Much to be Thankful For

Thursday is Thanksgiving and I have a lot to be thankful for. I am very grateful that I will be with my wife and children on Thanksgiving – they are the loves of my life.

I have a lot to be thankful for at GBMC, too. Last Friday, I was on a panel sponsored by the Baltimore Business Journal, discussing health care reform. While I was on the stage and listening to the conversation, I reflected on how lucky I am to have so many people in the GBMC family focused on our vision of being the healthcare system where everyone, every time, gets the care that we would want for our own loved ones. Our system has embraced the need to change. We are focused on our four aims because they are what we want for everyone getting care and for everyone delivering care – better health, better care, and lower cost with more joy for those providing the care. We are not lamenting change or struggling to hold on to the status quo. We are in action because that is what our community and our country need us to do! 

I was also very proud on Monday of this week when we hosted Carmela Coyle, the President of the Maryland Hospital Association and other leaders of the MHA at our GBMA Hunt Valley office. Our colleagues had come to learn about the transformation of our company, our accountable care organization, and how we were implementing the patient-centered medical home concept.  With the State’s new Medicare waiver, the MHA will be convening hospitals to help them transform toward managing the health of a population.  I again realized how much I had to be thankful for. 

So let me list just a few of those things here:

• The GBMC HealthCare Board of Directors who had the courage in 2010 to set a new course for our company
• The incredible GBMC Volunteer Auxiliary that is celebrating its 50th Anniversary and is made up of people who give of themselves to help others 
• Our phenomenal medical staff – because of their capabilities (once again GBMC had the most Top Docs of any community hospital in Maryland), their hard work, and their dedication our system does many things that cannot be done by others
• GBMC’s wonderful nurses – they are the core of our organization. Our nurses are smart, tireless and giving. Their work in the last year at improving our patient safety and service has been remarkable.
• Our nursing support technicians who are the face and heart of GBMC to so many patients in our hospital
• The nurse practitioners and physician assistants that work so hard to deliver exceptional care to our patients
• All of the rest of GBMC’s fantastic clinicians: therapists, laboratory personnel, and other technicians who use their expertise to improve clinical outcomes
• GBMC non-clinical personnel: from managers to patient access reps to billing personnel to food service workers and environmental service workers and everyone else who goes above and beyond for those we serve
• Gilchrist Hospice Care – our hospice along with Gilchrist Greater Living set a very high standard for patient-centeredness and the rest of our system learns from them every day
• The GBMC Foundation and its staff – where would we be without our excellent fundraising team?
• The GBMC campus – we are blessed to have such a beautiful environment for healing
• Our patients – they come to us for help and they show their gratitude even when we don’t get it perfectly right
• The staff at Einstein Bagels on the third floor of the hospital who make me smile every morning

I could make the list much longer - we really have a lot to be thankful for. Please enjoy Thanksgiving with your families, and Happy Hanukkah to all those in our GBMC family who celebrate the Festival of Lights. 

OUR PEOPLE, GIVING BACK TO OUR COMMUNITY, IN MORE WAYS THAN ONE

As a not-for-profit organization, GBMC exists to serve the community. Our HealthCare system is “owned” by the community and a group of people from our community, the Board of Directors, oversee it and hold the CEO accountable for serving the mission every day. The directors give of their time and talent to help GBMC. The Chairman of the Board, Harry Johnson, Esq., has served on our board for more than 10 years and has been involved with GBMC since the 1980’s.

Harry Johnson, Esq.

This is why many of us within the GBMC family felt privileged to have attended the Boy Scouts of America’s Whitney Young Jr. Achievement Award ceremony last week, honoring our Chairman Harry Johnson.  It was a true honor to attend this ceremony and pay tribute to a great community leader.

The Whitney Young Jr. Achievement Award is presented to a member of the community in recognition of their involvement in the development of scouting opportunities for youth from rural or low-income backgrounds. In Harry’s brief acceptance speech he spoke about his dad, who was a Boy Scout leader in Maryland in the early 1960s when Maryland was still segregated. His father led an all-black troop and had to deal with many issues stemming from racial inequality. But Harry’s father was a leader and helped these young boys, including his son, Harry, become leaders and contributing members of their community.

