On Becoming A Learning Organization

I ended last week’s blog by inviting people to comment and they did. I stopped replying to every comment as it appeared because I didn’t think that it would be helpful once I saw the emotions that were being released. So, let me try to respond to the comments now.

The blog is a mechanism for communicating. A regular reader of the blog knows that I am usually trying to accelerate change toward our vision of being the healthcare system that treats everyone the way that we would want our own loved ones treated, every time. Sometimes I highlight a “technical” concept, like the relationship between the number of hospital beds in an area and the cost of healthcare in that area, or the ability of the patient-centered medical home to make care less fragmented for people with chronic disease. Sometimes I highlight great work by our people in making change happen, like the blog on standard work and improving our hand hygiene scores, or the one on the great work of the team that created the design for our new inpatient pharmacy (see "What's a 3P?".) Other times I have interviewed patients to let them tell their stories about their care as a way to recognize our wonderful nurses, doctors, therapists, technicians, and other staff (see the February 24, 2012 blog with Chris Brandau’s Mom).

But until last week, I had only used “negative” incidents from other industries to highlight room for improvement, like the blog I wrote in which I talked about the poor (giving the appearance that the Southwest employee didn’t care) service that I saw at BWI airport; or my poor service due to a poorly designed system in getting a hot dog on the New Jersey Turnpike (see the August 24th blog, "Good Leadership, Poor Leadership, Well Designed Systems and Random Behavior"

Last week I took a chance. I decided that we had developed enough as a learning organization to begin to openly discuss negative feedback from one of our patients. I picked the letter in part because the author said many nice things about our people. I removed two names from the letter so that the individuals whose reported negative behavior was focused on by the writer could not be identified. I also removed the name of a nurse who had been complimented so that the floor of the hospital could not be identified by people who did not know of the episode.

The purpose of the blog was to get us all to reflect on how our behavior is perceived by those who we serve so that through this reflection we may all become better. The blog was not meant to hurt any individual. After the blog was published, more than one person told me that they knew of many incidents where we had left the appearance of callousness, the appearance that we did not care. All of these people also told me that they thought that GBMC had great people who really do care and who work very hard and usually delight their patients with their caring. But these folks agreed that it is good to reflect when we do appear to not care so that we can improve ourselves.

I know how hard people are working in our GBMC HealthCare System and I know that it is my job to make sure that they have what they need to get the job done; whether it be staffing or equipment. I realize that it is my job to see that they are empowered to improve the systems that they work in to make it less hard for them to get the job done. But I also am aware that it is my job to assure that we reflect on how we are doing because ultimately we are here for the people we serve.  

The Appearance Of Callousness

Have you ever seen the short film It’s a Dog’s World? (The “new” edition can be seen here).  This is a short film that makes the comparison of how a dog is treated with empathy, dignity and respect after an injury, while his master, also injured, does not get the same. The owner of the dog has to deal with among other things, people who don’t really seem to care about him.

I am very fortunate to be the CEO of the GBMC HealthCare system. I get so many wonderful letters about members of the GBMC family who do marvelous things for our patients. But I also get letters where we did not treat people the way we want our loved ones to be treated. When I read these letters, I most often believe that our people did care but they gave the impression that they didn’t.  I have come to call this the appearance of callousness. We often give the impression that we don’t care when we are overwhelmed or when we are busy trying to protect our teammates from being overwhelmed.

Here is an excerpt from a letter that I received this week:

“I am writing you about my recent inpatient stays at GBMC. I was admitted to GBMC for 4 days, went home for 2 days, but needed a readmission for another 3 days. My two stays couldn't have been more dissimilar. So I am writing about my observations, those who did a great job, and the few problems I found.

First, I think in general I got very good care. In the ED, I actually thought that the waiting was reasonable, they gave me a reasonable expectation of time delays etc. I found the ED nurses and techs very good- both in doing their job and giving the personal attention. One is struck by how busy they are and how they have to juggle many duties. Despite that, I didn't find it detracting from my care. Transport was fine, CT and sonogram people were pleasant, capable, and helpful.

