A Better Way to Serve Those with a Behavioral Health Crisis

Back in November 2020, the Greater Baltimore Regional Integrated Crisis System (GBRICS) partnership was designed to help people experiencing a behavioral health crisis. The partnership was created, among many things, to strengthen the crisis response system across the greater Baltimore area and to minimize the need for people to call 911 to be brought to hospital Emergency Departments. Recently, GBRICS started serving as a regional hotline. 

Over the last two years, our region has been planning for this transition. No one really knows what the call volume will be, but it is good to now have the 988 Suicide & Crisis Lifeline number available to those who need it. It will provide greater access to 24/7 confidential services. It will not replace the existing National Suicide Prevention Lifeline – but in fact strengthen and expand it. 

This week I have asked Adam Conway, Senior Director of Population Health at Greater Baltimore Health Alliance, to give us a breakdown of the GBRICS partnership, our involvement in the initiative and more details on the first-ever 3-digit dialing code for suicide prevention and mental health crises.

Can you elaborate on GBRICS and GBMC’s involvement in it? 
GBMC has been involved in this effort since the fall of 2019, as the Baltimore County Health Department and representatives from area hospitals were having discussions about the need to address patients experiencing behavioral health crises. The partnership will invest $45 million over five years to transform behavioral health crisis response services in Baltimore City, Baltimore County, Carroll County and Howard County. GBRICS will expand the capacity of mobile crisis teams and community-based providers to reduce police interaction and overreliance on emergency departments.

Why is a regional partnership important when addressing behavioral health crises?
Maryland’s Regional Partnership Catalyst Program awarded funding for GBRICS to all seventeen hospitals in Baltimore City, Baltimore County, Howard County and Carroll County. This regional approach is critical for success, as the Emergency Department (ED) of each hospital has been acting as a primary location for people in crisis. Patients often return to the ED even though the ED is not equipped to deal with mental health on-going treatment. But in the absence of other sites of care, patients and their families have no other choice. 

As of July 16, 2022, the National Suicide Prevention Lifeline is now the 988 Suicide & Crisis Lifeline. Can you discuss the importance of the move to the first-ever 3-digit dialing code for suicide prevention and mental health crises and how will it help those who are seeking assistance?
The sheer volume of calls to 988 as it transitioned speaks for itself. According to the Assistant Secretary for Mental Health and Substance Use, total volume increased by 45 percent and 988 Lifeline counselors answered 23,000 more calls, texts, and chats than they had the week before transition. This clearly shows that there is a need for an easy-to-remember resource for those dealing with mental health crisis.

When someone calls for help, who provides the mental health services?
The services are currently being provided by local agencies and organizations, and GBRICS will both increase the service capacity and improve the coordination among service providers to reduce wait times. By calling the 988 hotline, a person in crisis is automatically routed to the first available call center agent, who will either provide a brief intervention over the phone or dispatch a mobile crisis team.

Why is this happening now?
Emergency Departments are frequently overwhelmed by behavioral health patients in crisis. GBRICS was designed to help this, and now it can take advantage of the launch of 988. The National Suicide Hotline Designation Act was passed in 2020, and in July of 2020, the FCC issued the final order designating 988 as the new Lifeline and Veterans Crisis Line number, requiring all U.S. telecommunication providers to activate 988 for all subscribers by July 16, 2022. 

Thank you, Adam, for taking the time to explain GBRICS and our involvement and for all the great work you and your team are doing!

Implementing Technology- It Doesn’t Always Lead to an Improvement

We are very fortunate in the 21st century to benefit from various technological advancements. Computers and microchip technology have made so many things much easier. Being able to order things online or obtain information on your smartphone is a huge improvement over driving to the shopping mall or searching through a dated encyclopedia.

But technology implementation by itself frequently does not make things better and sometimes can make it worse. In a sad aviation disaster, American Airlines Flight 965 was a regularly scheduled flight from Miami International Airport in Miami, Florida, to Alfonso Bonilla Aragón International Airport in Cali, Colombia. On December 20, 1995, the Boeing 757-200 flying this route crashed into a mountain in Buga, Colombia, killing 151 of the 155 passengers and all eight crew members. The flight management system in the 757 is capable of flying the plane by itself. It follows the flight plan that is entered before the plane takes off. In the case of flight 965, the pilot and co-pilot decided to change the landing to a different runway and approach and essentially disabled the flight management computer.

Recently, a family member was on a trip from Boston to Bermuda. She was waiting for her JetBlue plane to board when she received an email that her bag had been put on the plane. She was shocked, however, to read in the email that her bag was on a plane bound for Nashville.  A hole in the Swiss cheese, in the James Reason error model was the similarity in the airport identifying letters – Bermuda (BDA) and Nashville (BNA). A baggage handler must have “seen” BNA when my family member’s bag tag was clearly marked BDA. JetBlue, evidently in trying to reduce the frequency of lost baggage had implemented a bar code or rfid scanning system such that the bags were scanned before being put in the baggage hold. However, it is likely that when my family member’s bag was going into the cargo hold of the plane bound for Nashville that a light flashed “red” to alert the baggage handlers that the luggage didn’t belong on that plane. But no human took action to get the bag on the correct plane, the one bound for Bermuda.

My family member reported her bag lost to the JetBlue staff in Bermuda. They created a lost baggage claim in their system and my loved one then got an email telling her how to use the on-line portal to follow her bag’s path from Nashville to Bermuda. She checked the portal frequently over the next 28 hours, but the system only said, “no information.”  Again, expensive technology that was not being used properly and therefore of zero value to the traveler. This is the definition of pure waste. 