Harry is an accomplished attorney and partner at the law firm Whiteford, Taylor and Preston, yet he finds time to volunteer and give back to numerous organizations. In addition to serving as Chairman of the Board at GBMC, Harry is also very active with the Maryland State Bar Association including the Maryland State Bar Foundation board of directors as well as many others. Harry is a shining example of someone who has dedicated himself to giving back to the community, and GBMC has certainly benefited from Harry’s service and leadership. We are very proud of Harry and grateful for all that he has given to GBMC.

Stroke Center Award

I also want to congratulate our rapidly growing Center for Neurology and GBMC’s Primary Stroke Center which, under the leadership of James Bernheimer, MD and Tracy Lamb, MSN, CRNP, CRN,   recently received the Gold Plus award from Get with the Guidelines®. The award is given by The American Heart Association and American Stroke Association in recognition to hospitals that have achieved 85% or higher adherence to all Get with the Guidelines Stroke Achievement indicators for two or more consecutive 12 month intervals. The award also recognizes hospitals with at least 12 consecutive months of 75% or higher compliance with five or more Get with the Guidelines Stroke Quality measures to improve quality of patient care and outcomes.

This award is the result of the hard work and commitment of our entire stroke team and demonstrates GBMC’s high level of commitment and expertise in caring for stroke patients. With an aging population, we are at the ready to provide superior care to all GBMC stroke patients day in and day out. Great work!

Are our Top Doctors Speed Dating?

Once again, GBMC had more doctors recognized in Baltimore magazine’s annual listing of Top Doctors than any other community health system or hospital in the region – a true accomplishment and a testament to the top notch physicians caring for our patients. In fact, 171 members of our medical staff were named to this year’s list in 71 different specialties – truly outstanding.

But, unlike many other healthcare surveys that poll people with very little knowledge or understanding of healthcare, Baltimore magazine’s Top Doctors list is actually compiled by surveying other doctors, nearly 10,000 area physicians, in fact.

The annual Top Doctors recognition isn't another popularity contest – it’s about people who really know about the quality of care being delivered by their peers. And, it’s clear that with 171 member of GBMC’s medical staff on this list, the medical community, as well as our patient population, recognizes this medical excellence. So, when we ask people, “What if it was your daughter?” the physicians surveyed for this year’s Top Doctors recognition feel confident enough in so many of GBMC’s medical staff to send their own loved ones to them for care.

I congratulate GBMC’s Top Doctors - we are extremely proud to have such excellent, caring clinicians on our team and very grateful for all that you do to care for our community.

Speed Networking Doctors

And speaking of GBMC’s great medical staff, I had the privilege of attending GBMC’s first ever Physician Speed Networking event on November 6. Just like speed dating, 140 GBMC clinicians – along with members of the GBMC senior leadership team, service line administrators, Physician Relations and GBHA representatives attended this special “meet and greet” event.

This speed networking event was one of the best medical staff events that I have ever attended! 

The idea was born out of general “meet and greet” sessions that our HR department has held over the past couple of years for our employees to meet with GBMC doctors. The creative idea of the physicians speed networking provided an enjoyable forum for our providers to put names with faces and become more acquainted with others’ styles of practice. PCPs met with specialists who could provide further care for their patients and the specialists had the opportunity to meet the PCPs who could refer their patients.

Physicians had the chance to kick back, enjoy some great food under the big tent and not only meet their peers, but have an entertaining time doing so. It was a win-win event for all who attended and I think we all look forward to the next event!

A Peaceful End-of-Life Journey with the Help of Gilchrist Hospice Care

The first of our four aims is to be the healthcare system where everyone, every time, gets the very best possible health outcome.

And, while we are focused on restoring patients to health, we also recognize that sometimes this is not possible. When patients have life-ending illnesses, it’s comforting to know we have the experts at Gilchrist Hospice Care to guide them through and to be there to support their families.

