Celebrating Great Saves

High reliability organizations are constantly evaluating and designing systems that enhance patient safety. Simply put, they want to make sure that what should happen…happens and what shouldn’t happen…doesn’t happen. We always encourage staff to report when things go wrong or even when they could have gone wrong so that we can analyze the incident, identify errors, and prevent harm down the line. Embracing this culture of safety brings us closer to our vision of providing all patients with the care that we would want for our own loved ones. 

We like to celebrate when we hear real stories of how staff within our system have used behaviors and systems associated with high reliability to prevent harm. I’d like to share one of these stories with you today. 

You may know that in the U.S., heart disease is the leading cause of death for men and women. Heart disease can lead to myocardial infarction (also known as a heart attack). Knowing the prevalence of heart disease and dire implications of heart attack, we must always take potential heart attack symptoms seriously.  

The GBMC Health Partners Communications Access Team received a call from a patient complaining of severe and worsening chest pain, shortness of breath, and arm numbness. Landri Hardiek, a Patient Services Assistant, recognized the severity of the symptoms as outlined in the GBMC Health Partners Policy for Patient Access and Scheduling. She immediately contacted the patient’s primary care office and transferred the call. She also sent a secure message to the patient’s primary care provider through our electronic health record system.  

Patient Services Assistant Linda Kirby assumed the call and kept the patient on the phone while the practice called 911. In the meantime, Landri notified the patient’s sister as requested. The patient was transported by EMS to a local hospital, was diagnosed with a myocardial infarction, and underwent a cardiac catheterization for a stent placement. Thanks to Landri’s attention to detail, adherence to the policy, clear communication with her team, and effective handoff, this patient received timely and lifesaving cardiac care. Thank you to Landri and Linda (and all others involved) for this great save! 

I am grateful to all our employees for reporting errors, as well as great saves, to help us make improvements that keep our patients safe! 

As a quick side note: I know I always tout the importance of advanced primary care and being good stewards of emergency department (ED) resources. That is, not using the ED for basic primary care or sick visits. However, if you ever experience symptoms of a heart attack, stroke, or other medical emergency (chest pain or discomfort, feeling weak or lightheaded, short of breath, etc.), please don’t hesitate to call 911. Calling 911 will ensure you get the fastest intervention possible. 

And lastly, congratulations to the Baltimore Orioles for clinching the AL East! Let's go O's!

A Re-Imagined Space for GBMC Health Partners Owings Mills

On September 12, we held a ribbon cutting to commemorate the naming of the Sandra R. Berman Medical Office Building in Owings Mills, home to one of our GBMC Health Partners advanced primary care practices. Advanced primary care is a fundamental building block of the GBMC HealthCare System, and we are grateful that longtime supporters Sandra and Malcolm Berman understand the true difference we can make in people’s long-term health with this type of accountable primary care. 

Owings Mills facility; photo credit: CRGA Design

Their generous donation has allowed us to remodel our Owings Mills practice to more closely mirror our Family Care Associates practice, located in Physicians Pavilion North on GBMC’s main campus. The innovative design of these practices allows for a more patient-centered experience that is also more streamlined and efficient for the providers. 

For those who regularly read this blog, you’ll remember that with advanced primary care, we don’t focus on the number of visits; rather, we focus on building our relationships between patients and providers. Our goal with this renovation (and our primary care philosophy overall) is to make it as easy as possible to access this coordinated care, with weekend, holiday, and extended hours, on-site blood drawing, and 24/7 access to an online patient portal for prescription refills, test results, appointment requests, and more. 

I’m excited that we now have the updated amenities to care for patients even better and support our talented Owings Mills team of six family medicine physicians and a nurse practitioner. They are all steadfastly focused on preventive care and managing acute and chronic illness to avoid unnecessary emergency department visits and hospitalizations.  

Thank you again to Sandy and Malcolm for helping to ensure that we can continue to provide innovative, personalized, and attentive care to the Owings Mills community and beyond. I’d also like to thank Elie Miller, MD, family medicine physician with GBMC Health Partners, for his work in championing this improvement for our patients and care team. I'm also grateful for the work of Kevin Ferentz, MD, Chair of the Department of Family Medicine, and Nihkolle McGirt, Senior Ambulatory Practice Manager, and the entire team.  

If you’d like to become a GBMC Health Partners at Owings Mills patient or learn more, please click here. 

Honoring a Dedicated Physician 

It is with sadness that I share the news that Dr. Frank Sanzaro passed away on September 19. More than 40 years ago, Dr. Sanzaro started his own private medical practice, which later became GBMC at Hunt Manor. He was well-loved by his patients. His dedication and expertise as a family medicine physician was critical to the patient-centered medical home model that we developed in the various advanced primary care practices across our health system. We are grateful for his service to GBMC HealthCare, and our thoughts are with his family, friends, and loved ones during this time. 

Clinical Documentation Improvement (CDI) Week 

Please join me in recognizing our CDI professionals for their continued accomplishments of service by celebrating CDI Week, September 18 – 22. GBMC’s CDI Specialists ensure the medical record reflects a clear, accurate, and complete picture of the resources utilized for the care received and the complexity of the condition of the patient. 

Surgical Technologists Week 

September 17-23 is Surgical Technologists Week! Thank you to our surgical technologists for their hard work and for making the operating room efficient while ensuring patient safety. 

Thank You for Your Patience with Parking

One thing that has been weighing on my mind lately is parking on our main hospital campus. In August, we made the difficult decision to close our oldest garage, Daffodil – located by Physicians Pavilion West (PPW) – for critical maintenance. This closure has resulted in parking challenges and traffic backups on campus. I recognize the extra stress this creates as people try to get to appointments or visit loved ones. I am truly sorry to all who have experienced an inconvenience with parking during their visit. 

