Stopping the Spread of COVID-19

In times of crisis, people become more concerned about each other. Over the past few weeks, many people have stopped me in the hallway to ask me how I am doing. I can honestly tell them that I am doing fine. I am fine because we have a great team at GBMC - experts in their fields who work very hard and who are focused on our vision.

The community needs us, now more than ever, to remain focused on our vision. Many people are scared, and they are hoping that we will be there for them if they get sick with the coronavirus (COVID-19). We are doing everything we can to manage what is in our control and we are actively creating plans for scenarios that we cannot control.

As a physician, I was trained to look for evidence to make a diagnosis - to use data to decide what to do. One of my frustrations as we deal with the pandemic is the degree of uncertainty that we are experiencing. Will we have a surge of patients and if so, when will they come? So far, we have not had a surge, but has it simply not happened yet?

I have been reviewing the epidemiology of infectious disease outbreaks. There is a statistic called the basic reproduction number (R₀) or R naught. A common definition of R0 is the number of secondary cases that one case would produce in a completely susceptible population (i.e. How fast is this disease likely to spread?). Since there is no immunization for COVID-19, we believe that everyone who has not yet been infected is susceptible. An outbreak of a disease will continue if R₀ is >1 and it will end if R₀ is <1.

There are three primary factors that determine the contagiousness or transmissibility of infectious agents and therefore the R₀. They are: 1. The duration of contagiousness of the agent (early data shows that this is about 10 days from the onset of symptoms in COVID-19); 2. The likelihood of infection per contact between a susceptible person and an infected person; and 3. The contact rate between infected and non-infected persons.

We obviously can’t do anything to change the duration of contagiousness, at least until there is a cure. We wear personal protective equipment (PPE) like face shields and N95 masks to reduce the likelihood of getting infected when we are in contact with an infected patient. These are precautions we must take, but the best way to reduce R₀ to <1 is to reduce the contact rate. This is why our schools are closed, why most people have been sent home from work, and why the GBMC Fitness Center and all my favorite restaurants are closed. We have essentially shut down our economy and put large burdens on our citizens to stop the spread of this disease.

Is it working? There are some hopeful signs. The number of Emergency Department visits are down, and we have not seen a surge in cases, yet. We can’t really tell what the actual R0 is, in part because we don’t have enough test kits to test a large enough segment of our community to see who has been infected. But we must stay the course. We will overcome the coronavirus if we stay together and stick with the science. If you have questions, our Infoweb is the official source of institutional information for the COVID-19 outbreak and it is updated frequently. Please check it at regular intervals to keep yourself in the know.

Thanks to all of you for your hard work!

Keeping yourself and those around you safe

The GBMC HealthCare System is focused on the COVID-19 pandemic and preparing for a possible surge in cases. What can the individual do to protect himself or herself? There are two things that we should all do: 1.Wash our hands.  The virus is generally spread through droplets that occur when someone with the virus coughs or sneezes. If you touch a surface that has a droplet and then you rub your eyes, you will contaminate yourself. So, wash your hands frequently and avoid touching your face. 2. Keep yourself at a distance from those who may be sick and could spread the disease to you by coughing or sneezing.

Two tents are now located outside the Emergency Department. They will be fully operational beginning Monday, March 16, at 11 a.m. We will use them to respond to an evolving situation as needed.

Currently, we are well stocked with personal protective equipment and our Incident Command Team, led by our Chief Medical Officer, Harold Tucker MD and our Chief Nursing Officer, Dr. JoAnn Ioannou, has a plan in place to deal with a potential surge in infected patients. Beginning Monday, March 16, we will begin screening visitors to our hospital and limiting visitation to patients to protect both the patients and our staff. It is critical that we protect our staff so that we will have enough people to care for the sick when they come. I am very grateful for all the work that has been done to prepare us for what might come. The Team is assessing the situation hour by hour and will adapt as necessary.

New Method for Measuring Hand Hygiene Compliance
Speaking of proper hand hygiene, starting on Wednesday, April 1st, we will no longer be using secret shoppers to measure our compliance with hand hygiene. This will now be handled by observers who are not only counting, but who will also intervene and provide real time feedback and coaching. This will help us “hardwire” washing in and out of rooms to get us closer to 100% reliability in this practice.

