How Did We Improve Our Hand Hygiene Rates?

I arrived at GBMC in the summer of 2010 shortly after we received our first “secret shopper” measurement of hand hygiene and learned that it was a toss-up if someone coming into your daughter’s room at GBMC had washed his or her hands before entering. I remember thinking that it wasn’t that people didn’t know to wash their hands nor was it that they didn’t care. The rate was only about 50% because people’s minds were elsewhere…they were busy or they were distracted. I wondered how we would ever get closer to clean hands every time? I couldn’t think of a design change that was likely to work.
 
We tried the “technology” route in the MICU. We worked with a vendor that had software that would measure the rate and prompt the individual. We ended the test concluding that the MICU rate was no better than rates without the technology. We started to get traction when units started doing audits on a few trips in and out of a room on a daily basis. It seems that the staff doing audits generated better engagement and it started to lock in the habit.

Our run chart of hand hygiene compliance is one of the best examples of healthcare improvement that I have ever seen. I am still reflecting on the drivers of this change so I asked some GBMC colleagues. More awareness and people looking out for each other…measuring on a unit LDM board…extra focus…spreading knowledge about hand hygiene….culture change…the realization that we were not washing our hands….making it more personal for you…. turning handwashing into a fun game….calling it out among colleagues….these are the reasons my colleagues listed for this great improvement. The rate of almost every hospital acquired infection that we measure has been reduced as our hands have been getting cleaner. I am very grateful to all of my GBMC colleagues for this improvement work.
 
I would love to hear your ideas on how we accomplished this because it is in learning what works that we can make more improvements faster!

Gilchrist Hospice Care and Gilchrist Greater Living continue their spectacular work in leading the region in compassionate, evidence-based care to seniors and those at the end of life. I applaud all the hard work that Gilchrist Hospice has done over the years to help so many individuals and families through the end of life. Gilchrist not only provides world class medical care to patients in their final days, but they also provide emotional and spiritual support.  In the past 20 years, Gilchrist Hospice Care has cared for over 40,000 patients and approximately 100,000 loved ones.
 
Please come and show your support for Gilchrist’s work by attending the Holly Ball this Friday, Dec. 12 at the Baltimore Marriott Waterfront.  This year’s black-tie event, which starts at 7:00 p.m., will benefit the Gilchrist Towson inpatient center. For more information on the Holly Ball, please go to http://gilchristhospice.org/hollyball . I hope to see you there!
 
Wishing all those who celebrate the Festival of Lights next week a very Happy Hanukkah!

Delivering on Our Vision

Wednesday of this week was a very big day for GBMC. We celebrated the opening of the new office of Family Care Associates. We began at 8AM. All GBMC staff were welcomed to tour the site on the ground floor of the North Pavilion. I hosted the Baltimore County Business Advisory Council and my colleagues were quite impressed. They couldn’t believe that there was no patient waiting room and they loved the idea of the “flow station” where the physician and medical assistant worked together to improve communication. The two physician leads, Dr. Sarah Whiteford and Dr. Ben Hand gave us a brief presentation on the patient centered medical home and how they had designed this new office to be able to efficiently care for patients. (See my blog on the 3p process that the team used in designing their new home: What would your ideal primary care office look like? http://ahealthydialogue.blogspot.com/2013/12/what-would-your-ideal-primary-care.html).

At 10 AM, the media arrived. We had reporters from a number of newspapers and television stations. We were covered on the evening news on both channels WMAR and WBAL. On Thursday morning, the story was on the front page of the Baltimore Sun!

In the afternoon we welcomed colleagues from Kansas City and Mississippi who were interested in seeing how the office was designed. All were impressed with what the team had built and with how it was being used. Chris Backous, the facilitator from the Virginia Mason Institute, who had helped the team in the design phase, flew from Seattle for the big day. In the evening, we unveiled the plaque honoring Jim and Jacqueline Stradtner and their family. Jim is the Chair of our Board Strategic Planning Committee and has been a force in helping to develop our vision back in 2010 and in holding us accountable to deliver on it. The Stradtner’s made a significant donation to help build the office. We are very grateful for the Stradtner’s’ gifts of both time and treasure.

What impressed me the most were the smiles on all of the staff of the office. From Drs. Whiteford and Hand, to their colleagues Drs. Jillian Klaucke, Dr. JoAnne Wills, Dr. Kathleen Mathey, and Dr. Courtenay Morrow, to Jeanne Gayle the practice manager, Anne Conrad the care manager and all of the medical assistants, and patient service assistants…everyone was proud of what they had accomplished and delighted to be part of a big team that was delivering patient-centered advanced primary care- the care that you would want for your own loved ones and certainly what I want for my loved ones!

