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my children, on this, my 39th bday.

Aidan, Bella and the wild one....

Perfecting the Hand-Off – to Better Coordinate Care

Our vision is to treat everyone as we want our own loved ones treated. Most of us have had loved ones with some chronic disease where our loved one was caught between providers of care and we had to try to bridge the gap. I often get calls from family members asking me to help resolve differences of opinion between providers. I have told the story of a woman who was admitted to the medical intensive care unit at GBMC with diabetic ketoacidosis because her insulin plan was wrong. Our physicians and nurses got her back on her feet and discharged her to the care of her doctor. Unfortunately, her doctor put her back on her previous plan and she ended up back in the Emergency Department. It seems that her doctor did not get the message about her new plan at the time of her discharge. A clear lack of coordination.

How do we fix this? 

Well, the improvement has to start with someone being willing to coordinate the care. This is why the GBMC HealthCare system has embraced the concept of the patient-centered medical home (PCMH) because the physician-led team knows that it is accountable to provide the coordination 24 hours a day, 365 days of the year, and actually has the capability to do that! Also, the other members of the healthcare system must work with the primary care teams at the time of handoff, like when a hospitalist is discharging a patient from GBMC back to the primary care physician.

The Head of the GBMC hospitalist group, Rekha Motagi, MD, and her team have been working tirelessly to improve the handoff back to the primary care doctor. You can imagine that communicating to literally hundreds of different doctors and offices can be quite a challenge. Rekha and her colleagues have been redesigning their communication process and measuring its performance as a measure on their Lean Daily Management board. Every day on our management rounds, Rekha or one of her hospitalist colleagues and members of our two internal medicine resident teams, report on the percentage of the previous day’s discharges where they have had a high quality communication with the primary care physician or his or her office staff. As a result of their work, they rarely miss a handoff with a GBMA PCMH practice and we are seeing improvement with our non-GBMA practice colleagues as well.

I’ve asked Dr. Motagi to explain the obstacles that have been identified and the improvements that have been made in the transition of care since the team started testing changes:

Rekha Motagi, MD

Dr. Motagi explains: 

The hospitalist group has always made it a priority to communicate with a patient's primary care physician to provide verbal hand-off when patients are discharged from the hospital. This is a very important aspect of the transition of care. Reviewing a patient’s hospital course, medication changes, test results and pending tests during this hand-off is also an important patient safety measure.

Previously, we were not sure how consistently this hand-off communication was occurring in our large group and the reasons we were not always successful. But since we started the lean daily management process, where one of our metrics is for each physician to note if they have been able to reach the PCP for discharge hand-off, we have identified several areas for improvement.  

About 90% of the time, our doctors have made an attempt to reach the patient’s PCP; but we've only connected with them from 50-70% of the time due to various reasons including:

• Offices were closed or the front office did not want to interrupt the PCP. In these instances, we left a message but were not sure if the PCP received it (This becomes much more challenging on weekends/holidays.)
• We have been put on hold for 10 minutes or more; in many instances, our doctors have had to hang up because they needed to respond to other calls
• The PCP was on vacation, so there was no way to ensure they received the message
• There is no attempt made to call when there is no PCP or if the patient is going to be transferred to a facility and no provider in the facility has been identified

Since we started Lean Daily Management, the physicians relations office (Mary Ely, Ann Veltre and Bonnie Longerbeam) has been working to reach out to several physician groups to obtain their feedback on the best ways to accomplish a successful transition of care. What we've found is that there are some PCPs who are very involved in their patient's hospital stay. Some are interested in receiving the call from the hospitalist, but only call back if they have questions. From this outreach, we've been able to make improvements and design a more effective system for coordinating the transition of care, including:

• Obtaining back-office telephone numbers for PCPs (and in some cases cell phone numbers) which provides us with faster access to some of the PCPs
• Updating incorrect physician office numbers in our database 
• Identifying physician offices that have care co-coordinators (RNs) who will take the patient’s information, relay it to the PCP and contact patients to arrange follow-up

We are now working with all primary care providers to further standardize this process. Our group is also committed to making sure the written communication (discharge summary) is completed within 48 hours of a patient being discharged. Currently, we are over 95% compliant with this effort and we are working to get this rate to 100% so that the information is there for the PCP to use in follow-up.