The Centers for Disease Control and Prevention (CDC) says that “on average, healthcare providers clean their hands less than half of the times they should.” Our Chief of Infectious Diseases, Dr. Ted Bailey, stressed multiple times, during a recent interview, that the best way to protect yourself and your loved ones from getting COVID-19 is with proper handwashing.

Thanks very much to all my GBMC colleagues for their efforts in combating the COVID-19 pandemic.

What if your loved one couldn’t pay their healthcare bills?

If you read my blog, you know I believe that the United States has the best doctors and nurses in the world; however, they work in a system that spends at least 40 percent more per capita on healthcare than all other countries. So, when an individual gets sick in our country, depending on his or her health insurance, it is very easy to end up with significant out-of-pocket expenses.

There are several groups of patients who are covered by programs that have little or no out-of-pocket expenses. This is often called “first dollar coverage.” Medicaid, a federal and state program, covers low-income patients and disabled patients and Kaiser Permanente offers a similar program. Veterans’ medical expenses are covered through the Veterans Administration (VA). The technical definition of “socialized medicine” is healthcare provided by the government. Like the National Health Service (NHS) in England, the doctors, nurses and other clinicians serving the VA are all federal government employees.

Medicare, the U.S. program that covers citizens over the age of 65 (and a few other groups, like those with end-stage renal disease), has out-of-pocket expenses, so Medicare beneficiaries can opt for Medicare Advantage (HMO) plans where they have limited out-of-pocket expenses but fewer choices of providers. Medicare does not employ doctors or nurses so, by the definition above, this is not socialized medicine. The only thing that Medicare does is pay the actual medical bills. By the way, by this definition, the Canadian system is not socialized medicine either, because the Canadian government does not provide care, it only covers medical costs. There is actually more socialized medicine presently in the U.S. through the VA than there is in Canada. Canada is one of the countries that pays about 40 percent less per capita on care than the U.S. and their average life-expectancy is longer than ours. There is no appreciable difference in healthcare quality between the U.S. and Canada.

The majority of working Americans have employer-based health insurance (like me and my 4,000 or so GBMC HealthCare System colleagues). These plans vary significantly from employer to employer. At GBMC, if you take our platinum plan and use GBMC medical staff members and GBMC facilities, you can run up large bills with no out-of-pocket expense. But, many employers have been dealing with the rising cost of healthcare by pushing more and more of the cost onto employees through deductibles and co-pays. We now have many Americans who have insurance through their employer but cannot afford care because they cannot afford the out-of-pocket expense. This is a real problem for many.

I know someone who is currently facing this dilemma. This person is a graduate of a prestigious college and a hard worker, with a good job and is making a reasonable wage. The person recently needed to have a medical procedure and the amount this person had to pay out-of-pocket was much more than the person could afford. I know that this story is not unique.

Middle class Americans are paying a greater percentage of their earnings than ever before for healthcare, according to this report, from The Commonwealth Fund, which says rising premiums have outstripped wage growth over the past decade. Medical debt is the most common cause of people filing for personal bankruptcy (65%). So, last week’s news about hospitals’ bill collection practices should not come as a shock. The number of people who can’t pay their bills is growing significantly and hospital margins are very slim, so they are trying to capture the reimbursement. We at GBMC make sure that we treat patient fairly by offering financial assistance for those patients in need and creating reasonable payment plans for those who have the ability to pay their medical bills.

The real question is: Do we believe that healthcare is a right or a privilege? If we believe that healthcare is a right, then we should learn from other countries where all people are covered, and the total cost is less to create a smarter insurance system. What do you think?

Thank You to Our Social Workers!
March is Professional Social Work Month and I would like to thank the devoted group of social workers who serve GBMC. Our social workers help inpatients and outpatients navigate the complexity of the medical care world and prepare them for discharge along with our care managers. Please thank our social workers for all that they do to move us closer to our vision.