I want to thank Drs. Whiteford, Hand and all of their team. I also want to thank Ben Beres, our Vice President for Physician Practice Management and Danielle Da Silva, the Ambulatory Service Line Administrator for working so hard to make this a reality. Many are now talking about patient-centeredness but GBMC is delivering it.

If Your Mom had Diabetes Wouldn’t You Want Someone Reflecting on and Improving her Care?

One of the most enjoyable parts of my job is meeting with teams who are improving patient care. Last week I visited our patient-centered medical home (PCMH) at Hunt Manor. Drs. Robin Motter-Mast and Joe Connelly led a meeting focusing on improving the team’s diabetes composite score.  Also participating were Diana Mantell, the Administrator for Population Health of the Greater Baltimore Health Alliance (GBHA), Yvonne Latchaw, RN, the care manager at Hunt Manor, and Amanda Harris, one of the team’s medical assistants. The diabetes composite measure is made up of a number of evidence-based elements in the care of diabetes. The diabetes composite score is the first measure of population health on our system-wide scorecard.

The Hunt Manor team explained to me that it is not easy to get this diabetes composite score right. Either all of the elements are present for an individual patient or it is considered a miss. The five things that they must be achieved are:

•    blood pressure needs to be less than 140/90measured in the normal range
•    LDL cholesterol less than 100 in range
•    Hemoglobin A1c level less than 8
•    daily aspirin or anti-platelet medication in patients with diabetes and ischemic vascular
     disease (IVD)
•    and non-tobacco use 

Dr. Motter-Mast explained to me that the team has worked on engaging patients 18-75 years of age with diabetes that were missing lab values. Some of these patients were also seeing endocrinologists, so the Hunt Manor team worked with those offices to gather the values.  Other patients had not been seen recently so members of the team began contacting those patients to schedule visits.  The team also reviewed their Diabetes Disease Registry to find the patients who needed to be on aspirin, and contacted them to start if appropriate.

The GBMC data warehouse, built a few years ago, now gives us the ability to create reports like the Diabetes Disease Registry. These reports show performance at the level of the system, the practice and the individual provider and are used to find the patients who are deficient on one or more measures. PCMH teams then decide which metric to work on based upon the scores for their practice.

Most primary care offices in our country don’t have such reports and are not holding themselves accountable for helping the patient achieve measurable improvement with their chronic diseases. The GBHA, with the Hunt Manor office as an example, practices advanced primary care and is holding itself accountable for maximizing the health of each patient it serves. I am very proud of them and grateful for all of their hard work.

While at Hunt Manor the rate of success on individual metrics within the diabetes composite varies from 44 percent (LDL cholesterol) to 87 percent (aspirin use in IVD and non-use of tobacco), the overall rate of patients with all five measures met is currently 20.58 percent compared to 15.9 percent in late August of this year. Although it will be very difficult to get to 100 percent, the Hunt Manor team won’t quit until they get there!


Linda A. Walsh, MD, a GBHA board member and family physician at Jarrettsville Family Care, was recently awarded the 2014 Humanitarian Award by the American Academy of Family Physicians (AAFP) at its annual meeting. The Humanitarian Award honors extraordinary and enduring humanitarian efforts by AAFP members, both within and beyond the borders of the United States.  As the medical director and chair of the Steering Committee for the Dominican Republic Medical Mission, Dr. Walsh has led annual medical missions to the Dominican Republic since 2003. Over the years, she has been instrumental in addressing the immense medical needs of the community and its lack of access to basic health care. In 2014, Walsh’s team held 13 clinics, treated more than 700 patients and initiated and oversaw the installation of a water purification system in Esperanza, a Haitian refugee village. Please join me in congratulating Dr. Walsh on her recent achievement and for her efforts to help the people of the Dominican Republic.

In my previous blog, I congratulated our Chairman of Radiation Oncology, Dr. Robert K. Brookland, for winning the Martin D. Abeloff Award for Excellence in Public Health
and Cancer Control.  This week I want to applaud him and his department for being awarded a three-year term of re-accreditation in radiation oncology as the result of a recent review by the American College of Radiology (ACR).  Re-accreditation is given to health facilities that meet specific ACR-developed practice guidelines and technical standards, following a stringent peer-review evaluation by board-certified radiation oncologists and medical physicists who are experts in the field.  This designation is an honor and reflects GBMC’s ongoing commitment to excellence in cancer care. 

