A Day to Reflect on the Great Commitment and Hard Work of Our Physicians

This year, National Doctor’s Day is March 30th. This is the one day of the year that we reflect on the many contributions made by our physicians and say thank you to them. The doctors of the GBMC medical staff work very hard to care for patients as they would want their own loved ones cared for. We have physicians throughout our healthcare system that are making a tremendous difference in the lives of patients every day.

This superior care is certainly evident in the 171 members of GBMC’s medical staff who were recognized in Baltimore magazine’s 2013 Top Doctor’s list, which also demonstrates just how good they are since the award comes from the votes of their peers.

And, last week we heard from patients who were very grateful for the coordination of care they received from their primary care physicians, Drs. Gregory Small and Nishi Das, and how the simple act of managing a person’s chronic health condition and providing them with a healthier, better quality of life, makes a world of difference. We are very fortunate to have a medical staff comprised of not only the best doctors in their fields, but doctors who dedicate their time, and their lives, to the care of people. So, in tribute to our physicians, I thought it fitting that we hear what our patients had to say, many of whom gave thanks throughout the year in our Foundation’s Gifts of Gratitude campaign for the care received from a GBMC physician:

“Dr. William McConnell is very kind, considerate and caring. He is always available when you need him.”

“Dr. Marshall Levine is so very special to me and my family.”

“I am fortunate to be in the care of Dr. Joseph Califano. He is a most caring and fine surgeon and a grand person.” 

“Drs. Lauren Schnaper and Sheri Slezak and their staff saved my life. They made me feel like I could make it and their skills made it true. I am forever grateful.”

“Dr. Geoffrey Neuner is a special doctor whose love of life and people shines through him in so many ways. I am here today because he cares.”

“Dr. Teresa Nguyen is fantastic! She takes the time to get to know the children and their families. We adore her!”

“I am 86 and walk pain free thanks to Dr. Victor Tritto.” 

“Dr. Thomas Guarnieri (cardiology)- For your care and wisdom, I thank you! Your referral last summer has resulted in a vast improvement in quality of life.” 

“I thank Dr. Kenneth Greene for his monthly medical updates and quick response to questions sent via email.”

“Thank you to Dr. Carter Freiburg, my vascular surgeon. He was so knowledgeable and caring and kind to me when I had my surgery. I rate him as a “10.”

From the surgeons and hospitalists to the ED physicians, primary care doctors and specialists all throughout GBMC, thank you for caring for patients and families from every walk of life, through all types of illnesses and injuries, and for helping GBMC move toward our vision: To every patient, every time, we will provide the care that we would want for our own loved ones.

In honor of Doctor’s Day and your physician, please share your thoughts and inspiring stories of patient care here…

What Do Our Patients Really Think About Our Care Management and the Patient-Centered Medical Home?

I've been discussing for a while the benefits of GBMC’s patient-centered medical home model and how we are working hard to ensure our patients receive coordinated care that focuses on the long-term management of chronic health conditions. We are building a system that delivers the care we would want for our own loved ones.

Over the past few months, I've talked about the new medical home office being designed and built for one of our primary care practices, Family Care Associates, and we've heard about coordination of care from one of our own RN care managers. But everyone knows how proud I am of GBMC and I am our chief salesperson. Readers of the blog expect me to say great things about our system and they should be curious about what our patients really think.  So, it was time I sat down and talked to some of them who are experiencing our care to hear what they really think about our system. Do they really believe that we are serving them better?

Last week, I met Alexis Watkins. Alexis has been a patient of Dr. Gregory Small, at our Texas Station primary care office, for several years and has worked closely with RN Care Manager Vergie O’Garro. Alexis, who is 65 years young, is being managed for type II diabetes, hypertension, and high cholesterol, among other conditions. She has seen significant improvement in her health because of the comprehensive coordination of her care. Vergie works with her to help her maintain proper diet and exercise as well as how to take her medications appropriately. She says, “When I first came in to the practice, Vergie took the time to really listen to me. She heard me and didn't overwhelm me. She took it one step at a time and that means everything. She and Dr. Small really know me and have helped me get my diabetes under control.”

As part of the coordination of care that has benefited Alexis, she tells me that the convenience has helped make staying on top of her health easier. “I use the GBMC patient portal to get my lab results, which really takes away some of my stress.”