***

I want to thank Dr. Motagi, our hospitalists, our internal medicine residents, the physician relations group and our PCPs for their commitment to creating a more reliable system for patient hand off. Continuous improvement requires a focus on who it is that we are serving, system design, measurement, teamwork, and empowerment. Lean daily management appears to be helping us speed up the implementation of all of the above!

Speaking in Lisbon on October 5

My friend Pedro Bastos graciously invited me to speak at a conference he organized in Lisbon on October 5 titled "Food, Nutrition and the Prevention of Chronic Diseases".  I will give two talks:

• "Ancestral Health: What is Our Human Potential?"  This talk will explore the health of non-industrial cultures in an effort to understand how much of our modern chronic disease burden is preventable, and it will briefly touch on one major aspect of non-industrial life that may protect against the "diseases of civilization".  This presentation will focus on age-adjusted data from high quality studies.  
• "Why Do We Overeat: a Neurobiological Perspective."  This talk will attempt to explain why most of us consume more calories than we need to maintain weight-- a phenomenon that is a central cause of morbidity and mortality in the modern world.  It will touch on some of the brain mechanisms involved in ingestive behavior, and outline a framework to explain why these mechanisms are often maladaptive in today's environment.

Pedro will speak about dairy consumption, vitamin D, and chronic disease.  

The conference is targeted to health professionals and students of nutrition, however it's open to anyone who is interested in these topics.  It's sponsored by NutriScience, a Portuguese nutrition education and consulting company.  Sadly, I don't speak Portuguese, so my talks will be in English.  

Access the full program, and register for the conference, using the links below:

Program

Registration

A fresh start in food…

By Melanie Leyshon

Home-delivery food service Hello Fresh is not a takeaway, more a  ‘make-at-home’. All you do is browse online and choose three meals from their current recipe selection. Each week a box of quality ingredients (meat is ethically reared and fish comes from sustainable sources), together with step-by-step recipe cards, is delivered to your home.

Hello Fresh Butterflied Mexican Chicken

Since the launch last year, 3 million meals with an international flavour have been delivered across the UK. Hello Fresh best-sellers include prawn and prosciutto linguine and lamb kofta with almond couscous and cucumber salad. Prices start from £36 for three veggie meals for two. Patrick Drake, who started the company and heads the creative recipe team, talks to HFG.

What your background?

I was a lawyer at Goldman Sachs, but always loved cooking and teaching, so I decided to quit law and try to get a cooking show! I remember writing down this notion one day at work, along with the five steps I’d need to take to get there.

Patrick Drake founded Hello Fresh

How did you get on…?

Step one – to get as many culinary mentors as possible, so I started cooking in the kitchen of my firm at lunchtime. After work, I’d hop a cab and swap pin stripes for chef's whites on the way to the Cuckoo Club in Mayfair, while weekends were spent working for top Spanish chef Jose Pizarro. Pretty soon I resigned from my job… and, when I told my boss I wanted to get into cooking on TV, he almost choked on his cappuccino. What followed were petrifying auditions at New York’s Food Network, hours making videos for YouTube and a stint with Heston [Blumenthal] at the Fat Duck in Bray. Five years on, I’m happy to say I have a TV series in 47 countries and Hello Fresh, my food company, which teaches thousands of people to cook from the comfort of their kitchen. It's almost scary how my thoughts turned into reality.

Hello Fresh are fairly healthy meals that come in generous portions?

Yes, it’s all about healthy food, but we are not a pure health food company. We design each recipe to be nutritious, balanced and fresh, but if we think a spoonful of crème fraîche will complete the dish, we'll add add it (your readers can use reduced-fat ingredients, if they prefer). The biggest problem in the UK is the amount of processed food people buy and the gap that creates between that and our vision of preparing simple healthy meals at home. Nutritious, home-cooked food shouldn’t be seen as an indulgence but rather an everyday habit.

