choose hospice care sooner. This has certainly been the case with GCC! The program has grown exponentially — since 2017, with referrals increasing by 100 percent. GCC, the fourth-largest program in the country, is one of the first to focus on continually improving internally-developed quality measures. This major achievement in growth from outpatient providers, was highlighted by the Centers for Medicare and Medicaid Services (CMS) in a recent publication. Congrats to Rene Mayo, MSW, GCC program manager, and her colleagues for this recognition!
We have made huge progress in reducing “missing” medications since 2013, when we first started studying the causes and testing changes to our delivery system. The pharmacy has a two-hour window from the time a medication is ordered to verify the order and deliver the medication to the unit if it is not already stored there. We saw considerable changes once we began studying one unit at a time and looking at each case of missing doses in real time. It’s difficult to tell what happened when looking back in time at an event. It is much easier to do the 5 Whys as soon as a miss occurs. Remember, the 5 Whys process is asking the “why” question FIVE times before you get to the fixable cause of a defect.
Prior to working on improving our system, busy Medicine units could have 30 or more missing medications per day. This has been reduced to 0-3 per day. The most recent work between our pharmacists and units 34 and 35 has resulted in many days with zero missing medications! This is a great achievement.
There are several Pharmacy leaders who oversee this work: Julia West, Assistant Director of Pharmacy, Julia McDonnell, Pharmacy Operations Manager, and Vaishali Khushalani, Pharmacy Medication Safety Officer. The Pharmacy Lean Daily Management (LDM) lead team also communicates with Pharmacy Director, Yuliya Klopouh, and the observations from LDM are used to make practical improvements in the pharmacy. These leaders are also in close communication with the nurse managers to study the defects and, when necessary, change the standard work.
A recent example of improvement involves the transfer of medications between the Emergency Department and inpatient units. The previous process was to send all the patients’ medications with them on transfer. The Pharmacy team worked with Emergency Department Manager, Mark Fisher, Assistant Nursing Director for the ED, Monica Goetz, and Unit 35 Manager, Temitope Oseromi, to create a better process for expanding the stock of medications on the inpatient units and in the Emergency Department. This allows for fewer medication transfers and improves access to and visibility of patient-specific bins. After this change, medication tracking became significantly easier and there was higher accountability between emergency and inpatient units. Now, there are fewer medications missing during the transfer process.
An added benefit of the daily improvement work is the better relationship and collegiality between pharmacists and nurses!
Gilchrist Care Choices (GCC) is a national test program which allows qualified Medicare beneficiaries who qualify for hospice to continue receiving curative treatment simultaneously. This is being tested under the belief that many people forego hospice fearing their providers will “give up” on them. The idea of the program is that allowing patients to continue curative treatment will allay their fears and encourage many people to choose hospice care sooner. This has certainly been the case with GCC! The program has grown exponentially — since 2017, with referrals increasing by 100 percent. GCC, the fourth-largest program in the country, is one of the first to focus on continually improving internally-developed quality measures. This major achievement in growth from outpatient providers, was highlighted by the Centers for Medicare and Medicaid Services (CMS) in a recent publication. Congrats to Rene Mayo, MSW, GCC program manager, and her colleagues for this recognition!
Friday, January 4, 2019
What will 2019 bring?
I would like to wish you all a very Happy New Year. I hope your holiday season has been filled with good health and joy.
Our healthcare system continues to improve and grow. We have great people who work very hard and we are getting pretty good at designing systems to move us faster towards our vision. We still have work to do, but almost everything we measure under our four aims improved during 2018.
2019 will bring the next iteration of Maryland’s waiver with the federal government and the State has committed to reducing the total cost of care for Medicare beneficiaries. We will have a new tool to help achieve this…the Maryland Primary Care Program. This is part of the plan to create incentives for providers to coordinate their patients’ care.
As you recall, since 2014, our state has paid hospitals via global budgets to dis-incentivize the provision of services that don’t lead to better health or better care. Maryland has lowered the rate of increase in the total cost of care by doing this. Now to reduce the total cost of care, it will be necessary to bring others to the waste reduction table. This new program will provide resources to primary care physicians to improve health and the care experience. Primary care offices will work with Care Transformation Organizations (CTOs) (Greater Baltimore Health Alliance being one of them), to better coordinate care. The CTOs will provide care managers, behavioral specialists, and others to help the primary care team accomplish this. You will recognize that we’ve been doing this in the GBMC HealthCare System for quite some time. The inclusion of primary care practices allows the focus to be more on population health, including other settings of care in communities, rather than relying only on hospitals.
Under our new total cost of care agreement, the State has also committed to work on six high-priority areas: substance misuse, diabetes, hypertension, obesity, smoking, and asthma. So, 2019 should be a year of change towards better care leading to better health for the citizens of Maryland. Thanks to all my colleagues for working hard on this agenda.
The Passing of an Outstanding Physician
I was saddened to hear that Dr. Randy Capone passed away last week. Dr. Capone was an outstanding plastic surgeon who served as the medical director of our Cleft Lip and Palate Team. He worked tirelessly at his craft and under his leadership, the team changed so many lives for the better. He will truly be missed.
Our healthcare system continues to improve and grow. We have great people who work very hard and we are getting pretty good at designing systems to move us faster towards our vision. We still have work to do, but almost everything we measure under our four aims improved during 2018.
2019 will bring the next iteration of Maryland’s waiver with the federal government and the State has committed to reducing the total cost of care for Medicare beneficiaries. We will have a new tool to help achieve this…the Maryland Primary Care Program. This is part of the plan to create incentives for providers to coordinate their patients’ care.
As you recall, since 2014, our state has paid hospitals via global budgets to dis-incentivize the provision of services that don’t lead to better health or better care. Maryland has lowered the rate of increase in the total cost of care by doing this. Now to reduce the total cost of care, it will be necessary to bring others to the waste reduction table. This new program will provide resources to primary care physicians to improve health and the care experience. Primary care offices will work with Care Transformation Organizations (CTOs) (Greater Baltimore Health Alliance being one of them), to better coordinate care. The CTOs will provide care managers, behavioral specialists, and others to help the primary care team accomplish this. You will recognize that we’ve been doing this in the GBMC HealthCare System for quite some time. The inclusion of primary care practices allows the focus to be more on population health, including other settings of care in communities, rather than relying only on hospitals.
Under our new total cost of care agreement, the State has also committed to work on six high-priority areas: substance misuse, diabetes, hypertension, obesity, smoking, and asthma. So, 2019 should be a year of change towards better care leading to better health for the citizens of Maryland. Thanks to all my colleagues for working hard on this agenda.
I was saddened to hear that Dr. Randy Capone passed away last week. Dr. Capone was an outstanding plastic surgeon who served as the medical director of our Cleft Lip and Palate Team. He worked tirelessly at his craft and under his leadership, the team changed so many lives for the better. He will truly be missed.
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