Redesigning Care

I have been reflecting a lot lately about our vision statement (click here) that was written by our Board of Directors after their retreat in late 2010. They were concerned about GBMC’s ongoing ability to bring health, healing, and hope to our community in the face of changes in the U.S. healthcare system and the exorbitant costs of that system. So, they wrote a 4-paragraph game plan that we have been executing since then. The core directive in that vision statement was to continually redesign care to drive greater value for those we serve.
 
On a macro level, GBMC has gone from being hospital-centric to creating a system of care through the eyes of the patient. We converted our primary care offices into patient-centered medical homes and added more of them. We added specialist physicians to our practices and made them more accessible to our patients and to our primary care physicians for consultation. We built Gilchrist to deliver elder care services through the end of life in the home and in many of our facilities. Palliative care and integrative care for symptom management have become strong components in our system.

GBMC added the concept of accountability for the health of those that it serves. No longer is it only about visits. Once a patient decides to get his or her care from one of our patient-centered medical homes, we are now accountable for his or her health outcomes. To do this, we had to build the analytic capability to reflect on how individuals and disease-specific populations were doing. We purchased Epic, our electronic health record to help us do this. Care managers now work with physician-led office teams to maximize the health of those they serve and reduce unnecessary visits. We now know precisely how many diabetics we are serving and can identify patients who are not properly managing their disease. With this capability, we can focus specifically on those patients who need extra help from their providers.

It would take me days to list all of the practical examples of redesigned care in our system. Our SAFE and Domestic Violence programs have totally redesigned the care for a sexually or physically abused individual who comes to our emergency department. We now have peer counselors in our Emergency Department who work with patients struggling with substance use. Our Orthopaedics practice recently added walk-in services to more efficiently handle injuries. Our Intensive Care Units now have in-house critical care physicians available 24 hours per day. Patients who require a rabies immunization are able to quickly receive their second dose at Family Care Associates rather than having to return to the ED. I know that this is only a short list of the examples of care redesign that we have done…we will complete many more as we move towards our vision!

Gilchrist Named a Great Place to Work…Again!
Gilchrist was certified for the second year in a row, by independent analysts, as a Great Place to Work®. Gilchrist earned this distinction based on ratings provided by employees in anonymous surveys. The certification process considered 436 employee surveys from across Gilchrist’s locations. Cathy Hamel, President of Gilchrist and Vice President of Continuing Care at GBMC, feels that being re-named as a “Great Place to Work” is a confirmation of the culture at Gilchrist: one where employees find meaning in what they do and share a strong sense of pride about their work. I applaud all Gilchrist employees and thank them for their hard work. Congratulations, everyone!

Let’s Not Forget…
This coming weekend is the “unofficial” start to the summer season. While many of us might be heading to the beaches or to the pool, let’s not forget that Monday is Memorial Day, a special day to honor those who have given their lives during military service to our country. We all have friends or family members whose lives of service included the ultimate sacrifice. So, on this Memorial Day holiday, let’s make time to honor our veterans for their commitment to safeguard our security and be mindful of our heroes — living and dead. Let this be a moment to recognize our nation’s champions with appreciation and respect.

National Hospital Week: Time to Thank Those Who Care for Others

Last week was National Hospital Week, and it was a great time to celebrate our hospital and acknowledge those that serve our community. Hospital Week, which dates to the early 1920s, according to the American Hospital Association, “celebrates hope and healing, and the hospitals, health systems, and the women and men who support the health and well-being of their communities through dedication and care from the heart.”

We use continuous improvement and Lean principles in our healthcare system, and we focus on key processes to improve clinical outcomes and the patient care experience, while driving out waste and creating more joy for those providing the care.

Lean Daily Management (LDM) has been a huge success for us, and through our daily rounding, we’ve also narrowed the gap between the “front office” and the “front line.” I have had the opportunity to get to know many of our front-line team members throughout the system who are studying problems and testing changes, allowing us to have open conversations with one another about how we can continue to move toward our vision. I am constantly reminded that we need everyone on the team in order to achieve our vision, from parking lot attendants, grounds crew, patient access reps, and billing staff, to transporters, environmental services workers, food service workers, security personnel, social workers, care managers, physicians, nurses, clinicians, volunteers, and all other non-clinical and administrative employees. Each member of the GBMC family is a very important part of our work.

Last week, we celebrated Hospital Week with an ice cream social day and other observances, and I want to sincerely thank all the members of our staff, our Board of Directors, volunteers, and everyone else who has helped us improve our designs and make our system of care more reliable to move us closer to our vision: to every patient, every time, we will provide the care that we would want for our own loved ones.

