Standardizing The Work Of Rounding

Humans do things in batches to make the most efficient use of their time. Years ago before I paid my bills on-line, I would put them in a pile on my desk at home and then write the checks all at once towards the end of the month rather than getting the checkbook out every day when each bill came in. This made sense if my goal was the efficient use of my time. However, “batching” is a huge problem in large complex systems because the “downstream” process is often idle, waiting for the batch to be run.

“Batching” is a big problem in healthcare. (See: “Getting Better at Getting Better” and “Using Technology and Standardized Work to Make Care Easier and More Reliable”)  I remember when I was a practicing pediatrician and was caring for inner city children with high environmental exposures to lead. I would see a child on a Wednesday and have to wait a week for the blood lead level because the test was only done on Tuesdays. Occasionally, we would find out that a child had very high levels of lead 7 days after I should have admitted him to the hospital for treatment for acute lead toxicity. The tests were all done on one day because it made sense for the lab….but it didn’t make sense for the system that was trying to take care of the children.  The system would have been better served by the tests being done one at a time as they were needed by the physician to make the decision to help the patient.

At GBMC, we too have problems created by batching. One that we have committed to fix in this fiscal year is the problem of admitted patients in the Emergency Department waiting to go to an inpatient bed. The rate of arrivals of patients to the ED starts picking up around 8 in the morning. By late morning, there are a significant number of patients who have been identified for admission at GBMC as in most hospitals in our country.  But in almost every hospital in our country, few admissions actually leave the ED until late in the afternoon or early evening. Why do they wait? Well, there are a number of reasons but the most common is that they are waiting for a discharged patient to leave a bed in order for the bed to be made ready for the next patient. Why are the patients not leaving sooner? Well, again there are a number of reasons, but the single biggest reason is that the doctors, nurses, and other clinicians have not yet done the work of discharge.

Late last year, we did a value stream analysis of the work required to discharge a patient and physician rounding was identified as a significant opportunity for improvement. The long wait time for a patient waiting to go home is nothing more than a characteristic of the system that we have designed to discharge them. Our doctors and nurses are working very, very, hard. It is not about them, it is about the system. 

If you were waiting to drive your mother home from the hospital and you were told early in the morning that she was ready to go but that it was going to take until the late afternoon before the team could do the work required to discharge her, you would not be happy. We owe it to our patients and their families to redesign our systems when they are not meeting our needs. Our vision is “to every patient every time we will provide that care that we would want for our own loved ones.” And, we don’t want our patients waiting unnecessarily.

I’m excited to report that last week we did a weeklong Kaizen event (a review by staff to reduce waste and improve efficiency) on physician rounding. A team spent a week studying physician work on the medicine hospitalist service and the medicine resident service and they mapped all of the daily work and then started testing changes to that workflow.  Team members were Jeff Biedronski, Michael Finegan, Lisa Griffee, Stephanie Mayoryk, Dr. Fred Chan, Dr. Ezza Khan, Dr. Rekha Motagi, Dr. Eugene Obah, Dr. Sajeet Sohi, Kathy Bull, Keith Jackson, Deb McCaffrey, Cate O'Connor, George Bayless, and Dr. John Saunders. The Team began with the evidence- the data on when physicians write the discharge order (peaking at 2 PM) and when patients actually leave (peaking at around 4 PM).

Their work included trying to plan the evening before who would be ready to leave the following morning; improving the signout from physicians going home in the morning to those coming in; and planning discharges to do a few each hour rather than all at once.

This work is very exciting because it “smoothes” or “load levels” the amount of work across the daylight hours, so if a patient is ready to go home early in the morning, they can, rather than have everyone go home in the afternoon. This effort is another example of GBMC learning to utilize engineering concepts as we standardize our work toward our goals.  It’s not about relying on hard work and good intentions alone, nor about telling doctors and nurses to work harder and faster. I am so excited to show you the same graphs as above on the second day after the team implemented some changes!

Our goal is not for everyone to go home in the morning, rather the goal is for everyone to home as soon as possible after they no longer need to be in the hospital.  We look forward to making this goal a reality in 2013.