Watch what else Alexis had to say about the care she receives from the team at GBMA’s Texas Station patient-centered medical home in this video:




I also had the privilege to meet with patient Eddie Bostic.  Eddie, age 40, was diagnosed with type II diabetes several years ago with an initial blood sugar level of more than 900. He soon landed in the ED with a blood sugar over 1,000. (He tells me he shouldn't be here, but he's a hard man to kill!). He sees Dr. Nishi Das and Vergie at our GBMA Texas Station primary care practice and says they have worked with him to get his diabetes under control through the use of appropriate medication as well as lifestyle changes such as diet. He has learned to use a Smartphone app to monitor his blood sugar and during his follow up visits, he provides the information from the app to Dr. Das to make sure everything stays in check.

Eddie explains, “They've helped me find a better way to manage my diabetes. I can share information through the GBMC patient portal and know I will always get a response from my doctor, which is very helpful. I feel like I’m talking to friends when I come in for an appointment.”

We had a nice conversation and Eddie ended it by telling me, “GBMC has always been amazing, for me and my family.”

Watch what Eddie had to say about the care he receives and how GBMC is making a difference in his life:



I sincerely thank Alexis and Eddie for sharing their experiences and stories of patient care with me. It’s heartening to hear how our system of care is working for our patients and helping us move toward our vision - To every patient, every time, we will provide the care that we would want for our own loved ones.

Mistake Proofing in the PACU

Everyone knows it – GBMC has outstanding anesthesia care. We have great anesthesiologists and nurse anesthetists. Our OR staff is second to none and we have excellent, dedicated nurses in our Post Anesthesia Care Unit. I have now been at GBMC for almost four years and I can’t remember a complaint about this team.

The system that they have been working in is not perfect, however.

High Reliability means “what should happen, happens and what should never happen, doesn't.” The Joint Commission has been concerned that there are infrequent events around the country where patients who have received anesthesia have suffered a bad outcome because they were not truly ready to leave the care of the anesthesia team after a procedure, but left anyway. So, to prevent against these rare events, the Joint Commission has a rule that a licensed independent practitioner must evaluate the patient before the patient can go to a lower level of care (the inpatient unit if an inpatient, home if an outpatient). Well, GBMC has not had untoward events that I am aware of, but we have had a significant problem with getting the documentation that the anesthesiologist has evaluated the patient.

Two weeks ago, the PACU joined the units participating in LDM (Lean Daily Management). Charlene Mahoney, the Nurse Manager of the GOR PACU decided with her team to measure daily completion of the Post Anesthesia Evaluation Note as one of their metrics. Earlier this week on LDM rounds, I was stupefied at how fast they had driven their performance to 100% completion of the form! On rounds, Charlene explained that the Team had implemented two process changes to meet their goal. First, she had met with Dr. Lewis Hogge from our Anesthesia group to discuss the charge anesthesiologist rounding on an hourly basis. This helped their compliance but did not get them to 100%. Charlene, CJ Marbley, our Director of Perioperative Services, and Dr. Hogge then decided to put a hard stop in the PACU. No patient would be allowed to leave the PACU without the form being completed. This is a huge culture change for our staff who are trained to keep the unit open for incoming patients from the OR. They have accepted this challenge with the support of Jennifer Trunk, the PACU’s clinical partner and our PACU charge RN's. And, the Team has gotten to perfection in this measure without slowing down the operating room.

Experts in mistake proofing identify three levels of this. The first level is when people remind others of the possibility of an error and ask them to be vigilant. This has a positive effect but since the operators are human, sooner or later someone will get distracted and forget. In healthcare we frequently turn to education of the staff as a level one mistake proofing action.

In level two mistake proofing, we make a process change that improves performance but does not fully stop the error from occurring. In the PACU example, Charlene, Dr. Hogge and their Team did this when they instituted hourly rounding of the anesthesiologists.

Level 3 mistake proofing is when a constraint or “hard stop” is created that totally prevents the bad outcome. An example of this from my daily life is that I cannot start my car without having my foot on the brake to assure that the car doesn't start moving before I intend it to. The PACU Team turned to this successful level 3 action when they stopped anyone from leaving without a signed form.

I am very proud of the PACU Team and grateful for their speedy problem solving to fix this hole in the Swiss cheese and make our patients safer!

Transparency…Does it Matter in Healthcare?

One of the reasons why people say that market forces don’t work in healthcare is because the consumer (patient) has poor access to data to judge the quality of the product. GBMC HealthCare has now had many of its quality data publicly available and updated monthly for over a year. Are people coming to our website www.gbmc.org/quality before they choose where to go for care? It is very hard to tell.