I was admitted to an inpatient unit. My hospitalist was Dr. Renu Thomas, whom I found to be excellent. She was very thorough, had good insight into my care, was prompt about writing orders, and showed compassion and concern. Medically I thought she was excellent.  I was in a typical GBMC room- very small, but it was quiet.  I didn't really require a lot- mainly IV antibiotics etc. The nurses were all excellent, caring. One is struck by how busy they are, how they have to juggle many things. I liked that they wrote their names down each shift and left the direct number to the nurse. Once I used the call button, didn't get a response, but just waited since it wasn't that urgent. Later, I just called the nurse. Once a tech forgot something I asked for, and she was so apologetic. It really was fine. I had one aide who could have been a little quicker to help, but in general I found the staff great. The phlebotomists at 5:30 am were incredibly quick, quiet, and excellent at getting the blood work done. A night nurse, who clearly has many years of experience, was particularly helpful with her suggestions.

I was discharged home but the symptoms returned, so I came back for more intravenous medication. On my second visit my ED stay was again appropriate, not too long a wait, good staff. Then I was readmitted back to an inpatient unit. However I was put by the nurses’ station, in between a demented woman, and a hard of hearing man. And I was down from the ice machine- which is very noisy. So the room was very noisy and not ideal. This time I had a different doctor, whom I was not very impressed with. I found her manner not very caring. She made a mistake ordering me a medicine. When I mentioned it the next day- next time I saw her- she didn't even apologize. She just said that the computer wouldn't accept her code etc. When it was time to be discharged, she said I would have to wait at least 3 hours because she had sick patients she had to care for. I am sure that this was true but not what I needed or wanted to hear.

However my worst experience was from the unit coordinator. During my second stay, I developed a headache (my headaches often progress to severe migraines), and at 7:10 am hit the call button to ask for Tylenol. I was answered right away and told that it was change of shift so that it would be awhile for the medicine. At 8am when I still hadn't received the Tylenol, I called again. No answer. So I tried 2 more times over 5 minutes. No one even answered the button. So I got out of bed, and with my IV pole in tow, went out to the desk. As I approached, the unit coordinator said she told me the nurse would be coming. I said that no one answered the call button. She then, in front of many people at the desk, said that she had talked to me several times and told me that the nurse would be coming. At that point, I told her that she had only told me once at 7:10 and I wasn't sure that the bell had even worked the next time since no one even answered me. The nurse then came and gave me the Tylenol.

Later that day I spoke with the charge nurse, who was extremely polite, apologetic and helpful. She arranged for my room to be changed to one away from the nurses’ station. I did mention that I thought it was a problem that someone couldn't even get a Tylenol for an hour due to change of shift.

I will probably be returning again to GBMC as an inpatient because of my chronic medical problems. I am hopeful that I will have a better experience than my second stay. But in general the nurses are all excellent, caring, and very busy. You really get a sense of all they are taking care of with their patients. So many things go well at GBMC, but there is always room for improvement.

I am very grateful for the work of our people at GBMC, especially all of the nurses and technicians that this patient thanked and Dr. Renu Thomas.  But, as the patient said:  “There is always room for improvement”.  I called the patient and apologized for the appearance of callousness by that unit coordinator.  I told the patient that our unit coordinators do an excellent job but sometimes people slip and make it appear that they don’t care when they do, and sometimes they say the wrong thing when they are trying to prevent their nurse teammates from being overwhelmed. The patient accepted this and she told me that GBMC is still her preferred hospital. I thanked her for her trust in us.

I know that there was a discussion between that unit coordinator and her supervisor, to get her to reflect on her behavior and change it. I should also mention that our nurses are working to redesign our approach to answering the call light and they have embraced bedside handoffs and hourly rounding to reduce the frequency of patients needing to call them.

But in addition we all need to work to eliminate the appearance of callousness.  I look forward to your thoughts on this.

A Wonderful Legacy Remembered: The End of Catholic Health Care In Our Region

This week marks the end of Catholic healthcare in our region. With the purchase of St. Joseph’s Medical Center by a non-denominational hospital company, a 148 year legacy of service is finished. I spent three years in Catholic healthcare in Boston and that company, Caritas Christi, is also a thing of the past, having been purchased by venture capitalists.

The reality is that we have too much hospital capacity in Baltimore. The owners of St. Joseph’s, Catholic Health Initiatives (CHI) of Denver, Colorado, had only one hospital in the area and it was losing a lot of money. CHI is a very large company with $9.65 billion in annual operating revenues but after a number of years of losing money in Towson, they decided to divest themselves of St. Joseph’s. CHI is a mission-driven organization and they are also realists. It appears that the company could only rationalize losing millions if they could prove that there was an unmet need. With all of the excess hospital beds in Baltimore, they could not justify the need so they got out. Now, a smaller hospital company is the new owner.