Welcome to the GBMC Family
We have some very exciting news to share!  We recently received commitments from two local outstanding physicians to join the GBMC Medical Staff. Drs. Michael Sellman and James Bernheimer will join the Department of Medicine as employed members of GBMA and will be leading our Division of Neurology and nationally-accredited Stroke program beginning July 1.  This is an exciting and important event for GBMC as we build a strong hospital-based neurology practice.

Go Ravens!
One final thought for the week – Go Ravens!  The GBMC family wishes the best of luck to our Baltimore Ravens in this weekend’s Super Bowl XLVII.  Hopefully many staff, patients and visitors have enjoyed the lights, banners and other “Purple Fever” activities throughout the GBMC HealthCare system this week and I look forward to celebrating a victory for the Ravens on Sunday night!

Showing Our Work to Our Legislators

Maryland lawmakers have begun their annual legislative session in Annapolis with many pressing issues on the agenda, from finances to gun control.  Perhaps the most pressing issue however is healthcare – it affects each and every Marylander and is a huge source of budgetary stress.

I had the privilege this week of welcoming two of our District 42 legislators, Senator Jim Brochin and Delegate Susan Aumann, to GBMA Hunt Valley, our site that has been operational as a patient centered medical home for the longest time.  Among those joining me were Harry Johnson,  the GBMC  HealthCare Board chair; Jim Stradtner, chairman of the board’s Strategic Planning Committee; Mark Lamos, M.D., physician at the Hunt Valley practice and president of Greater Baltimore Medical Associates; and Robyn Schaffer, Hunt Valley practice manager. 

The presentation, “What Is The GBMC HealthCare System Doing To Create A Better System Of Care For Our Region”, highlighted our efforts over the past few years to transform care to be better coordinated and to increase value through the eyes of the patient.  We reminded Senator Brochin and Delegate Aumann about the capabilities of our wonderful hospital, our outstanding surgeons and specialists, and our award-winning Gilchrist Hospice Care. We then shared with them how we’ve launched Greater Baltimore Health Alliance (GBHA), that joins private practicing physicians with GBMA doctors in alignment towards the quadruple aim of better health, better care, lower cost and more joy for those providing the care. We shared how the medical homes have implemented electronic medical records; how they have expanded their hours of care; how they have used the patient portal myGBMC to improve communication and how they have begun to provide care in new ways – like group visits for diabetics.

I shared how the United States of America has the most expensive healthcare in the world; that the costs are putting extreme financial pressure on our state and country and making it difficult for small businesses to compete but isn’t yielding better results for patients than healthcare in other countries that spend much less of their GDP.  (Health expenditures in the United States are more than 18 percent of GDP while in Australia, Canada, France, Germany and the United Kingdom the expenses range between six and 12 percent).

We absolutely have the best trained doctors and nurses in the world, and they work very, very hard, but they work every day in a broken system that is clearly not the best healthcare system in the world if the measure is value for what people pay.  If someone is in a motor vehicle crash and they need immediate access to emergency services, or they have a heart attack, the best place for them to be is in America.  But our national system just doesn’t manage chronic diseases very well and that has to change.  We have got to get better at coordinated, evidence-based care.

These elected officials now know that the GBMC HealthCare System is working hard to provide the  citizens that they serve a better healthcare product. 

Remembering Dr. Martin Luther King Jr.

When I reflect on the life of Dr. Martin Luther King Jr., I am reminded that progress in any endeavor comes to those who get in action for change. Waiting idly is the friend of the status quo. But depending on the nature of the issue, getting in action for change is often done at great peril to those in action, as we saw in the tragic end of the life of Dr. King.

History tells us that even some strong supporters of the Civil Rights movement told Dr. King that he was moving too fast, that he should wait and that freedom and equality would come with the passage of time.

In an open letter in the press eight clergymen reprimanded him for this and other aspects of his campaign. Dr. King answered these charges in a letter written in Birmingham Jail in the spring of 1963. In that letter Dr. King said:

"Actually time itself is neutral... Human progress never rolls in on wheels of inevitability; it comes through the tireless efforts of men willing to be co-workers with God, and without this hard work time itself becomes an ally of the forces of social stagnation." 