Second ”A” In a Row!!!

Last Wednesday, it was announced that GBMC received its second consecutive ”A” grade from The Leapfrog Group.
 
The Leapfrog Group is a national hospital safety organization that grades hospitals twice a year on how well they protect patients from errors, injuries, and infections. The grades range from A through F based on safety measures in place and the hospital’s actual performance in preventing harm. The goal is to give the community a tool to use in selecting a hospital.

The Leapfrog Group rates over 2,600 general acute care hospitals across the country, including 40 in Maryland. Earning an “A” is not an easy achievement –  we are one of only 10 hospitals in the state to receive this high mark.

This recognition validates our strong commitment to the vision of providing our patients with the care that we would want for our own loved ones. While we are proud of this consecutive honor, we will not stop our improvement work until we achieve zero harm. I want to thank our entire team for all that it has done to move us to this point. I also want to thank Laura Hines, RN, SCNR, Director of Clinical Quality Outcomes, and Carolyn Candiello, Vice President for Quality and Patient Safety, for their tremendous work in culling the data for the survey. Great work, everyone!

Oh! What A Night!
I had the privilege of attending our recent annual Art of Nursing celebration on May 9. This was a special evening for our nursing staff. It was a great opportunity to thank our nurses for all they do for GBMC and its patients every day, and to have some fun!

Caring for sick patients who have many needs requires physical and mental stamina. Our nurses are smart, well-trained, and resilient. Their work is not predictable. I am so grateful for their ability to adapt to the variability in demand for their services from day to day and sometimes, from minute to minute.

I would like to thank everyone involved in the very successful Art of Nursing celebration, especially our Marketing and Communications team and our Philanthropy team.

Thank you!
The Kahlert Foundation recently agreed to endow The William E. Kahlert Research and Discovery Fund to support oncology clinical research with a $1 million pledge.
 
This fund was created by the late Bill Kahlert, for whom the William E. Kahlert Physicians Pavilion North was named in 2018.

Bill developed a strong relationship with Dr. Ronald Tutrone and Dr. Paul Celano during his battle with cancer.  To demonstrate his gratitude to Dr. Celano and the oncology team, he established a fund to promote multidisciplinary medical research. The fund has helped GBMC increase enrollment in oncology clinical trials by 25% and endowed a Urologic Research Fund to support research efforts under the direction of Dr. Tutrone, which was the first endowment of its kind at GBMC.

Although Bill and Yvonne have passed away, their son Greg, his wife, Roberta, and their children, Heather and Scott, have continued their family’s support of GBMC and giving in honor of the great care they have received at GBMC. 

I want to thank them for their recent endowment and I am extremely grateful for the ongoing support from The Kahlert Foundation. Thank you, Greg, Roberta, Scott, and Heather, for continuing your family’s support of our work in the community.

GBMC Nurses Recognized for Their Excellence

This week is National Nurses Week, a time to reflect on the many talented nurses throughout the GBMC HealthCare System. Through their expertise and dedication, they drive us closer to our vision every day.

Nursing requires selflessness and commitment. The more than 1,400 nurses in our hospital, in Gilchrist, and in GBMC HealthPartners give of themselves to make the experience better for those they serve.

We have been able to retain our experienced nurses and recruit new nurses due to the vision of JoAnn Ioannou DNP, MBA, RN, NEA-BC, our Senior Vice President of Patient Care Services and Chief Nursing Officer. JoAnn, who recently appeared on our Facebook Live program, To Your Health, does an excellent job in assuring that our nurses are recognized for their value to our system. JoAnn has overseen the creation of a professional development model for nurses that helps them choose their career direction and grow and develop their skills. Please take some time to watch the interview below.



Nursing has always been a marvelous profession and it is exciting to see so many young people choosing nursing as a career. I’d like to take this opportunity to extend my gratitude to all of our dedicated nurses for bringing health, healing, and hope each day to our patients and to our community. Thank you!

Congratulations are in order
In case you haven’t heard, SEVEN GBMC nurses were recently recognized in Baltimore magazine's 2019 “Excellence in Nursing” issue!
Nominations were submitted from across the region and 50 winners in 21 specialties were selected by a panel of nurse advisors. This is truly great recognition for GBMC HealthCare and our exceptional nursing staff. Please join me in congratulating the following nurses:

Mark Fisher, BSN, RN, CEN, TCRN – Emergency Department
Kristine Baker, RN – Neonatal Intensive Care Unit
Kenneth Griffith, CRNA – Anesthesia
JoAnn Parr, MS-HCM, BSN, RN – Care Management and Continuing Care Services
Elaine Dougherty, RN, WCC – Wound Center
Kristin Trawinski, MSN, RN – Neonatal Intensive Care Unit
Jennifer Spahn, MSN, RN, NEA-BC – Nursing Education

The fifth annual “Top Nurses” issue is already on newsstands. Get it to learn more.