Finally, I want to wish everyone in our GBMC family a Happy Thanksgiving.   I have much to be thankful for.

Synchronizing to Start the Day on Time

Imagine if only 30 percent of BWI’s first flights of the day took off on time.  Commercial aviation is a large complex system. If 70% of flights from Baltimore arrived at their destinations late, it wouldn’t be long before the whole country was getting behind. Imagine how many upset travelers there would be. Imagine, also, the pressure on the air traffic controllers as they had to delay other flights to allow late flights to land.

We know that the hospital is also one large, complex system. If the operating room is sending cases out late, the PACU (Post Anesthesia Care Unit) will be delayed and cases will arrive to their inpatient beds (or outpatients to their homes) behind schedule. The downstream staff will be overwhelmed and people will have to stay longer than anticipated. The hospital will have to pay overtime to many or ask more staff to come in to handle the load. Subsequent operating room cases will start and end after their scheduled timeslots and some patients who have been fasting since the previous midnight will need to fast longer. No one is happy. 

It is not easy to make sure that everything is ready to go on time in all operating rooms in a surgical suite. Team members can arrive late, the patients can arrive late, there can be missing lab work that is required to assure that the surgery can be done safely, or the patient may be nervous and want to ask a few more last minute questions. But studying the reasons why cases are late and using problem solving to test changes will result in more on-time first cases. This is just what our Sherwood Outpatient Surgery Center Team has done under the leadership of its medical director, Dr. Aaron Wood, and its Clinical Unit Coordinators,  Holly Clevenger, RN and Kate Devan, RN3 BSN, CAPA.  This team selected first case on-time starts as one of their Least Waste metrics for Lean Daily Management and they have tested many changes and made great progress. You see from the run chart below that in March they had over 70% late first case starts and that number is now down to 34%. They have reduced the defect rate by more than 50% !

Team members understand that cases start late most frequently because of the system for getting ready, so they continue to study their system and ask the “why” questions when one does not start on time. I am so proud of them and I am very grateful for all of their hard work.

Congratulations to our Chairman of Radiation Oncology, Robert K. Brookland, M.D., who earlier this week was honored with the Martin D. Abeloff Award for Excellence in Public Health and Cancer Control by the Maryland State Council on Cancer Control.  For those who don’t know, this award is given annually to a Marylander who has contributed to reducing the incidence, morbidity and mortality of cancer through research focused on cancer control. Dr. Brookland is a great leader at GBMC and we are proud of him for earning this prestigious honor. Please congratulate him the next time you see him!



While on the topic of significant recognitions,
I am so pleased to announce that our hospital was named Top Performer on Key Quality Measures® for 2013 by The Joint Commission, the leading accreditor of health care organizations in America. 

This is a big deal because less than one-third of U.S. hospitals earn this distinction. According to The Joint Commission, we were chosen for “our commitment to assuring that evidence-based intentions are delivered in the right way at the right time – because it’s the right thing to do for your patients.” I want to thank the following individuals and teams for helping us attain this major achievement:  Carolyn Candiello, Vice President of Quality and Patient Safety, the executive sponsor for the Core Measure reporting, Michele Cave, BSN, RN (Director of Clinical Quality Outcomes), Laura Hines, RN, Sara Helman, RN, and Laura Wieber.

The following nurse leaders also contributed: Lindsey Cromwell-Rims, RN (Nurse Manager of IR and the Kroh Center), Stephanie Topscher, RN (Clinical Director ED/UC), Charlene Mahoney, RN (Nurse Manager PACU), along with physician champions: Jeff Sternlicht, MD (Chairman, ED), Reed Riley, MD (Chief of Cardiology), Jack Flowers, MD (Chairman, Surgery), and all of our outstanding physicians, nurses and other clinicians.  Thank you for all you do for our patients.

I am truly proud of this recognition as it clearly demonstrates that we are moving toward our vision of treating everyone the way we want our own loved ones treated.  We are pleased that the Joint Commission has recognized us as one of their “top performers” on key quality measures. 

Again! GBMC Tops the List with More “Top Docs” and Thank-You to our Veterans

Again!  GBMC Tops the List with More “Top Docs”

Last week, we voted in the 2014 Maryland general election and on referendum questions. But recently there was another “election.”