Our data show that we have made excellent progress in many areas. Hand hygiene is significantly improved over just a few years ago. Perhaps because of this and the hard work of our nurses, physicians, and other clinicians, our rates of hospital acquired infections- catheter associated urinary tract infections in particular, have decreased significantly as well. We have now gone seven months without a hospital acquired pressure ulcer. Do our patients care? Why have other local hospitals not followed us in making their data public? Do they know something that we don’t?

U.S. News and World Report continues to name “Best Hospitals” that the national data reporting system shows frequently as having average performances (see www.medicare.gov/hospitalcompare/search.html). The last round of awards did begin to generate some conversation among academics about the illogical nature of these awards but the public didn't seem to care. It appears that healthcare organizations keep their “brand” strong or otherwise independent of the evidence.

I believe however that the public is beginning to wake up and so called value-based healthcare will start to get some traction. We can no longer afford the 40% waste in the U.S. system. Please discuss this with your friends. Do you have ideas for helping patients make decisions about healthcare? Please share them.

Good Volume…Bad Volume?

GBMC HealthCare gets paid for the work that we do in serving patients in a number of ways. Physicians submit bills for their “professional” fees when they see a patient in the office, do a procedure, care for a patient in the hospital, or provide a consultation on a patient being managed by another physician.  The hospital and Gilchrist Hospice Care have always submitted bills to insurance companies, Medicare, Medicaid and individuals for services provided.  GBMC has always taken in more money if we see more patients. This is the so-called “fee-for-service” system.

The danger in fee-for-service is that people will provide unnecessary services due to the lure of making more money. In healthcare, there are very few examples of people knowingly providing unnecessary services (otherwise known as fraud.) In healthcare, most “unnecessary services” are delivered with good intentions with those providing the care believing that they are necessary. In the fee-for-service world, executives (like me) have no or little incentive to scrutinize whether care is truly necessary according to the evidence or if the patient could have been served as well in a more efficient, less costly setting. We executives have primarily been judged by the financial bottom line. Since we got more revenue for more services, we have been happy with full Emergency Departments and numbers of procedures over budget. I have often thought that it was sad that we would get upset if the Emergency Department was not packed. We were incentivized to make it full. But if your loved one was one of those waiting in the packed Emergency Department, you were wishing that the visit could have been prevented.

A New Direction

Well, this is now all changing. Maryland’s new contract with the Centers for Medicare and Medicaid Services (CMS), the so-called “new waiver,” sets us in a new direction. Since the State now needs to keep increases in hospital spending under the rate of increase of Maryland’s economy, projected to be 3.58 percent annually over the next 10 years, our hospital will be paid a fixed amount of money per year. If we bill more services, the hospital will not be paid more money unless the population grows significantly or something significant happens in the market, like a hospital closes and we must serve their patients. Gilchrist Hospice Care will still be paid for every individual service and our physicians will continue to be reimbursed fee-for-service.

Is this change in the payment system a good thing? I think it is because it begins to align incentives to keep people healthy and to create systems that serve their needs efficiently. Care coordination will now be critical. If we can serve someone more efficiently in their home or in the patient-centered medical home, then that is what we must do.

But now, our people are asking me, “Do we want to grow our programs? Because if we do, we may not be able to afford it.” My answer is simple: we want every person in our community who needs hospital care to get it at GBMC. Our vision is to be the healthcare system where everyone, every time gets the care we would want for our own loved one. This new payment system is better aligned with that vision. It gives us more room to do things that have not been paid for in the past, like coordinating care.

I have no illusion that this will be easy, but I have complete faith in our ability to do it. A major issue is that with physicians still paid fee-for-service, the major players’ incentives are not totally aligned. I am on a Health Services Cost Review Commission (HSCRC) committee that is studying how to bring physician payment in alignment with the new waiver. We will work on new solutions to solve this dilemma. The other obvious concern is that people will game the system and stop providing needed services; if the danger in fee-for-service is unnecessary care, in fixed revenue systems the danger is that patients won’t be able to get care that is necessary. We will not let this happen. We will stay focused on our vision and our 4 Aims: Better health and better care with less waste and more joy for those providing the care.

I want to thank all of my colleagues at GBMC HealthCare for all of your hard work as we enter this new phase in our transition to a more patient-centered and value-driven healthcare system in our State.

The Passing of a Giant

Last week, GBMC lost a great friend. Mr. Willard Hackerman, the President of the Whiting-Turner Contracting Company (America’s fourth largest construction company and the builder of many edifices in our region) died at the age of 95. Mr. Hackerman was a great business leader and also a great philanthropist. Many, many organizations and individuals benefited from Mr. Hackerman’s gifts. In 2009, he gave GBMC $1 million dollars that allowed us to purchase a da Vinci robot for advanced surgical care.