So, the moral of the story for us in healthcare is that technology by itself does not eliminate errors. It just moves the error to the so-called man-machine interface.  When we implement technology, we must enroll the people who will use the system in the reason why we are implementing the technology. Then we must engage them in creating their standard work in the use of the system and lastly, we must assure ourselves that the standard work is being followed. Otherwise, we will get no benefit from the technology and we might actually make things worse.

Reducing Waste in Pharmacy Operations through the Lean Management System (LMS)

When it was time for our Pharmacy department to choose what system to improve next, the decision was unanimous – optimization of the refill process for Omnicell medication dispensing cabinets. 

Staff recognized that some of the settings implemented when Omnicells were deployed in 2019 no longer made sense. Too often, medication would get depleted from pockets (stockouts) before the Pharmacy was able to refill them, leading to potential delays in patient care. Technicians found themselves restocking the same pockets multiple times a week. Imagine going to the gas station every day just to add another gallon to your tank! Finally, low-use medications were stagnating in Omnicells and expiring, generating waste, and using limited Omnicell space.

To address these issues with a systematic approach, the Pharmacy department formed an LMS team and broke down the optimization objective into three goals aligned with GBMC’s four aims. Specifically, these were: 1) Decrease stockouts by 10% (Better Care), 2) Remove low-use items that are not needed for emergencies (Least Waste), and 3) Improve technician work life by reducing rework (More Joy).

The Pharmacy’s LMS team utilized Omnicell analytics and developed their own formulas to optimize stock levels and refill thresholds of high-use items, while reducing or eliminating low-use items. These strategies were applied to a pilot Omnicell on Unit 36. The team then studied the effects of the interventions and used the model for improvement to learn and improve on the initial approaches.

Results: Stockouts decreased by 15.6%. Fifteen low-use items, totaling over $300, were removed from the Omnicell. Average daily restocks decreased by 28%.

The Pharmacy’s LMS team has begun applying this new design to the Omnicell on Unit 45, with the ultimate goal of applying these changes throughout the hospital.

This work is preparing the Pharmacy department to serve the two new units that will come on board with the Promise Project. The team is moving as close as possible toward a cart-less model of medication management. Today, technicians bring medications (in a cart) to inpatient units every day for medications that are not stored in the Omnicells. This LMS initiative helps the Pharmacy team study the current process, and then redesign to create the most efficient system possible. 

What a great example of redesign work to move us closer to our vision! Please join me in thanking our Pharmacy colleagues and LMS teams for this fabulous work!

A Leader Steps Up to Her Next Big Challenge

After nearly seven exemplary years of service to GBMC HealthCare, JoAnn Ioannou, DNP, MBA, RN, NEA-BC, Executive Vice President of Hospital Operations and Chief Nursing Officer, is leaving us to return to Johns Hopkins to serve as Senior Adviser to the President of Johns Hopkins Health System for Strategic Initiatives.

As you can imagine, I was surprised when JoAnn informed me of her decision to move on, and I have to say that I will truly miss her. She is a seasoned and dedicated nurse and executive who brought with her great knowledge of nursing leadership and a passion to elevate nursing in the healthcare system and to improve patient care.  

Since her arrival, the positive impact that she has made can be felt inside the GBMC HealthCare system and in the community. JoAnn developed the annual Art of Nursing program, which recognizes nursing staff members from all three work systems for their skill, compassion, and commitment to our patients. In 2020, one of the most challenging years in GBMC’s history, JoAnn was promoted to Executive Vice President of Hospital Operations. She has been a strong leader for our system throughout COVID-19 and the cyber-attack, and always made sure we paused to honor and celebrate our frontline staff, who were working harder than ever. JoAnn helped our system shine during our Baldrige site visit and was instrumental in our health system achieving this wonderful recognition. JoAnn has done a fabulous job in overseeing the planning for and construction-to-date of the Promise Project.

Under her leadership, GBMC HealthCare implemented a professional excellence model for its nursing staff with the goal of encouraging continuing education and creating clear pathways for career advancement. Dr. Ioannou’s passion for promoting nurses as healthcare leaders is evident to all who know and work with her. GBMC’s Nurse Residency Program, which supports and mentors newly graduated nurses, was the first program in Baltimore accredited with distinction by the American Nurse Credentialing Center. This is the highest level of recognition awarded worldwide for nursing education programs

With JoAnn’s departure, Stacey McGreevy, CPA, will assume the position of Executive Vice President and Chief Operating Officer of Greater Baltimore Medical Center. In this role, Stacey will lead the hospital work system and be responsible for its financial and daily operational activities. 

Michael W. Stein, MHSA, FACMPE, will serve as interim Vice President of Support Services. Michael has been the Executive Director of Oncology Services at GBMC since 2014. Over the last two years, he has also served as the Service Line Administrator for the Laboratory and Imaging Services. 

Angie Feurer, RN, MSN, NEA-BC, will serve as interim Chief Nursing Officer. Angie has been a nurse leader for 24 years, including her most recent role as Director of the Emergency Department, Intensive Care Unit, Medicine/Telemetry, SAFE, and the Stroke Program. Angie played a critical role as an Incident Commander during the cyber-attack and COVID-19. 

There is no doubt that Dr. Ioannou has served our healthcare system well during her tenure and that she has been a transformational leader throughout her time with us. Please join me in thanking her for her service and wishing her all the best with the wonderful next step in her outstanding career.