November is National Hospice and Palliative Care Month and I’d like to recognize the excellent staff and volunteers at Gilchrist who are devoted to ensuring a peaceful and respectful end of life journey. Gilchrist Hospice Care is the largest hospice in Maryland and is repeatedly recognized nationally for its work. In fact, Gilchrist is often referred to as the platinum standard for hospice care.

To commemorate National Hospice and Palliative Care Month, I've asked Cathy Hamel, the Executive Director of Gilchrist Hospice Care, to talk about hospice and the vital role it plays in caring for patients:

Cathy says:

“Every day in the United States, 10,000 people turn 65. Seven out of every 10 Americans die from a chronic illness. A century ago, our ancestors, more often than not, died suddenly. But today, many of us have the good fortune to live longer thanks to the wonders of technology and advances in medical care.

We’re also more likely to suffer from one or more chronic illness at some point in our longer lives. As a result, we now have more choices in both life and death, and both studies and practice have shown that hospice is a wonderful alternative -- I would argue the best alternative -- for terminally-ill patients as they seek to balance quality of life vs. quantity of life. It is the former that is the focus of hospice.

If you ask most Americans to envision a "good death," they would tell you they prefer to die at home, surrounded by loved ones. Few wish to spend their last days in a hospital room, and even fewer in an intensive care unit, surrounded by machines. However, as a society, we tend to avoid conversations about death. We avoid planning for the day when we will need a feeding tube or assistance with breathing. We don't tell our family, our caregivers -- our doctors -- our wishes for care at the end of life. As a result, when those last weeks and days arrive, so many patients find themselves headed to the ICU, and more invasive, often futile treatment, against their better wishes.

Every November, during National Hospice and Palliative Care Month, we applaud those who have had what we call "courageous conversations" with their families and physicians and have created a game plan, of sorts, for their death. Every November, we encourage those individuals who haven't yet had these discussions to begin thinking and talking about their wishes for care when they are terminally ill. And every November, we recognize the teams of hospice workers -- physicians, nurses, social workers, chaplains, hospice aides, volunteers, bereavement counselors and support staff -- who are able to transform an emotionally-wrought time into a celebration of life for our families, and who are there to ensure that patients are able to approach the end of life in comfort and with dignity, surrounded by their loved ones.

At Gilchrist Hospice Care, our staff and volunteers understand that building relationships and memories with our patients and their loved ones is of the utmost importance. They understand that terminally-ill individuals still have life goals, even if time is fleeting, and they go above and beyond to help their patients achieve those goals. Gilchrist has earned its stellar reputation because of our commitment to providing individualized, compassionate care to each and every patient. The death of a loved one is a lifelong memory and we’re committed to making that memory as positive as we can.”

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I sincerely thank Cathy and the entire team at Gilchrist Hospice Care for their devotion to making the end of life journey a peaceful and positive one for so many families throughout the years.  You can also read more about Hospice care and Cathy’s insights into end-of-life issues in The Gilchrist Blog.

Have you or a loved one been touched by the care of a hospice or palliative care team member? I’d love to hear your personal stories of exceptional care…

Change is a Learning Process

Winning organizations recognize the importance of learning. Companies that don’t learn new ideas don’t change to meet the demands of those they serve. When an organization doesn't change to meet new demands, it eventually fails. That is why we set aside time for learning.

Last Thursday, GBMC leadership had a marvelous day of learning with our teachers from Next Level Partners who taught us about focused problem solving to get better execution of meaningful change.

The former President of the Institute for Healthcare Improvement, Dr. Don Berwick, says there are three important factors required for improvement:
1. The will to change
2. Ideas
3. Execution

I have no doubt that at GBMC our people want to change. They embrace our vision of providing the care that we would want for our own loved ones to every patient, every time. We have the will to change.

I know that GBMC has a workforce made of many intelligent individuals with great ideas to improve our processes. I also know that with the Internet, many solutions are just a few clicks away. So, there is no lack of great ideas.

Our dilemma is number 3: execution. Healthcare in general has not been particularly good at executing change. Many healthcare service processes haven’t changed much since the mid twentieth century. Many companies have unwittingly instilled the notion into their people to hold on to the status quo, and to learn to deal with systems that don’t work, rather than getting them the idea that not only is it their right to fix broken systems – it is their duty.

