It Should Be Easy to Move an Admitted Patient from the ED to a Floor Bed….Shouldn’t it?

This week a Team of GBMC people spent 5 days studying our system from when a patient is first seen by an Emergency Department physician until those that need to be admitted to the hospital are actually in an inpatient bed.

The Team was chartered because we identified this as a strategic opportunity for improvement when we created our operating plan for this fiscal year. We set a goal for ourselves to reduce the average time from when a patient arrives in the ED until they are in an inpatient bed from 8.5 to 6.8 hours… a reduction of 20 percent. 

GBMC HealthCare set this goal because our patients get very upset when they are still in the Emergency Department long after they have been told that they need to be admitted. This is no surprise. Almost every adult has accompanied at least one family member who has waited in some ED to be moved to an inpatient bed. If we don’t want this for our own loved one, no one should wait. Not to mention the cost to our system of extra staffing and foregone admissions when other people leave our ED and go somewhere else for care.

The Team included doctors and nurses from the ED, hospitalists and inpatient nurses, secretaries and people from many support services. Their mentor was Neil Crockett from Next Level Partners and they were aided by a number of our Performance Improvement Masters. After getting some training, the team set out to study the current processes. They went to the ED and the inpatient floors and watched them and documented the way they were doing things. The Team identified 89 sources of unnecessary variation and waste.

They were amazed that for almost every step that they studied, each person doing a task was doing it differently.  They then identified 56 actions that they could take to redesign the processes within the system.  The Team then divided these actions into things that they could change right away: “Just do it’s”, things that they could test immediately (trystorming), and more complicated things that could be changed over time. They immediately implemented the “just do it’s” and began implementing the things that seemed to work in the “trystorms”.

I went to the final Team report today and was amazed at how much they had accomplished. Every team member had a greater understanding of how the other team members were doing their job and how complex the system of admitting a patient from the ED actually is.

There is a lot of work to be done to redesign healthcare in our country and in the GBMC system. When we talk about delivering better health, better care, and lower cost, the uninitiated believe that this means more work for those providing the care. It is only when they develop the deeper knowledge of what is going on in our existing system that they see that a lot of what they are doing is not really benefiting anyone and if they do the work of redesign, they will accomplish better health and better care with less work.

It was really exciting to see that this was one of the learnings from the Team’s efforts this week. I am awed by what they accomplished and am more excited than ever about the transformation of the GBMC HealthCare system. 

Perfection

Our GBMC HealthCare system is working towards a vision of perfection. When we strive to give everyone the care that we would want for our own loved ones, every time, it is perfection that we are after. When I say this to people, I always add that we will never quite get to perfection because we are human and as good as we can make them - our systems will still be fallible.  There will always be at least a few holes in the “Swiss Cheese”. So when we do get to perfection, even if it is just for some subset of our patients on one parameter I am surprised and delighted!  

I am happy to report that Unit 58, our Joint and Spine Center inpatient unit, has achieved perfection in hand hygiene in January and for two of the last three months. The team, under the direction of nurse manager Conchetta Jackson, RN and medical director Lee Schmidt, MD are doing great things. In January, the secret auditor watched 45 separate incidents of a staff member walking in and out of a room and the individual cleansed his or her hands every single time! This is not easy! When people are busy it is very hard to not slip at least once in remembering to clean their hands so as to not spread germs from one patient to another…but they did it!

In addition, 5 different “disciplines” also had a perfect score in January. They were: Nutrition/Food Services, OT/PT, Phlebotomy, Radiology, and Volunteers. My hat is off to these colleagues who are doing great things to keep our patients safe.

Purple Baltimore

While I am congratulating folks, I would be remiss if I didn’t congratulate Ray Lewis, Joe Flacco, Anquan Boldin and the rest of the Ravens. It was a great game and although I would have preferred the game to have ended at halftime, I was delighted with the final score. I felt sorry for the people operating the Superdome, we at GBMC know what it is like  to deal with power outages!

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!