Are you health-conscious?

I have a busy lifestyle and need to refuel at least every two hours to keep going – as my friends and colleagues know! Many of us tend to put healthy food last, but it should be our priority. Whenever I’m tight for time, I force myself to take the time to eat and that way I work far more efficiently.

There’s an international flavour to Hello Fresh dishes…

That’s because I'm from London, although my family lives in Hong Kong and I've lived in France, Japan and Hong Kong - I love to move around - keeps life adventurous!

For details of the boxes, visit hellofresh.co.uk

Tina tries... Up close and personal

By Tina Betts

In her first ever gym session, Tina is put to work by her personal trainer…

I’m nervous about meeting my personal trainer for the first time. My most pressing worry is… argh, what do I wear?

My trainers are caked in mud, as the last time I used them was for gardening, and my trackie bottoms are stored safely in a suitcase on top of the wardrobe (they’re certainly going to need an iron!)

But with trainers cleaned and bottoms pressed, I'm ready to meet my nemesis… Nuffield Health’s Lloyd. Turns out he’s a laid-back kind of guy who quickly puts me at ease, but just as quickly puts me to work. Taking into account last week’s MOT and having listened to my goals, he’s worked out a programme for me. I start with a set of exercises, so he can gauge my fitness level (squats, twists, mountain climbing). With each set he ups the challenges. So far, so good as, 20 mins in I'm still standing and confident I can get through this first session without looking like a numpty.

I resist the urge to giggle every time Lloyd asks if I can "feel it in my glutes yet?" I have no idea where my glutes are (I now know they’re bottom cheeks, and yes, I can feel them). I’m also introduced to my core – that’s tummy, mid and lower back, hips, shoulders and neck regions. And, boy, do they get a work out (I’m really feeling it the next day).

Was the workout worth it? Well! I’ve overcome my reluctance about gyming it - I’m even excited about my next session. Best thing is, I’ve realised I can do it. Over the next few weeks Lloyd is going to help me build up my stamina and, to help, he’s suggested I fit in a cardio session. So next week you can read all about my aqua aerobics session. Now where’s that cossie?

Personal training sessions at Nuffield Health Fitness & Wellbeing Centres cost from £55 for a single session. A five-hour booking costs £230 (that’s £46 a session) but it’s cheaper if you pay by direct debit. See www.nuffieldhealth.com.

We’d love to hear about your endeavours to get fit… 

Honoring, Remembering One of GBMC’s Founders, Mrs. Jeanne H. Baetjer

Last week, GBMC lost an inspiring and visionary leader. Mrs. Jeanne H. Baetjer, one of GBMC’s founders, passed away at the age of 91 years. What a legacy she left behind. Mrs. Baetjer was a true leader in every sense of the word. Her strong sense of community was quite evident in her life’s work, which included her vision for the development of a community hospital in Towson.

In 1958, while serving as President of the Hospital of the Women of Maryland, of Baltimore City, Mrs. Baetjer and other community leaders saw the need for a hospital in this area and set out to work on making this vision a reality. This was no small feat as the creation of GBMC entailed combining The Hospital for the Women of Maryland, of Baltimore City (Women’s Hospital) with the Presbyterian Eye, Ear, and Throat Charity Hospital. But, her tenacity and dedication to filling a greater community need paved the way for the establishment of our hospital, and from 1962 to 1965, while building was underway, Mrs. Baetjer oversaw the massive project. Her commitment to GBMC spanned five decades and she served in various roles in our history including the very first President of the Board of Trustees.

Since GBMC first opened its doors to the community in 1965, we have cared for countless individuals and we are forever grateful for Mrs. Baetjer’s vision and dedication. Her impact on GBMC and the community is immeasurable and far reaching. To this day, GBMC embraces her guiding principle that the patient always comes first– through our current Vision of “to every patient, every time, we will provide the care that we would want for our own loved ones.”