What a long way from the reality found by the Sisters of St. Francis of Philadelphia in 1864 when Mrs. Catherine Eberhard donated three row houses on North Caroline Street to be used for the sick and infirm. In that era, there was not much available to cure disease. Hospitals were started as a place to care for the sick who were also poor. Those with means were cared for in their homes by their families. The Sisters of St. Francis and others who joined with them in this noble mission dedicated themselves to helping others in their time of need.

In 1870, the State approved the Act of Incorporation to create the Saint Joseph German Hospital and in 1872 a new facility with that name opened at Caroline and Oliver Streets in Baltimore City. During the 20^th Century, with the advances of modern medicine, the hospital grew and changed and in 1965 (the year of the opening of GBMC), St. Joseph’s moved to Towson. In 1981, the hospital became a part of the Franciscan Health System and they began doing open heart surgery the next year. In 1996, St. Joseph’s became a part of CHI and continued their growth in heart and orthopedic procedures.

Everyone in Baltimore knows what happened next with the governmental investigation and the accusations of unnecessary procedures. What has not been discussed is how the hard-working nurses, doctors, and other clinicians kept serving patients. Unfortunately for them, the business model that St. Joseph’s had chosen is hard to make work with so many hospitals pursuing the same model, and the American people and American businesses are desperate for a new model. You see, building a lot of hospital beds and waiting for people to get sick to use them, or only providing a lot of elective procedures because that is where you make the money, has led us to our national predicament where we are bankrupting our federal government, our state government and making it difficult for businesses to provide health insurance to their people. The new model, a system of health care that works to keep people healthy and limits the need for patients with chronic disease to be admitted to the hospital, requires different capacities and capabilities.

The biggest capacity that is required of the new model is primary care. In the Greater Baltimore Health Alliance, (our system’s Accountable Care Organization) we now have close to 100 primary care providers, many of whom are working in Level 3 patient centered medical homes with care managers, extended office hours, and a fully functioning patient portal, among other things, to keep people healthy. None of these things are focused on by hospital companies using the old model, like St. Joseph’s.

It is sad to see the end of the legacy of the dedicated Sisters of St. Francis and all of the hard working physicians, nurses, and others who worked with them on a mission of service to others. We know however, that their spirit lives on in those who embrace the new model of service and who are willing to let go of the old model where filling hospital beds and focusing on services that make money were acceptable endpoints in and of themselves.    

Health, Healing and Hope for Victims of Domestic Violence

Last week I had the privilege of welcoming Maryland Lieutenant Governor Anthony Brown to the GBMC campus as he announced Maryland’s seventh hospital-based Domestic Violence Program (DVP).  Joining Lt. Gov. Brown was Maria Harris Tildon, vice president of corporate communications for CareFirst BlueCross BlueShield, who presented GBMC with a check for $15,470 toward the DVP. 

As a pediatrician, I have seen firsthand the impact of domestic violence in the home and the critical role medical providers can play in addressing this issue. We are fortunate to have two outstanding professionals leading these programs,  Linda Kelly and Sally Hess, who are educating and training our medical staff to better identify and respond to patients in need.  In this way, GBMC is adding a new program that will help us better meet our mission of health, healing, and hope for those in our community. 

This is another example of GBMC HealthCare focusing on what patients need. While others are amalgamating hospitals and propping up unnecessary bed capacity to get market share and drive up the cost of care in our region, we are adding this new service which will never cover its direct costs on patient revenue, let alone be profitable.  

GBMC has been serving victims of violence for many years through our Sexual Assault Forensic Examination program (SAFE), which has always had the goal of expanding its services to include victims of Intimate Partner Violence (IPV). Now that this is a reality, the goals of the GBMC DV program include providing direct services (24/7 crisis response such as support, education, safety planning, referral to community resources and follow-up) to any patient, staff or community member experiencing IPV, educating staff on the effects of DV on health, and how to best identify and support patients experiencing IPV.

To date, GBMC’s DVP has provided services to more than 50 individuals.  We anticipate serving an average of 30 patients per month by 2014 based on similar-sized hospital programs.  In addition to corporate and state grants, the program is being financially supported by generous donations from our community.  We are grateful for all the support that is allowing GBMC to continue its legacy of providing healthcare services for women across the community.

To learn more, watch a video of the press conference announcing the program.