Revising our Mission Statement to Make our Purpose Clearer

We formally launched our new mission statement this week. The reason we have a mission statement is to make the purpose of the organization clear to all — it lets everyone know why we exist.

The mission statement of GBMC, since its inception in 1965, has been to provide medical care and service of the highest quality to each patient leading to health, healing and hope. Over the past few years, leaders in our organization have come to me suggesting that this was inadequate because it was clear to them that we also exist to teach future generations of clinicians. GBMC has hosted residency training programs for physicians and trained nurses and many other clinicians. During visits from the Accreditation Council for Graduate Medical Education (ACGME) we were asked why education was not formally in our mission statement.

So, in September of last year, the GBMC HealthCare Board voted unanimously to change the mission statement to: The mission of GBMC is to provide medical care and service of the highest quality to each patient and to educate the next generation of clinicians, leading to health, healing and hope for the community. This change makes it clear to our people and to the members of the community we serve, that we are a teaching and learning organization. We believe in following evidence-based medicine and teaching this to new practitioners. It is in seeking new knowledge that we push the science of care forward.

Please share your thoughts and thanks for celebrating this change with us. Here is a two-minute video that explains more.

Moving Towards a Lean Management System
GBMC has been very successful with its use of Lean Daily Management (LDM) to create a company of focused problem solvers and to narrow the gap between the “front office” and the “front line.” We have used this technique for seven years and have seen significant improvement in each of our four aims.

Under the direction of Rhonda Wyskiel, Director of Performance Improvement, a team has been working on the next iteration of LDM, to systematically use lean tools to drive all the work of our leaders. The team first began working on Units 45 and 46 and they have now expanded some of the work to the other medicine inpatient units. They are intent on driving out non-value-added tasks in these units to improve clinical outcomes and the care experience while making it easier for staff to get the job done. This helps to increase the joy in their work of patient care. Staff on the medicine units are working to improve purposeful rounding, a practice that creates standard work in assuring that inpatients are visited at regular intervals and that all their needs are being met.

Our transporters are also working with their nursing colleagues in the emergency department and the medical intensive care unit to maximize the probability that patients move from the emergency department to an inpatient unit expeditiously and with everything that they need. We are already seeing improvement in patient flow and our patient engagement scores. Let me thank all involved in this great work under our core competency of redesigning care!

Checking in on the Maryland Waiver

On Wednesday, I participated in a panel discussion sponsored by MedChi, our state medical society, entitled “Cutting the Cost of Health Care - Is Maryland's Health Care Model Working?”

Maryland is the site of two major experiments to drive us towards the Triple Aim of Better Health and Better Care at Lower Cost. The first is our Medicare waiver, also known as the Total Cost of Care Model, and the second is the Maryland Primary Care Program (MDPCP). MDPCP is designed to reward primary care physicians financially for transforming their practices to better manage the health of their patients. State leaders recognize that hospitals cannot manage the health of a population; they are constructed to deliver services to those who are acutely ill. Primary care physicians, supported by nurses, technicians, and social workers can be held accountable for the health of a panel of patients.

It is not financially possible with the current fee-for-service system for small groups of privately practicing primary care providers to deliver the kind of advanced primary care that GBMC has been delivering for almost a decade. So, the MDPCP model has upfront payment built in to support the costs of the added team members. Private practicing primary care physicians can contract with a Care Transformation Organization to get the social work and care management support needed for their patients. GBMC operates a care transformation organization, the Greater Baltimore Health Alliance (GBHA), and we support several private practices in the MDPCP.

There is some inherent tension between physicians and hospitals as we transform the delivery system. Money flows to hospitals through the Health Services Cost Review Commission (HSCRC) and physicians want to be assured that they are benefiting financially as they become more active in redesigning care. This will also become true for community agencies as we build new alliances to deal with the social determinants of health, which play a larger role in population health than the care delivery system itself.