Please join me in honoring her life and legacy by sharing your memories and thoughts about Mrs. Baetjer with our blog community.

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this week with Che and Fidel

Aidan: the drummer
Bella: the pianist
Kai: hockey boy

this week's kitchen creations.

 roasted cauliflower (a member of the brassica family, with its strong anti-cancer properties)

potatoes

coriander (oh how i love this herb)

 aidan woke me up at 4:30 am with a sore throat. in classic aidan fashion it was intense. I gave him hepar sulph and within 5 min, he was back asleep (the classic picture in this remedy is the great sensitivity to all impressions). i also, yes, at 4:30 am, made a honey garlic cough syrup so it would be ready in the morning. i used one of my garlic cloves and topped with unpasteurized honey.

side note this is an email i got from a mom i know that had a terrible cold and i helped her out with a remedy.

"I feel so MUCH better!!! This stuff is awesome, it works great!!

Thanks so much."

what can i say, when homeopathy works, it's awesome!

 this lovely lady in my herb course gave me some kefir grains. i am attempting to make it. it is actually quite easy, but looks rather unpalatable. if anyone consumes this your input would be greatly appreciated! it's supposed to be wonderful for digestion as it is rich in probiotics. here it is fermenting.

lastly, we made pesto in this week's herb course with john redden of viriditas. 

recipe:

3 cloves garlic

1/2 cup pine nuts

1/2 cup olive oil

1/2 cup butter (this was different to me)

1 tsp salt

food process

then add

1 cup parsley

4 cups basil

food process

done and delicious!

i made about 30; 500 ml jars. i'm an expert. 

we each got to take one home. yum yum!

Get all your five-a-day in one dish!

By Harry Eastwood

This salad is a deconstructed version of ratatouille, which makes for a delicious, fresh and full-flavoured alternative to the traditional vegetable stew. It can be made ahead – and, in fact, tastes even better. It ticks plenty of health boxes as it’s high in fibre and low in calories, fat, saturated fat, sugar and salt. Most people can enjoy it, as it’s vegetarian, gluten-free and dairy-free. And the best thing about it? One serving counts as a full five portions of your five-a-day.

Ratatouille salad with anchovies and lemon

Serves 4

1 large aubergine, cut into small cubes

2 medium courgettes, topped, tailed and cut into very small cubes

4tbsp olive oil

1 large Spanish onion, peeled and finely diced

1 medium yellow pepper, cored and chopped into small cubes

1 medium orange pepper, cored and chopped into small cubes

2 garlic cloves, crushed to a paste

3 anchovies, very finely chopped

10 medium ripe tomatoes on the vine

Freshly squeezed juice of ½ lemon

Handful of basil leaves, torn from the stem

1. Heat a large frying pan until very hot.

2. Toss the aubergine and courgette cubes in the olive oil until evenly coated. Add them to the hot frying pan and cook over a high heat for 5 min, until the edges have turned a golden colour. You may find that you need to do this stage in two batches.

3. Tip the hot vegetables into a large bowl with the onion, peppers, garlic and anchovies. Season generously with pepper, then cover with clingfilm. Set aside for 10 min, while you prepare the tomatoes.

4. Chop the tomatoes in half and scoop out the seeds and centre with the help of a spoon. Finely chop the flesh, then add to the bowl with the rest of the ingredients.

5. Finally, squeeze the lemon juice over the salad. Set aside (wrapped in clingfilm) for 1 hr in the ambient temperature of your kitchen to let the flavours mingle and develop. Scatter the basil leaves over just before serving and add more pepper if needed. Serve with crusty bread, if you like.

SWAP IN/SWAP OUT

I love the savoury flavour the anchovies bring, but you don’t have to add them – this ratatouille is delicious without. You could include pine nuts if you want the salad to be a little more hearty and reduced-fat feta or mozzarella chunks are lovely thrown in at the last minute, too.