Dr. King made many personal sacrifices to gain freedom and equality for the oppressed. At this time of the year when we remember him we should reflect on our own action or inaction toward the goal of social justice. We should further reflect on the actions that we can and must take to further any noble cause, like the creation of a more value-driven and equitable healthcare system, because as Dr. King reminds us, time itself is neutral and waiting idly is wasteful. 

Let us rededicate ourselves to stay in action for meaningful change towards justice and equality.

A Great Day for Our HealthCare System 

On Monday of this week, Dr. Laddie Ross, Dr. Frank Rotolo, Dr. Joel Turner, and Dr. Jack Flowers officially became employees of Greater Baltimore Medical Associates (GBMA). We know them collectively as Finney Trimble Surgical Associates and individually as fantastic surgeons. I am so grateful that they have committed themselves to working at GBMC and helping to make our system better and better every day.

Getting In to See Your Doctor and Her Team

I spend a lot of time with groups of people talking about the need to redesign our healthcare system.  The one topic that always gets people’s attention is the issue of hours of operation.  People get very frustrated when they have a healthcare need and they can’t get in to see their physician or nurse practitioner. 

So I am delighted to report about the work of Greater Baltimore Medical Associates (GBMA) and its primary care practices and specialist practices at increasing access to care. To help reach our vision of providing the care that we would want for our own loved ones every time, we have been working to make it easier to get in to be seen when you need to be seen.  The number one strategy for this is increasing hours of operation. Through the hard work of GBMA Medical Director Mark Lamos, M.D. and Chief Operating Officer Ben Beres and with the leadership of physicians at each site and the practice managers, we have significantly increased the probability that a patient can get in to see us when he or she needs to.

Back in 2010, GBMA physician offices were open Monday through Friday, 9 am – 5 pm – which admittedly is often not very convenient for many people and often not when illness and sickness strikes. Now, all of the GBMA Primary Care offices have extended office hours Monday through Friday between 7 a.m. and 7 p.m - patients should contact their individual practice for their specific hours or check the GBMA website. In addition, our Hunt Valley office has already started Saturday hours between 9 a.m. and 1 p.m. and over the next several months all of our Primary Care sites will be open on Saturdays. 

The underpinning of our strategy is the Patient Centered Medical Home, which is centered on an ongoing relationship between the medical care team and the patient such that there is joint decision-making and joint ownership of the patients’ health. In order for this joint ownership to work, the physician and her team need to be available when the patient has a need. The team has to share the responsibility and not act like it is a surprise when the patient calls and needs to be seen. No longer is it ok to use the Emergency Department as the pathway of least resistance. The ED was made for emergencies, and it should not be encumbered with fixing the problems of a poorly designed primary care system. I am so proud of our GBMA teams that they are redesigning to get to better health and better care at lower cost. Their redesigned system is not perfect but is surely a more joyful place to work than the old model.

And we now have the evidence that our patients appreciate the redesigned system! The control chart below shows the monthly improvement on our patient satisfaction survey on the question “How easy is it for you to get an appointment when you need it?” Our score over the last two months has reached an all time high!

Let me thank all of our GBMA people for this great work. It is our intention to continually increase our hours of operation to better meet the needs of the people we serve and to continually move from fragmented care to seamless care. Watch us in 2013!

Using The Evidence To Reduce Catheter Associated Urinary Tract Infections

A basic tenet of Western medicine is that science holds the answers. We discount the beliefs of individuals if scientific evidence contradicts those beliefs. In the 20th century we were not as quick as we should have been, however, in banding together to assure that every patient benefited from medical care that was based on the evidence of what works best. Too often we let people do things “the way they were taught”, “the way that worked for them”, or the way that was quickest and most convenient for an individual practitioner, even if it was not the way that the evidence showed was best. Most often, the people who were not doing things “the best way” didn’t even know that there was a best way. Well, things are changing dramatically for the better.