Our Green Team Gets Recognized for its Accomplishments

L-R: Keith Magel, Regional Manager, ARAMark; Jim Duerr, Corporate Materials Manager Director, GBMC; Matt Tresansky, Nutrition Director at GBMC, ARAMark; Ryan O'Hara, Retail Manager at GBMC, ARAMark ; Keith Sappington, Food Production at GBMC, ARAMark; Michael Forthman. Vice President of Facilities & Support Services, GBMC; John Chessare, M.D., President & CEO, GBMC HealthCare system

Congratulations to everyone involved with our Green Team, led by Michael Forthman, vice president of facilities and support services, on the occasion of the GBMC HealthCare system being recognized with one of five Trailblazer Awards at the Maryland Hospitals for a Healthy Environment (MD H2E) Environmental Excellence in Health Care Conference. Trailblazer Awards are given annually to hospitals that have shown leadership in advancing sustainability in their operations.

GBMC was recognized for its dedication to providing improved diet options for patients, employees, and visitors. During the first month after launching a campaign to promote healthier beverages, hospital sales of non-sugary drinks exceeded sugary ones for the first time on record. GBMC reduced food waste by 1,100 pounds per month from March to August of 2012, and installed hydration stations which encourage refilling reusable bottles with filtered water.

Treating everyone the way you want your own loved ones treated…with clean hands.

I also wanted to recognize our employees, who are working hard to reach our hand hygiene goal. As you know, if we achieve a score of 79 percent or greater in November, we will pay out a bonus in December to eligible employees.  We are just past the halfway point for November, and our hand hygiene compliance score is at 81%.  We still have a ways to go, though!  I encourage you to keep up the good work!  Practicing hand hygiene is the number one way to prevent healthcare acquired infections.

If it were your loved one, you would want to be sure that any staff entering the room had clean hands.   This will be an excellent achievement, so let’s all work together to make sure we clean our hands on the way in and on the way out every time!  

Finally, I hope everyone in our GBMC family had a happy and enjoyable Thanksgiving holiday.  Each day I am thankful for every member of our team who does the very best they can do in whatever role they play in helping provide the best possible care for our patients. 

Welcome To Our Family

I’ve been in healthcare for quite awhile and I know that every healthcare organization of any significant size does formal orientation. I firmly believe that orientation is a great opportunity to have a conversation with people when they are first forming their impressions of the new workplace.  New people don’t yet know the ways of their new organization so they are kind of a constant opportunity for change.  I believe if you can get to the new people they can make change happen faster, whereas someone who has been in your organization, although they may be a wonderful person, they kind of accept the way the organization operates and it’s harder to see opportunities for change.

Every two weeks I give the opening welcome for the GBMC HealthCare system orientation. I start by talking about our mission, vision and values and our plan for the future. I talk about the fact that we are not just a hospital, we are a wonderful healthcare system with a great hospital and a great hospice (Gilchrist) and a great physician company (GBMA), and now a great new physician company (GBHA) to embrace private practicing doctors in the pursuit of the Quadruple Aim of Better Health, Better Care, Less Waste and More Joy. I underline for the new staff that we are a system of care, and explain that if we could get the kind of coordination that Dr. Tony Riley and his colleagues in Geriatrics get for frail elderly patients for example, for every patient, we’d be a marvelous healthcare system.

I often have a great dialogue with the new staff at orientation about what doing it the way you would want for your own loved one every time actually means. The experience every two weeks has been invaluable. It's probably the best interaction I have with employees about where we are headed as a company.

As we approach the Thanksgiving holiday, I want to take a moment to thank all of the GBMC HealthCare system private practice physicians, employees, volunteers, and board members who help us in one way or another provide outstanding care around the clock for our patients.  Healthcare is a 24/7/365 enterprise, and we recognize that many individuals make personal sacrifices during the holiday season in order to help care for our community.

Speaking of our community, Joe Hart, GBMC’s chaplain and Spiritual Support Director, recently suggested that we ought to get to know our religious neighbors, so we have launched a "visiting our neighbors" series.  Joe and I recently visited the School Sisters of Notre Dame at Villa Assumpta on North Charles Street.  There are nearly 60 sisters who live in retirement at various stages of life.  We met with members of the provincial council and discussed the healthcare needs of their community. I explained our philosophy of care and asked how we might assist them in meeting their healthcare needs/goals.  Knowing the community well I was able to speak to the spiritual support offerings we have when their members come to GBMC for care.  It was nice to hear the many complimentary things they had to say about GBMC and how well the sisters have been cared for recently and in the past. 

Working Toward A Safer Culture For All Patients

This week I invited Carolyn Candiello, Vice President, Quality and Patient Safety, to write a guest blog post highlighting the organization's upcoming Safety Attitude Survey.