Also, it's that time again when Baltimore magazine is collecting votes from area physicians for its “Top Doctors” issue. Docs, please vote for the colleagues you most respect! The survey may be found here.

Thank You, Readers, of The Sun
Our healthcare system was recently recognized by readers of The Sun as Best in Audiology Services and Best Hospital. I want to THANK all who voted for recognizing the hard work and dedication of our clinicians, other staff, and volunteers, as well as for your confidence in our ability to treat every patient, every time, the way that we would want our own loved ones treated.

GBMC Health Partners LDM Celebration
Earlier this week, I attended the GBMC Health Partners Lean Daily Management (LDM) celebration, which showcased more than a dozen poster presentations from 14 multispecialty practices. Each practice highlighted an improvement that they achieved using LDM problem solving to generate improvements in one or more of our four aims. The clinical teams used the Model for Improvement with Plan, Do, Study, Act (PDSA) cycles. Additionally, the Neurosurgery and Perinatal Associate practices gave a presentation that focused on the teamwork in their departments with both metric selection and the creation of sustainable standard work. I want to congratulate Dr. Harold Tucker, our Chief Medical Officer and President of GBMC Health Partners, Evelyn Bowmaster, BSN, RN, CPHQ, CBN, Director, Quality and Patient Safety for Physician Practices at GBMC, Carolyn L. Candiello, Vice President of Quality and Patient Safety, and all the event volunteers for putting together such a wonderful celebration!

Golfing for A Cause
The annual GBMC Golf Classic was held this past
Monday at Turf Valley Country Club. The sun made an appearance and the weather was just right as more than 180 golfers “hit the links” to help raise funds for continuing education in the GBMC HealthCare system.

Countless hours were spent by the entire golf tournament committee preparing for this great event that grossed more than $192,000. I’m very grateful to everyone who helped us raise the money and to those who came out to play. Kudos to the entire golf committee, co-chaired by Laurie R. Beyer, MBA, CPA, Executive Vice President and Chief Financial Officer, and David Brierly, Client Executive for Sodexo, as well as Jenny Coldiron, the GBMC Foundation staff, and all who volunteered at the event.

A Word of Caution in Overriding at the Electronic Drug Dispensing Cabinet

In December 2017, a nurse in a prestigious academic medical center used the “override” function in an electronic medication dispensing cabinet to get a medication to sedate a patient who was anxious about going into an MRI scanner. The nurse had been sent to the radiology suite to quickly administer a medication to calm the patient and get the study done. The nurse used “override” because the nurse did not find the medication on the patient’s profile. The nurse typed “Ve” into the search function and removed vecuronium, a paralyzing agent, from the cabinet and gave it to the patient. It was only later when the patient’s condition deteriorated in the scanner and the patient subsequently died that it was learned that vecuronium had been administered when the nurse had intended to give Versed, the trade name for midazolam, a sedative.

This is obviously a very sad case, but it was made even worse in January of this year when the nurse was indicted for murder. Following the notion of the Just Culture, punishing the nurse for this error would only be justified if his/her action was intentional or if there had been a reckless disregard for the standard procedures that other nurses in the same situation would have followed. Assuming there was no malicious intent, imagine how the nurse feels. He or she is clearly a second victim.

I don’t know all of the facts of the case, but none of the news reports suggest the nurse was trying to harm the patient. They all suggest that the nurse did not realize she had taken the wrong drug. I don’t know if another nurse in that particular hospital would have used the override in that situation, but I am concerned that in many hospitals, it would have been. Why do I believe this? Because all too often, we are concerned about speed and efficiency and we give our people the message that they need to move quickly to get the job done. We do not spend enough time coaching staff about our safety systems and making it clear with both our words and actions that safety is more important than speed. 

In the typical hospital case, there are 4 steps in the process to administer a medication to a patient (by the way, neither in my medical school education, nor during my pediatrics residency did anyone fully explain this sequence to me and the importance of all the steps). First, the licensed physician or advanced practitioner orders the medication. Next, the pharmacist checks the patient’s record for allergies and incompatibilities, as well as the dose and route of administration. He or she then verifies the order. Next, the pharmacy dispenses the medication. The drug dispensing cabinetry saves time because the drug does not need to be transported from a central location. The act of verifying the order in the computer tells the machine what to dispense. The nurse then does a final check that the patient, drug, dose, route, and time are correct and administers the drug to the patient. The drug dispensing cabinet has an override function because the manufacturer wants to allow the medication to be removed and administered quickly, if necessary, before ordering and verifying have been done.