We look forward to the opening of our new garage at the base of the Promise Project’s Sandra R. Berman Pavilion in November, as this will significantly improve the situation. However, in the meantime, we know we need solutions to alleviate the problem and improve the experience for all who visit us. 

Our Security, Parking, and Emergency Preparedness teams are working closely to monitor issues and implement real-time solutions that ensure patients have parking as close to their appointments as possible and alleviate traffic congestion on campus. 

We have taken a number of actions, including: 

• Relocating employees who park in Iris garage (by Physicians Pavilion East) to Tulip garage (by Physicians Pavilion North) or Farmhouse Hill. This makes more convenient parking spaces available to our patients. 
• Increasing the number of valets available at Physicians Pavilion West and the Sherwood Loop to accommodate  additional needs 
• Stationing security on the first floor of Iris garage to assist with directing the flow of traffic 
• Automatically dispensing tickets upon entering Iris; this process is faster than pushing the button to generate and pull a ticket 
• Better coordinating large deliveries that could block traffic flow 
• Improving outdoor campus signage to make parking options clearer 

I am so appreciative of your understanding and support as we navigate this challenge. If you have an appointment in Physicians Pavilion West, please remember the option of valet parking, and thank you to everyone for allowing extra time for parking when arriving for appointments, regardless of where they are on campus. I’m grateful for your patience. 

Thank You to our Environmental Services Team! 
September 10-16 is Environmental Services (EVS) & Housekeeping Week, and I'd like to take a moment to acknowledge the valuable contributions made by our EVS personnel. They play a pivotal role in the broader healthcare delivery process, investing countless hours in maintaining the cleanliness of our facilities and in helping prevent infections. While cleanliness is a shared responsibility at GBMC, our EVS staff are the true experts who work tirelessly to ensure the job is carried out effectively. Please join me in recognizing and thanking our exceptional EVS team! 

National Neonatal Nurses Week 
This week also marks National Neonatal Nurses Week. We are proud to have a 22-bed Level III NICU, providing complex and compassionate medical and general pediatric surgical care for about 400 babies annually that are born too small, too sick or too soon. The contributions of our neonatal nursing professionals make a difference that lasts a lifetime for neonates and their families. We are thankful for their compassion and skill in caring for our tiniest patients. 

Employee and Volunteer Appreciation BBQ 
Wednesday, we held our annual Employee and Volunteer Appreciation BBQ, complete with great food and fun. It is an event I truly look forward to as it gives us an opportunity to thank staff and volunteers for their dedicated service year-round. We had beautiful weather, and it was rewarding to spend time with team members across the organization. I want to thank Richelle Tighe, Executive Assistant, and Alissa Smith, Community Relations and Events Specialist, for their leadership and attention to detail in putting this great event together.

Understanding the Treatment Plan

A hospital stay can be an overwhelming experience, not only for patients but also for their loved ones. It's a time when clear communication and understanding are very important. Because of the complexity of healthcare and medicine, though, it is common to have challenges around communication. One way that organizations measure the effectiveness of their communication is through their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores.  

Today, I am highlighting an initiative that involved excellent collaboration between residents and nurses on Unit 36, whose scores around physician communication revealed opportunities for improvement. Tristan Flack, DO, Medical Director – Unit 36, and Theresa Dupski, MSN, RN, Nurse Manager – Unit 36, worked together to explore the key drivers impacting the scores. As part of this research, the unit began conducting its own bedside surveys with patients and realized that staff members could make a real difference by focusing on the question, "Do you understand your treatment plan?"  

Hospital inpatients are given so much information to comprehend on a daily basis. They are in an unfamiliar environment dealing with a stressful health situation and being given tons of complicated medical information to digest on top of it.  

Dr. Flack and Theresa studied the literature to learn what other organizations have done to help patients better understand their treatment plans. The studies showed the most effective tool was a visual aid for patients to refer to as frequently as needed. Equipped with this knowledge, the unit decided to develop a communication card designed to provide structure to the way care teams convey treatment plans to patients. 

This 3-inch by 5-inch card is completed daily during rounds and breaks down complex medical information into four concise sections: 

• What you’re being treated for: This section explains the diagnosis in easy-to-understand terms, rather than standard medical jargon. 
• When the team expects you to be discharged: Although it isn’t always possible to say for sure when a patient will be ready for discharge, we can typically provide an estimated range of time so that patients get a sense for how long they are likely to be in the hospital 
• What your discharge is dependent upon: This section covers what is keeping the patient in the hospital or what needs to happen in order for a patient to be ready for discharge. 
• The plan for today: This section includes check boxes for common needs, such as consultations, imaging, lab work, physical or occupational therapy, as well as a fill-in-the-blank option that can be customized.

It takes only a minute or so to discuss the information with the patient and is a valuable reference point for patients and their loved ones, who also appreciate reading the card for quick updates when they stop in to visit.

I’m proud of the collaboration between the nursing and resident teams that breathed life into the project as well as the way they have engaged patients to develop this solution. Under Dr. Flack and Theresa’s leadership, nurses and residents felt empowered to share suggestions for modifications that would make the cards more effective. The residents have really embraced this tool and made it a part of their practice.  

While we will have to wait to see any official impact on HCAHPS results, initial feedback from patients and their families has been overwhelmingly positive. We have gathered immediate metrics through patient surveys at the bedside, which suggest that patients feel more informed about their treatment plans.

Most importantly, it's not just about HCAHPS scores; it's about making a real impact on the lives of our patients and their families. Thank you to Unit 36 for all of your hard work and for reminding us that seemingly small changes can yield significant results in patient experience!