We all heard over and over in this most recent election about the importance of getting out to vote!   Next week we will begin our second annual Safety Attitude Survey.  I am very excited about this year’s survey and am looking forward to learning how we can continue to improve our safety culture.  I am also interested to see if our scores reflect the good work our staff has done over the past 18 months to reduce serious safety events and infections.     I hope everyone in our patient care units will take the time to “vote”!

When we conducted our survey last year, we learned that in those units with the lowest perception of teamwork there was a higher incidence of patient harm. We also learned that nurses and doctors working on the same unit can have a different perspective of patient safety and teamwork.  We learned that some of our staff felt that it was not easy to talk about errors and that we didn’t always address behaviors fairly.

Christina Welch, Clinical Unit Coordinator of Unit 58,
demonstrates the Quantos reporting tool.

In response to the survey, each unit reviewed their findings and implemented action plans aimed at specific improvement.    In addition, we initiated several organization-wide changes.   For example, our survey revealed that we did not have a good mechanism to report safety events. Since the survey, we have implemented our on-line incident reporting tool, Quantros, which allows for ease of reporting.  The increase in reporting and the quality of the reporting has allowed us to identify trends that block holes in our system.  The Quantros tool is located on the InfoWeb - look for the Patient Safety button on the homepage.  As a reminder, staff should report any incidence of patient harm, near misses or unreliable care. 

Quantos reporting on the InfoWeb

We also heard that it was difficult to discuss errors and there was inconsistency in our responses. We have since adopted a philosophy of a Just Culture were we console human error, coach at risk behavior and appropriately discipline reckless behavior.  We also continue to learn from our errors and share our learning throughout the organization.  Staff are involved in root cause analysis and participate in identifying permanent solutions to prevent an error from re-occurring.

A great example of learning from our experiences has been in our efforts to reduce falls.  Earlier this year, we noticed an increase in patient falls.   In response, a a multi-disciplinary improvement team  was appointed whose aim is to reduce falls and prevent injury.    So far, we have seen significant improvement (see the FY2013 system goals).    But also, we are seeing a culture change.  Units are measuring the time between falls.  Now, when a fall occurs, everyone takes notice.   The team does a post-fall huddle and looks for ways to prevent a similar occurrence.    Having everyone engaged and in action to prevent falls is powerful.

The Safety Attitude Survey will be conducted across all patient care units within the organization.  This is a confidential survey that focuses specifically on staff perception of clinical safety in their unique work setting.  The 33 questions focus on teamwork, safety, leadership, stress, working conditions, and learning.   While some of the questions are similar to the employee opinion survey, this questionnaire is designed to provide direct feedback around the clinical safety climate.  Responses to the survey are completely confidential and will be processed electronically by Pascal Metrics.

Staff who will participate in the survey will receive a  “token” and a link for the survey from their manager—this will be a similar process to the employee opinion survey.  Gilchrist Hospice employees will receive a paper survey.  Results of the survey will be shared throughout the organization in early 2013.  I look forward to sharing them with you and seeing where we have made improvements since last year.

When you receive the token or paper survey, please take the time to “vote”—our patient’s safety depends on it.

No, not that election!

This week, many of us voted in the Presidential election, statewide elections and on referendum questions. But recently there was another “election”.

Nearly 10,000 physicians in the region “voted” for which physician, in a variety of specialties, they would send a member of their own family to if they needed healthcare.  The highly regarded Baltimore Magazine annual “Top Doctors” November issue was recently released and the votes are in.

I’m proud to say that many doctors agree on who is best!  Once again, GBMC had more members of our medical staff cited as a “Top Doctor” than any other community  health system or hospital. It is with a great deal of pride and pleasure to share with you that 120 GBMC physicians, covering 60 specialities, were recognized a total of 132 times as a “Top Doctor”!  That’s right, there were several GBMC physicians who were cited as a “Top Doctor” in more than one specialty or sub-specialty!

Being recognized as a “Top Doctor” is an extraordinary honor, because it is a selection by peers for which physician they would select for a member of their own family.  To all of the “Top Doctors” at GBMC, congratulations from all of us! The rest of us in the family are very proud of you.

To view a listing of our “Top Doctors” and to learn more about who they are, please visit GBMC's Top Doctors 2012 webpage.

I would be remiss if I didn't thank our Chief of the Division of Gastroenterology, Dr. Niraj Jani, who was one of the five survey advisers (and thus was ineligible to be selected as a "Top Doc" by his peers), and recognize family medicine physician Dr. Sarah Whiteford, whose "Why I Became A Doctor" story was one of several profiled.