We are implementing Lean Daily Management to change this. Since we started this technique last April, our senior team visits departments and units every day. On our daily walk, members of the unit and department teams tell us about the performance of key indicators from the day before. They tell us about the reasons why goals were missed and about their problem solving to improve the process.

A great example of excellent problem solving can be seen in the work done by both the Emergency Department and inpatient unit teams, including doctors, nurses and techs, with the help of housekeepers and transport aides, to move patients more quickly from the ED and into a hospital bed. We have reduced the time in the ED of patients admitted to the hospital by more than two hours.

So, our friends at Next Level Partners taught us more of the science of improvement to help us execute faster. It was a great day of learning for GBMC leaders. Such offsite trainings make us stronger as an organization and make our people more skilled. We all came back to work more inspired and better prepared to move us faster toward our vision.

Continuous Improvement – The Method that Will Get Us to Our Vision

GBMC HealthCare is using the management science that other excellent organizations use to provide ever-increasing value to those they serve. This way to manage, created by the likes of W. Edwards Deming and Walter Shewhart in the 20th Century, is what is helping us get closer to our vision every day. How are we doing at using this science? Well, we recently “took a test” when examiners from the Maryland Performance Excellence Awards program reviewed us. The examiners studied GBMC through the lens of the Malcolm Baldrige Performance Excellence criteria.

On October 15th, I attended the Maryland Performance Excellence Awards dinner with a group of my colleagues. GBMC received a silver award. Congress established the Baldrige Program in 1987 to recognize U.S. companies for their achievements in quality and business performance and to raise awareness about the importance of quality and performance excellence.

Forward thinking organizations like GBMC utilize the National Malcolm Baldrige Criteria for Performance Excellence to make themselves better, faster. This was GBMC’s first application for this distinction, and to be honored with the silver award recognizes the advances our organization has made in improving care to our patients. Our vision is a vision of perfection, and we won’t get there unless we use scientific management. We will apply for the award again next year, because it is a great way to learn and improve our management systems.

At the awards dinner, I had the opportunity to explain our vision to a large group of people assembled from other industries. I told them about our quadruple aim (Better Health, Better Care, with the Least Waste and the Most Joy for those providing the care) and I gave them some examples of the progress we were making. As I was speaking I realized how proud I was of everything that our people were accomplishing, but I also recognized how much work there still is to do to become even more patient-centered.

Our vision of perfection includes always delivering the correct medication at the correct dose to the correct patient. This is the definition of a highly reliable medication delivery system. Our Pharmacy team is using continuous improvement to build this highly reliable system. And, with this week being National Pharmacy Week, I asked our pharmacy team to explain their expanded role in patient care and safety.

Todd Jackson, Automation Systems Analyst, Pharmacy Informatics explains:

“In both the hospital and community setting, Pharmacists play an integral role in patient care by preventing medication errors, advising physicians on the best drug choices, safeguarding against medications allergies and drug interactions, and working with nurses to ensure that patients understand how to use their medications safely and effectively.

Several members of the Pharmacy team including (L-R):
Mahsa Mahmoudian, C.Ph.T, Nicole Garrison, R.Ph, Dana Hack, R.Ph.,
Heather Orach, C.Ph.T., Peter Furgiuele, R. Ph.
(Not pictured: Min Min Than, R.Ph., Pharmacy Director, and Todd Jackson)

Certified pharmacy technicians play an equally important role in the healthcare continuum. Incorporating a high level of multitasking ability, they are involved in compounding medications, packaging and labeling, and delivering medications.

Pharmacists and certified technicians have taken on enhanced patient care roles through the use of special technologies including DoseEdge, Medex, RobotRX, as well as the Acudose and Anesthesia RX stations.  Here at GBMC, technology is utilized at many points in the pharmacy workflow. 

Computers also help pharmacists monitor every patient’s medication therapy and provide quality checks to detect and prevent harmful drug interactions, reactions, or mistakes. But, it still takes a human being to evaluate what the computer says and to know what to do to prevent adverse medication events.”