Joining me on the panel were Scott Krugman, MD, Vice Chair of Pediatrics at the Herman & Walter Samuelson Children’s Hospital at Sinai, Chris L. Peterson, MPP, CHFP, Principal Deputy Director for Payment Reform and Provider Alignment at the Health Services Cost Review Commission, and Gene M. Ransom III, CEO, MedChi, The Maryland State Medical Society. The room was full and the conversation was lively. Gene acted as the moderator and he began the session with a brief presentation on how the Total Cost of Care Model works. Chris spoke about how the HSCRC has no direct accountability for physician payment rates but that they were working within the model to find ways to financially incentivize physicians to create better systems. Scott voiced his concern about the lack of focus on the needs of children.

I was honored to be on the panel and I think the sharing of ideas was very powerful.

Councilman Marks Visits GBMC
This past Monday, I had the pleasure of being joined by Baltimore County Councilman, David Marks, on our Lean Daily Management (LDM) walk. I updated Councilman Marks about our progress in building a patient-focused system of care and our recent recognition by the Baldrige Performance Excellence System. He offered high praise for our use of LDM to generate improvement and was impressed with our patient-centered medical homes.

Over the last four years, I’ve had the privilege of hosting visits from many policymakers, on various levels, to our system. The common feedback from these visits is that we should be very proud of our accomplishments and the creation of a system of care that the patient experiences as a whole. I couldn’t agree with them more. I am truly grateful for the fabulous efforts of the entire GBMC HealthCare family and the hard work by all of you in moving us towards our four aims and closer to our vision every day. It is truly amazing, and it’s being recognized by many in our community and beyond. Thank you for all your hard work!

Celebrating Black History Month 
On Wednesday, we hosted our annual celebration in honor of Black History Month. This year’s program, entitled Black History Month Celebration: The Power of Unity, was truly remarkable and was attended by approximately 100 employees.

This event gives us an opportunity to recognize the accomplishments of African Americans whose hard work, commitment, and dedication serve as an inspiration to all people who value the ideals of freedom and democracy.

The ceremony’s guest speaker was the renowned preacher, teacher, and author, Rev. Dr. Ann Lightner Fuller. She told her very moving story about how she went from growing up in a poor household to having an outstanding career as a minister and speaker. She encouraged all of us to remember those less fortunate than ourselves and to try to create opportunities for people to create a better life for themselves and their family.

Other highlights included a moving presentation by Jalisa Monroe from the University of Maryland Baltimore County (UMBC) and entertainment from the Parkville High School Dance Team. Ms. Monroe was a very talented orator and the students from Parkville dazzled the crowd with their talent.

Our New SAFE Space

The statistics in Maryland are alarming. It has been reported that one out of every five adult women has been the victim of rape during her lifetime and there were 15,301 domestic violence-related crimes in Maryland in 2016. According to the National Human Trafficking Hotline statistics, there were over 300 victims of human trafficking identified in Maryland in 2018.

This past October, our Sexual Assault Forensic Evaluation (SAFE) and Domestic Violence (DV) Program saw more patients than any other month in its history. In the final three months of last year, our SAFE and DV nurses performed 74 forensic examinations (an 80% increase from 2018) and cared for 112 domestic violence patients (a 45% increase from 2018). Unfortunately, these numbers continue to increase, and victims need to know that they have a protected place to come for help.

Earlier this week, our SAFE and DV Program officially opened its new location to help meet this growing need. The new unit will offer patients a unique setting for evaluation, diagnosis, and treatment.

The more than 2,500-square-foot facility has two exam rooms with everything needed to provide the highest quality of care to patients. Each room is equipped with an array of diagnostic tests that a forensic nurse examiner will administer as needed, allowing them to be present with the patient throughout the entire assessment.

The new unit also has an interview room that includes audio-video capability along with additional security measures to ensure that victim privacy is protected, and that chain of custody is maintained. The room provides a private and secure space where specially trained staff from organizations such as Baltimore County’s Child Advocacy Center and the Special Victims Unit as well as forensic interviewers and Crimes Against Children Unit detectives can interview victims. These interviews can now be conducted in a confidential, non-judgement atmosphere at no cost to the patient.

GBMC HealthCare has been a key player in the movement of providing compassionate and empathetic advocacy and in getting justice for victims of sexual assault, intimate partner violence, and human trafficking. Since 2016, the program has helped, on average, 370 victims of intimate partner violence and 280 victims of sexual assault annually. Since April 2019, it has cared for 15 victims of human trafficking.