Our latest example of this at GBMC is our reduction of Catheter Associated Urinary Tract Infections…otherwise referred to as CAUTI’s (where would we be without our acronyms!). A CAUTI is when a patient gets an infection in their bladder and urinary tract because they have a catheter placed in their bladder to drain urine. As you can see from the annotated run chart below, not too long ago we had 6-7 per month (and there were probably many more before we started measuring them.) In the old days we would consider CAUTI’s just a natural by-product of our care. We don’t anymore. We now look at CAUTI’s as defects in our care and in the spirit of continual improvement we ask what we can do to prevent them. We consider this our ethical duty. If it was our loved one who was the patient, we would be pretty upset if he or she got a CAUTI.

So GBMC put together a team that began learning from the literature about the evidence on how to prevent CAUTI’s. The team included Lynn Marie Bullock, Erin McCoy and Susan Collins from Nursing Education; Cherie Christopherson from Unit 58; Sheila Eller from Unit 25/26; Monica Niedermeyer from Unit 38; Jade Santiago from Unit 35; Linda Henderson, the ACE Clinical Program Manager/Unit 35,; Concetta Jackson, the Nurse Manager of Unit 58; Dr. Aaron Charles, the Medical Director of Unit 35; Phyllis Tyler from Infection Prevention; Cate O’Connor Devlin, Nursing Administrative Director; Jody Porter, our Chief Nursing Officer; and Carolyn Candiello, our Vice President for Quality and Patient Safety.  

They studied indications for using urinary catheters in the first place and alternative strategies for avoiding their use. They made some progress. They then studied the evidence around how to best put in a urinary catheter and started to disseminate this information to the broader GBMC clinical community. But as you can see from the annotations, it wasn’t until they began using a standardized checklist for catheter insertion, that they began to see a major improvement. Using the checklist as a way to assure that catheters only go in using the best technique is powerful. We know that humans often forget things and the checklist helps them avoid bad technique that leads to infections.

High reliability means: What should happen, happens and what should not happen, doesn’t. In this case, using a checklist has helped us get to higher reliability in urinary catheter use.

I am very grateful to our CAUTI Team and all of our hard-working nurses and physicians for standardizing care when it should be standardized. Our patients are benefiting from it and they thank you, too!

Time Flies

It’s hard to believe that another year is ending. As we get ready to make our resolutions for 2013, it’s good to take a moment and reflect on how well we met our commitments in 2012.

In 2011 we committed to a new vision – a new direction for GBMC. We committed to becoming a true system of care through the eyes of the patient. Since we and our family members are all (at one time or another) patients as well, we created the vision phrase To every patient, every time, we will provide the care that we would want for our own loved ones. For our own loved ones we want the best health outcome, with the best care experience, at the lowest cost…so we said that this is what we want for everyone. We created a strategic plan to get to our vision. 2012 was essentially the second year into that strategic plan, so did we continue doing what we said we would do?

A fundamental building block of our system of care is the new primary care team: the Patient-Centered Medical Home (PCMH). In 2012, our Hunt Valley office was the first primary care team to reach Level 3 PCMH status and now most of our employed primary care offices have achieved this. The primary care teams now reflect on how they are doing for groups of patients and actively work to improve the health of individual patients with chronic disease with the help of care managers who work side by side with their doctor and nurse teammates. They have all extended their office hours and now some are open on Saturdays. In 2012, we implemented our patient portal, myGBMC, to make it easier for patients to participate actively in their care, see their own records, and to communicate with their physicians.

Now that we designed the foundation of a better system to help keep people well and to help people with chronic illness to better manage their health, we created a new company, Greater Baltimore Health Alliance (GBHA), that includes not only our employed physicians, but also many of our wonderful private practicing doctors working together on our vision. In 2012, we learned that GBHA had been accepted into the Medicare Shared Savings Program as an accountable care organization. In 2012, GBMC HealthCare became the first company in Maryland to sponsor an accountable care organization that included a hospital.