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To move toward our vision of perfection: “To every patient, every time, we will provide the care that we would want for our own loved ones,” we must continue to have outstanding professionals who continually improve our systems. I thank teams throughout GBMC, such as our Pharmacy team, for holding themselves accountable for the attainment of our vision.

What are your teams doing to redesign systems and improve quality in your departments?

Important Insights for Breast Cancer Awareness

You may have noticed that the world looks a little more “pink” in October. This is because October is national breast cancer awareness month and to recognize the important strides GBMC’s Comprehensive Breast Care Center has made in diagnostics, treatment and overall care for our patients, I’ve asked Dr. Lauren Schnaper, Director of the GBMC Sandra and Malcolm Berman Comprehensive Breast Care Center, to be a guest blogger this week. Dr. Schnaper is nationally recognized for her breast cancer expertise and patient care and has been active in a number of national clinical trials. She was named one of Maryland’s Top 100 Women in 2010 and is passionate about sharing lifesaving information with women. I hope readers of this blog will find Dr. Schnaper’s observations on breast cancer screening and biases as enlightening as I did:

Dr. Lauren Schnaper

Dr. Schnaper writes…

The first mammograms were performed in Europe, as early as 1913.  They were not the high tech digital films we know today and did not catch on for many decades because surgeons treated all breast tumors, no matter the size or the behavior, with radical surgery.  Finding smaller tumors that might be treated with more limited procedures was a concept foreign to physicians. They believed, erroneously, that removal of as much tissue as possible was the only way of keeping breast cancer from “coming back.” That is a tenacious concept, still believed by many people.

By the early 1960s, when surgeons began to question radical mastectomy dogma, mammography was resurrected and the first screening trials began. Screening mammography was not widely performed until the 1980s.

The definition of a screening test for a population or an individual means that they are asymptomatic (no lumps or bumps, skin changes, nipple abnormality, etc).  The screening criteria also may not apply to individuals who are considered to be at high risk (strong family history or genetic mutation carrier, previous breast cancer).  The benefits (reduction in the risk of dying from breast cancer) must be weighed against the financial and non-financial costs (radiation exposure, additional tests and biopsies, anxiety, money per test).

There are two major problems with screening:  Underdiagnosis means that the mammogram failed to find a cancer that will eventually be discovered when it becomes a lump or presents with some other symptom. Overdiagnosis means: (1) that an abnormality is found that is not a cancer but is evaluated with multiple procedures as if it was a cancer or (2) a true cancer is found but one that would never become clinically significant during the indivdual’s life-time and would not influence how they are treated, how they live or die.

In America, we have trouble with the concept of costs vs. benefit.  We believe that if a million women need to be screened to save one life, then so be it.  We picture ourselves or our loved ones as that one life saved.

The non-financial costs of screening are influenced by several biases:

Lead time bias means two women develop a deadly breast cancer on the same day.  They die of that cancer on exactly the same day, five years after diagnosis.  They both have treatment but no treatment that they receive will change the behavior of their cancers or save their lives but they are not aware of that fact.  The first woman’s cancer is picked up on a mammogram in year #1 after the cancer is born.  She and her family believe that mammography has benefited her because she has had four additional years of life following her diagnosis.  The second woman never had a mammogram.  Her cancer is picked up as a lump in year #4.  Her survival appears to be shorter than that of the first woman, even though it is identical to the first woman’s.  To be effective, screening must decrease mortality from the disease, not just give the appearance of doing so.

Length time bias speaks also to the variable behavior of cancer.  More poorly behaved fast growing tumors do not lend themselves to screening as they often occur in between the screening test interval and have already spread before they are detectable.  Slow growing tumors are amenable to screening because they might hang around for a long time before doing any damage.

The concept of “early detection” is a simplistic view of a disease that has numerous and complex behaviors; no two cancers are the same.  In the extreme, a few are deadly from the day they are born but most require treatment and are ultimately curable.