When I first came to GBMC in the summer of 2010, I went to Mr. Hackerman’s office to thank him. He was so kind and generous with his time to me. He told me the story of the Whiting-Turner Company and his role in its development. He was so joyful in speaking of his mentor, Mr. Whiting, and he was so humble when asked of his own accomplishments. Mr. Hackerman invited me to visit his map collection…an invitation that I could not pass up even though I knew nothing about maps. I was fascinated not only by the maps but also by the depth of his knowledge of the topic.

Willard Hackerman worked very hard and accomplished much. He was the exemplar of someone who knew to give back to the community. GBMC and the entire Baltimore region benefited greatly from his presence and his actions. We will miss him dearly.

I Hate Snow!

My family and I moved here from New England so I am no stranger to cold and snow. But one of the reasons I was so excited to come to Baltimore was to get away from snow. I don’t enjoy winter and I enjoy it less each year. So this winter has been tough to take! Last Thursday, after shoveling the snow off of my street for about 50 yards, I got in the car and blasted through about 200 yards of snow to get to the first street in my neighborhood that was plowed. I drove to work and found what I always find….dedicated staff, most of who had been there since the previous day. Let me take this opportunity to thank everyone who worked so hard to get the job done for our patients and our community in that snow storm.

Special thanks must go to our beloved four man grounds team: George Dillon, Bob Marshall, Eduardo Rivera and Dave Mier. These guys worked just about around the clock with our snow removal vendors to make our campus safe and passable! Thank you, guys.

Thank You Team GBMC

Check out this video that shows some of our dedicated team members who helped keep GBMC fully operational to provide seamless care for our patients during the recent snow storm.

Coordinating Care for Patients

As I continue to explore how the patient-centered medical home benefits our patients, I’ve heard from practitioners who are on the front lines, working hand-in-hand with patients to effectively coordinate their care. The lack of coordination for those with chronic disease is the biggest problem with the U.S. healthcare system.

I heard from Vergie O’Garro, RN Care Manager at GBMC’s Texas Station and Owings Mills primary care practices, who has been a nurse for more than 20 years. She talks about how the care she delivers today is very different from the primary care of years ago.

Here, Vergie shares her perspectives as a healthcare provider on the patient-centered medical home model of care: 

“Before the medical home, some patients would get lost in the shuffle. For example, when patients were discharged from the hospital, we didn't have a good way to ensure they understood their condition and we didn't have a way to follow up with them to make sure they understood the plan and were following it. There’s so much information provided at discharge and many patients have trouble remembering everything they need to do for their health once they are out of the hospital. Now, however, we contact the patients and guide them in the transition from the hospital to home, help them find resources, help them understand their care plan, ensure they are receiving and taking their medications and just manage their care better overall.

As an RN Care Manager, when I have a patient discharged from the hospital, I call the patient once they are home, go through the list of medications they need to take and make sure they understand how to take the medications. Follow-up and creating a plan of care is important for long term management of a patient’s condition.”

What does it mean to coordinate care?

“I work closely with our care coordinators to provide patients with the resources they need to maintain their health and manage chronic conditions. Coordinating care not only means guiding a patient through a chronic health condition, but also helping patients find resources, financial or otherwise. For example, some patients need help finding transportation to and from doctor appointments. Our care coordinators work closely with patients to help them with things like this, which is another important part of coordination of care.”

Can you give an example of how you help manage a chronic disease like hypertension?

“As an RN care manager, if a physician refers a patient to me for hypertension, for example, I’ll look at factors like hereditary and other causes of the hypertension. Maybe it’s stress, so I’ll  find out about how the patient handles stress and help them manage it better. We’ll discuss things like diet and I’ll create a plan for modifying their diet to promote a healthier lifestyle. I’ll also talk to the patient about incorporating an exercise plan. It’s important that I really listen to the patient. I’ll let them tell me what their symptoms are and how we can manage the condition together. After we come up with a plan for managing their condition, I’ll call the patient on a monthly basis to make sure they are progressing in the care plan. This is a very comprehensive way to manage disease that also helps cuts back on hospital re-admissions.”

I thank the members of our healthcare team like Vergie for making the patient-centered medical home reach its potential as we generate our four aims of better health, and better care, at lower cost and with more joy for those providing the care. The patient-centered medical home is a fundamental building block of our transformation towards our vision of being the company where everyone, every time, gets the care that we want for our own loved ones.

Have you had experience working with a care manager? Has it helped you coordinate your care?