In a true clinical emergency, time is of the essence. Think of a patient coming into the ED in full cardiac arrest. In this case, the provider running the code is giving verbal orders and other team members are getting the drugs (generally from a code cart) and administering them without the verification step. But what do you think about the case of the anxious patient? Is this truly an emergency? It is easy to see retrospectively that if the nurse had not used the override or if it was not even an option, and instead the nurse had waited for an order for Versed and its verification, this tragedy would not have happened.

At GBMC, we have some emergency medications in some drug dispensing cabinets, and therefore, we do not want to eliminate the ability to override. However, we do want to eliminate non-emergency overrides.

Our pharmacy leaders study the use of the override function at GBMC. Vaishali Khushalani, PharmD, GBMC’s Medication Safety Officer, has shared with me the insight gained by our daily medication override reviews. Most overrides that are occurring before a provider has entered the order are not for emergency medications; rather they are for acetaminophen (Tylenol), amoxicillin, and ibuprofen (Advil). In addition, there are many overrides within a minute or two of the order being entered. This does not give the pharmacist enough time to review and verify the order. The provider can order a medication “STAT” and the administering nurse can ask for a drug as “high priority.” In the month of April, there were 3,609 STAT/high priority orders and the average time to verify high priority/STAT medications was 6 minutes. There were 78,415 total medication orders in April and the average time to verify all medications was 12 minutes. While I am sure the mean performance includes some outliers, I believe that these are reasonable times to wait for the extra protection of the pharmacist verification step.

Vaishali and her colleagues are working closely with our nursing leaders to learn more about the reasons for the use of the override. They want to assure there are no significant delays in the verification of ordered medications so that we can eliminate non-emergency overrides. This ensures that patient needs are met without compromising patient and staff safety.

Our physicians, nurses, advanced practitioners, and pharmacists work extremely hard to get our patients what they need. We must all work together to make our system even safer than it is today. What do you think?

Way to go, Gilchrist!

Gilchrist was recently awarded the 2019 Health Care Hero Award for “Advancements and Innovation in Health Care” by The Daily Record. This award honors organizations and individuals who have played a major role in improving the quality of healthcare in Maryland. Recognized for “its professional achievements, community involvement, and inspiring change,” Gilchrist was applauded for its innovative patient care programs, which focus on meeting the needs of the seriously ill in our community. This includes home-based elder medical care for those who have difficulty physically making it to the doctor’s office.

Congratulations to all our Gilchrist colleagues for their hard work and for getting the recognition they so rightfully deserve!

Above and Beyond…

I want to extend my appreciation and gratitude to James Wilkins, a GBMC security officer, who was instrumental in helping a patient of ours reunite with his family.

Officer Wilkins was at home when he recognized a photograph from an Endangered Missing Person alert as a GBMC patient. The patient, who suffers from dementia and other medical conditions, was unfortunately separated from his family.

When James saw the alert on Facebook, he immediately notified the Aberdeen Police Department. The police positively identified the missing man, who was eventually reunited with his grateful family.

I want to THANK Officer Wilkins for his quick thinking to ensure this patient's safety and for doing his part, outside of his place of employment, to reunite this man with his family.

GBMC Employees Helping Our Community…

It’s no secret that we have some amazing GBMC employees who freely volunteer their time and do wonderful work in the community.

I was recently made aware by David Vitberg, MD, Division Chief of Medical and Surgical Critical Care Medicine, that GBMC NICU Nurse Manager, Kristin Trawinski, and Labor & Delivery Nurse Manager, Rachel Farbman, graciously volunteered their time for a very important training session with Baltimore County Fire Department's (BCFD) EMS providers. The event was attended by both career and volunteer EMS personnel.

Two BCFD paramedics presented during the training session a case of a complicated neonatal delivery. Although neonatal resuscitation is a rare call in the EMS world, EMS providers must be prepared for these low frequency, profoundly high-acuity emergency calls as the first link in the emergency medical system.

After the presentation of the case, a roundtable conversation took place between the two EMS presenters, Kristin, Rachel, and the audience. The lecture was also live-streamed to providers around the county.

The training, according to Dr. Vitberg, who is also Deputy Medical Director for Baltimore County Fire Department, was incredibly well-received by all in attendance, and as Kristin’s and Rachel’s colleague, he was extremely grateful they joined him at this event.

Thank you, Kristin and Rachel, for being stellar representatives of our Maternal Child Health Services and of GBMC!