Herein lies the controversy that waxes and wanes in the popular press.  Who should be screened and how often?  The United States Preventive Services Task Force (USPSTF) has reviewed screening mammography studies in 2002 and 2009.  The members took many factors into account.  In 2002, they recommended that the screening interval be changed to one to two years.  In 2009, they changed their recommendation to every two years because they saw the same decrease in the death rate in the annually screened groups as in the longer screening interval groups.  They also found that there was no difference in the chances of detecting an aggressive cancer between the one year and the two year screening interval.

The risk of developing breast cancer increases with age.  The “readability” of mammograms gets better after menopause when breast tissue goes away and is replaced by fat.  The average age of menopause in America is 52. The behavior of breast cancer is also less aggressive in older women.  The USPSTF recommend screening every two years between 50 and 74 and individualized screening for women over 74.

In women who are still menstruating, there is a lot of breast tissue which is referred to as “breast density” on mammogram – as if this is an abnormality or a disease.  It is not. The breast is a round object, compressed by the mammogram plate to be a flat picture.  The overlapping shadows of the tissue are white on the film.  Because all of the abnormalities – good or bad – are also white, they may not be seen if transposed on a white background.  Digital mammography has more contrast and is more sensitive to changes in mammograms of menstruating women or those on exogenous hormone therapy.  Again, the USPSTF recommends individualized screening decisions for women in their forties but at a two year, rather than a one year, interval.

It should be noted that the American College of Radiology, the National Comprehensive Cancer Network, and the American Cancer Society continue to recommend annual screening for all women over 40.  They do not offer an opinion as to at what age mammography screening should stop.

The National Cancer Institute advises screening every one to two years beginning at age 40.  The American College of Physicians, every one to two years age 50-74 with individualized recommendations ages 40-49.  The American College of Ob/Gyn recommends every one to two years from 40-49 and annually thereafter, with no stopping recommendation.

Interestingly, the United Kingdom National Health Service recommends screening every three years from age 47-73.

NO organization recommends a baseline mammogram at age 35.

In order for a screening test to be adopted or changed it must improve on all of the parameters already discussed.  Touted as the new era in breast imaging is Tomosynthesis or 3D Mammography.  It is a digital mammogram, that instead of taking a flat top-to-bottom and side-to-side picture, the machine swings around the breast, taking as many as 60 thin “slices” through the tissue.  This may benefit women with dense breasts on imaging as it does away with overlapping tissue shadows so that white lesions can be separated from the white tissue background.  Another advantage is that there will be fewer call-backs for additional films to evaluate vague areas of density.

Although some say there is less pain during a 3D mammogram, this is not true.  Compression is the same. Other disadvantages:  Although 3D mammography has FDA approval, there may be additional out-of-pocket expense to the patient because there is no insurance reimbursement at this time.  There is increased radiation exposure, approximately that of the old analog films, because both 2D and 3D mammograms are performed at the screening visit.  The 2D films will probably not be needed after the technology for creating a 2D picture out of the 3D slices is improved.  Radiologists have to be trained in new reading techniques and interpreting the films takes about twice as long as for the 2D films alone.  In terms of increasing ability to detect cancer or decreasing mortality from breast cancer, studies are underway.

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I thank Dr. Schnaper for her insights and continued work on behalf of all the patients who turn to GBMC for superior breast care.

For anyone who isn’t familiar with GBMC’s program, the Comprehensive Breast Care Program and its affiliated Advanced Radiology Breast Imaging Center have received national accreditation as Centers of Excellence, which speaks to the integrated and superior care our patients receive. From the Breast Cancer Risk Assessment Program to GBMC’s Rapid Diagnostics Program, our patients truly benefit from the expertise of our physicians and care providers and the advanced technology available for diagnosis and treatment of breast cancer. But, most importantly, our team of specialists takes to heart GBMC’s vision of treating every patient, every time, the way they would want their own loved ones to be treated.

Finally, GBMC is currently offering 3D Tomosynthesis Mammography at the Breast Care Center. You can call 443-279-9639  for more information or to make an appointment or visit the Comprehensive Breast Care Center page on GBMC’s website to learn more.