In 2012, we made our outstanding hospital even more outstanding. We made our care even safer than it had been. We rolled out a mandatory course called Getting in action for patient safety and all of our employees took the course. Teams made outstanding quality improvements in areas such as hand hygiene, central line associated blood stream infections, surgical site infections and catheter associated urinary tract infections. Our outstanding surgeons made patient care even better by participating in the National Surgical Quality Improvement Program. We are one of a few community hospitals to participate fully in this program. We opened our simulation lab as a place for people to learn and practice as individuals and in teams in a safe environment. We opened our Geckle Diabetes Center building on the strengths of the education center and now focusing also on the actual care of diabetic patients wherever they are in our system.  We empowered our physician leaders in Medicine, Surgery, Oncology, and Women’s Health to run these service lines and continually move us in those areas towards our vision. We added medical directors to all of our inpatient units and now have them working in partnership with our wonderful nurse managers to continually improve the quality of our care. We improved our ability to create standard work and use continuous improvement tools, specifically LEAN and the Model for Improvement and ran a number of value stream mapping and redesign events. An example of this was our weeklong 3P event to design our new inpatient pharmacy. Through the hard work of all, but especially our nurses and housekeepers, we achieved the highest overall inpatient satisfaction score in years and perhaps in our history (see the chart below). We added new flooring in many places in our hospital. We are the first hospital that I know of to scientifically calculate bed need for Medicine patients using queuing theory. This work resulted in our opening 12 more beds. In 2012 we opened our new Domestic Violence Program, becoming one of only seven such programs in Maryland. All of this work and much more combined with the wonderful dedication of our staff led to a very successful Joint Commission survey.

Gilchrist Hospice Care and Gilchrist Greater Living continued their spectacular work and truly lead the region in compassionate, evidence-based care to seniors and those at the end of life. Their year culminated in an outstanding outpouring of support from the community in the 2012 Holly Ball.

Our Human Resources Team redesigned our employee health benefit that reduced out of pocket costs for most of our employees and kept more of our dollars within our own system.

120 of our outstanding physicians were named to the Baltimore Magazine Top Docs list. Once again, GBMC had the most physicians of any community health system or hospital on this list. We are so fortunate to have outstanding surgeons, internists, pediatricians, family physicians, and other wonderful specialists.

In 2012, GBMC was recognized for the wonderful work of our Green Team. We won the Trailblazer award from the Maryland Hospitals for a Healthy Environment organization for our work in waste reduction and healthier food options. Our fantastic volunteer auxiliary again broke records in fundraising through our Nearly New sales and our Foundation ran a spectacular Legacy Chase steeplechase event that showcased our HealthCare system to the community.

I realize that these things only represent a small fraction of what the GBMC family did to move us closer to our vision. All I can say is thank you! I look forward to all of our accomplishments to come in 2013.

Compassion

For this week’s blog post, with her permission I am sharing a letter I received from Tara Holicky, a practice manager in Geriatrics, about her experience as a patient at GBMC when delivering her second baby.  Tara’s story is a wonderful example of GBMC delivering the kind of care that we would want for our own loved one.

After sometime, I’ve finally found the words to write to say thank you to hard working employees at GBMC.  I, myself, am actually a GBMC employee.  I started here after my first child was born in 2005.  It’s taken me some time to write this letter, because despite multiple attempts I’ve been unable to find the right way to express how grateful I am to the nurses, techs, doctors, and downright everyone for the miracle I have today.

In 2011, I was pregnant with my second child.  It was a very uneventful, normal pregnancy.  I had a c-section with my first and planned to have a scheduled c-section on 8/29/12 at 8 am.  (I wasn’t due until Labor Day, ironic I know).