The growth of the SAFE and DV Program has brought new challenges that this unit will help us address. It has the capacity to accommodate victims with disabilities and creates an environment where our nurses can provide both physical and psychological care to all patients. I want to thank Laura Clary, BSN, RN, FNE-A/P, SANE, our SAFE clinical program manager, Ashley McAree, RN, FNE-A/P, SANE-A, our human trafficking liaison, Valerie Weir, BSN, RN, FNE-A/P, CMSRN, coordinator for GBMC’s domestic violence program, and all our forensic nurses and victim advocates who do so much for our patients.

The Netflix Series “YOU”
There is a very popular American psychological thriller series on Netflix, entitled “You.” For those of you that are not familiar with the show, it deals with a fictional serial killer, Joe Goldberg, who falls in love with a young lady and develops an extreme, toxic, and delusional obsession with her. He uses social media and other technology to track her presence and remove obstacles to their perceived romance.

The show gives you an inside look at abusive behavior and dating violence, two issues, among many, that our SAFE & DV Program see on a consistent basis. The assessment and treatment of these victims is very complex. Expertise and caring are required not only to address the medical and psychological needs of the patient but also to complete the forensic work necessary to aid law enforcement in the identification of the perpetrator and to see that justice is served. Under the leadership of Laura Clary, our SAFE program is growing and expanding in new directions, helping us to better meet our mission of health, healing, and hope for those in our community and our vision of serving everyone the way we want our own loved ones served.

I won’t spoil it for those who are watching the first or second season of the show, however I encourage you to read this interesting op-ed, written by our very own Briana “Bri” Rogers, one of our marketing communications coordinators, that was recently printed in the Baltimore Sun. Click here to read her piece. Nice job, Bri!

GBMC Achieves the Highest Score from CMS

I am proud to announce that GBMC has earned a five-star rating from the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare Program. We are one of eight hospitals in the state and one of only 407 in the nation to achieve the highest score!

CMS is a federal agency that pays for the care of Medicare and Medicaid beneficiaries. CMS sets conditions of participation and incentivizes healthcare providers to continually improve the value of care through optimizing health outcomes and the care experience. This needs to be done while also reducing cost. The CMS Hospital Compare website reports quality measures for more than 4,500 hospitals nationwide.

CMS created the star-rating system to give patients the tools they need to find the organizations that will provide the highest value to them. The Five-Star Quality Rating System uses scores for seven groups of measures in its calculation. The seven groups are:
1. Mortality
2. Safety of Care
3. Readmission
4. Patient Experience
5. Effectiveness of Care
6. Timeliness of Care
7. Efficient Use of Medical Imaging

A hospital summary score is calculated by taking the weighted average of these group scores, and the overall hospital rating is calculated using the hospital summary score. For more information about how hospitals are scored, click here.

Much has been said about the “age of consumerism in healthcare” and how patients are using data to decide where to receive their care — I wish it were true. GBMC has been putting its quality and safety data on our public facing website (https://www.gbmc.org/quality) for eight years, but we have not seen much evidence that patients are using it to make decisions. This can also be said about Hospital Compare.

One of the reasons for this is that the data metrics can be confusing to the average person. They are complicated and often not well explained. We owe it to those we serve to make this information as accessible as possible. What ideas do you have to make it easier for patients and their families to compare providers and make informed decisions?

I hope that many members of the community see that we have achieved this distinction and explore all that GBMC has to offer!

Congratulations!!!
We recently learned that GBMC is the first hospital in the state to earn the Joint Commission Advanced Certification in Perinatal Care! This certification means that patients can expect integrated, coordinated, patient-centered care through their pregnancy and childbirth. Throughout its history, GBMC has been known to be one of the best places in the area to have a baby and this certification is further evidence of our excellence. Let me thank and congratulate Victor Khouzami, MD, Chair of Obstetrics, Lisa Groff, DNP, RN, Director of Women and Children’s Services, and their entire team for this fabulous achievement.