Nearly 10,000 physicians in the region “voted” for the physicians, in a variety of specialties, that they would send a member of their own family to if they needed care. The 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 138 GBMC physicians, covering 60 specialties, were recognized as a “Top Doctor.” Several of those medical staff members were recognized in more than one category, and some have been recognized many years in a row! 

Being recognized as a “Top Doctor” is an extraordinary honor, because it is a selection by peers. 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 2014 webpage.

Let me thank Dr. Alexa Faraday, one of our general internal medicine physicians practicing on our campus, who was one of the three survey advisers (and thus was ineligible to be selected as a "Top Doc" by her peers).

Thanking Our Veterans on Veterans Day and Every Day

Millions of American military veterans have honored us with their service. Today, we set aside a special day to honor them and thank them for all they have done. We enjoy our freedom because these individuals were ready to make the ultimate sacrifice. Without their service, our daily lives might be very different.

Veterans Day is a time to remember and pay tribute to the brave men and women of the U.S. armed forces who have served in the past and those who are serving today. As Americans, we owe a tremendous amount of gratitude to our veterans who, during peace and war, have demonstrated a steadfast commitment to safeguarding the principles upon which our nation was founded.

Everyone in the GBMC family should pause today and reflect on the gift of our fighting men and women and our veterans.

Finding Truth and Taking the Appropriate Action

I received a call last week from a family member asking me, in the wake of the Ebola outbreak and media frenzy, if it was safe to fly on US commercial aviation. I told her that unless she was flying to West Africa and headed to one of the three Ebola-ridden countries, I did not see any reason why it would be unsafe.  This is a prime example of fear affecting people.  The fact that this family member called me was a good thing, but I am very concerned about well-intentioned people acting in ways that actually make a situation worse.

As we enter flu season, there is a great public health risk that people will take actions out of fear and ignorance and neglect actions that will actually protect them….like getting a flu shot. Because Ebola has a high mortality rate and the media has been talking about it for weeks now, we are all on heightened alert. But one must have direct contact with the body fluids of a patient with active Ebola to contract the disease. What has happened in Dallas should allay people’s fears about the communicability of Ebola.   The influenza virus is much more easily transmitted than Ebola. It is spread by respiratory droplet through coughing, sneezing, touching contaminated surfaces or shaking hands.

It is important to know the facts, to investigate the truth about something before making decisions, and this is particularly true about immunizations. I remember one day in 2005, when I was taking care of children on the inpatient unit at Boston Medical Center, a big inner-city trauma hospital, that we received a call from the Life Flight system.  We were getting a child from Nantucket. I immediately thought that the child must have been the victim of trauma, but I instead learned that the boy was suffering from invasive haemophilus influenza type B bacterial disease. The residents working with me had never seen a case of this disease.  This was because the Hib immunization came out in the mid 1980s, but when I was a resident in the early 1980’s, we had many cases and a significant number of children with serious complications and death.  Then the vaccine came out, and it was so effective that within a few years the disease became nearly eradicated in the States. Why, then, 20 years later, was this child being Life Flighted to Boston Medical Center from Nantucket, sick with a case of H-flu?  Because his parents did not believe in immunizations, and the child was on the verge of death from a preventable illness. The parents had never seen a child sick with the disease or heard about the devastation that it caused, so they minimized the risk. They also fell victim to misinformation and ignorance about the risks and benefits of the immunization. Luckily for them, the child survived the disease and did not have a significant complication.

We should be worried that people will drop their guard on influenza (the viral disease that we get annual immunizations to prevent) because they are scared about Ebola. Ebola has affected a mere handful of people in the United States, whereas influenza kills an average of 30,000 people per year.  If my family member had called me and said, “I’m going on a plane, what would you recommend?” I would have responded, “Get your influenza vaccine.”  Since influenza does not generally kill otherwise healthy people, many people ignore the evidence and don’t take the appropriate precautions.

Unless someone is less than 6 months of age, has a true chicken egg allergy or has had Guillain Barre syndrome after a previous immunization, there is no contraindication to the influenza immunization.  In our society, we have a tendency to fall into the trap of fads and pseudoscience, believing in ideas that are contrary to the actual facts.

GBMC must work hard to help people get the care that will cure them or keep them healthy. Let’s work to maximize the rate of influenza vaccine this season, and help get the facts out about Ebola to minimize fear and the nonsensical actions that fear can trigger.