To my surprise on the evening of July 11, 2011, my water broke.  I honestly thought I had an accident at first, and ignored it.  But when it seemed to be continuing, I called my OB’s office who advised I go in just in case.  Imagine my horror when I was told that indeed my water had broken.  I wasn’t even 32 weeks yet.  I panicked at the thought.   But the nurses were there for me.  They explained what would happen – I would be admitted.  They wouldn’t actively try to induce labor since it was a slow leak and the baby seemed okay, but they also wouldn’t try to stop labor if it happened either.  I would be staying in the hospital one way or another until my baby was born.  Fear cannot explain what I went through that first night in Labor and Delivery.  Wondering if I would get transferred to high risk, would everything be ok?  What would the NICU consult mean?  I didn’t sleep the entire night.  My nurses comforted and talked to me even though they were busy with other families having babies.  Each person who came into my room took time to really talk to me, knowing how scared I must be.

After a few days, despite not going into labor my fluid levels were too low for the baby to be safe, and I was whisked to the OR for an emergency c-section.  I was again terrified.  I had been through a c-section before, but this was different she was too early, I had to prepare myself that she might not cry, she may not make it, all the “what-ifs” that go along with a preemie.  But again, GBMC employees were there for me.  They explained exactly what was happening; the team in the OR all explained what would happen when she was born.

On July 13, 2011, around 10 am, my beautiful little 3 lb miracle was born at 32 weeks and 1 day.  And she screamed!  It was the most beautiful thing I’d ever head.  As it turned out she actually had a true knot in her cord, so it was quite lucky my water broke when it did.  The NICU team gave me a quick look and hug before they whisked her off to be fully evaluated.  My husband quickly followed them out, and the remaining OR team was there to comfort me while they sewed me up.  In recovery, I was fraught.   All the other women got to see their baby and I was there alone.  But the nurses understood my pain, and helped me deal. 

In postpartum, again, my family could all go to the NICU but I wasn’t able to yet.  Nurses, techs, housekeepers, even the people who delivered meals, were all sensitive to this.  They took the time to ask how she was, asked to see pictures, etc.  They were truly caring.  That evening when they told me I could up to the NICU, I was thrilled.  The NICU nurse who said I could hold her was my hero in that moment.  I had never seen a baby so small, much less held one.  To have my baby there in my arms doing okay, was such a miracle to me in that moment. 

It is tough to be in Post Partum when you can’t just have your baby in the room.  It is difficult to see families going home with their new little bundle of joy, knowing you will not get to do the same thing.  The nurses in Post Partum and the NICU were amazing people.  On my discharge from GBMC I cried so hard.  And Taylor my nurse sat down and cried with me.  She made me understand that it was okay to be sad, but I would be back tomorrow morning to see her.  The nurses in the NICU encouraged me to call in the middle of the night if I wanted to check in.

Since I worked at GBMC, my plan was to just go to the NICU for the full day while my husband was at work.  I could sit my office when I needed to.  Monica, a NICU nurse, knew that I wasn’t thinking clearly as woman who was recovering from her own surgery and arranged for me to use a room to rest during the day when I needed to.  I was so thankful to be able to take a nap during the day.  I was in the NICU essentially every day for at least 8 hours thereafter during the day.  I would cry when my husband came at 5 pm knowing we’d have to go home for the night. 

However, we were extremely lucky, despite her small size, my little girl was a fighter, and even though I was told she would need to stay until she was at least 35 weeks, she was discharged after only 13 days.

She is now a happy, healthy almost 17 month old, that you just saw the other day at the T. Rowe Price Scholarship award ceremony.  Despite her small size she is bundle of energy.  I thank the superb employees of GBMC for making this happen.  I am certain I cannot remember everyone by name and for that I am sorry, but I want to specifically thank Post Partum nurses Taylor, Suzie, Susan and all the others I know I’m forgetting.  The NICU nurses, Monica, Tamara, Janice, Pat, Ellen.  The doctors, my OB. Dr. Allen, the NICU team, Dr. Pane, Dr. Birenbaum and Dr. Helou, and the countless others at GBMC, housekeepers, techs, and meal servicers.  You are all special to me in that you each contributed to making my family whole.

What a great example of Team GBMC rallying around a patient and her family!  We need to continue our work to make this happen for every patient, every time.

This story is a good reminder that during this time of year we have many things to be thankful for and appreciative of, both in our personal lives as well as at work. Happy Holidays to all and best wishes for a safe and enjoyable holiday season.