Per serving: 210kcal, 6g protein, 12.8g fat, 2g saturates, 19.2g carbs, 17.1g sugar, 9g fibre, 0.3g salt, 77mg calcium, 2.7mg iron

 

Harry’s supporting our mission to Fight the Fads – Make Every Meal Healthier. To find out why she’s rallying against the fad diet industry, pick up our October issue.

For more substantial salad recipes, check out Harry Eastwood’s A Salad For All Seasons (Bantam Press, £20).

What can we do to make GBMC safer for our people?

Our fourth or “quadruple” aim is more joy for those providing the care. All of us in our healthcare system should derive joy from serving those in need. But how can work be joyful if it is not safe? Safety on the job is surely relative. There are many jobs that have higher risk of injury than working in healthcare. Nonetheless, it is unethical to not be working toward zero injuries among our people.

The run chart below shows the monthly number of injuries reported to employee health. 

In fiscal year 2013, which ended on June 30th, we had 327 injuries. That number is an improvement of 12% from fiscal 2012’s 370 injuries. We have set a goal of no more than 294 injuries in fiscal 14, a further 10% reduction. Our Senior Executive Team receives a daily report of the number of employee injuries in the preceding 24 hours and measures this on our Lean Daily Management board. We are driving toward a goal of zero injuries.

The injuries can be grouped into a number of large categories. The most dangerous of the injury groups is the needle stick/body fluid splash category. Being injected with hepatitis C or HIV contaminated blood can lead to a lifetime of therapy and/or long term morbidity. These injuries can be prevented by using the appropriate safety devices like needle-less systems, needles with protective sheaths and protective eyewear. A respiratory therapist was recently exposed when the therapist did not use protective eyewear when inducing cough in a patient.

System design is also important. Standard work in the passing of sharps in the operating room is critical to reducing needle stick injuries. Recently, a resident physician stuck himself with a contaminated needle because he used his fingers rather than pickups to reposition a needle on a needle driver.

Another category of injury among workers at GBMC is sprains and strains, usually from lifting. With the national epidemic of obesity, it is very important that we use the appropriate lifting devices to avoid musculoskeletal injuries. Slips and falls is a category of injury that usually occurs from spills that go unnoticed or from workplace clutter. An employee recently fell after tripping on an exposed electrical wire. Our IT Team has recently been doing environmental rounds to make sure that computer and printer electrical cords are not creating tripping hazards on our units.

Our last major category of injuries is those due to workplace violence. We have made some progress in this area by implementing training for employees in high risk areas like the Emergency Department and also by stationing a security guard on Unit 36. There are other injuries that don’t fit into common categories like the employee who was recently harmed when a swinging door came off its hinge.

So what can we do to drive towards zero workplace injuries? First, we can make sure that we are following safe practices and using protective devices when appropriate. Secondly, we can report all injuries and participate in the learning from injuries to make our systems even safer. Thanks very much for sharing your ideas on how we can reduce employee injuries in the GBMC HealthCare system.

A Day of Remembrance

Finally, tomorrow is a somber day for our nation as we remember those we lost on September 11, 2001. It’s hard to believe it has been 12 years since that tragic day in our country’s history. We should all take some time out of our daily lives to reflect on the sacrifices made by our first responders and every day citizens. Instead of focusing on the inhumanity and the horror of the day, let us focus on the many stories of hope and humanity that we witnessed as people came together to help others in any way possible. It’s the examples of humanity that keep us strong and we hope that by remembering incidences of the past, we can grow and change to create a better future. My thoughts are with everyone touched by this tragedy as we remember and hope for a more peaceful tomorrow.

Tina tries…

In our new series on shaping up, Healthy Food Guide’s art director Tina Betts starts on her journey towards a proper exercise plan to supplement her day-to-day walking…

By Tina Betts

How did it happen? I’m 43, and things are starting to sag. I haven’t changed my eating and drinking habits, so age is starting to catch up with me. I inherited my ‘walk everywhere’ gene from my Dad. I don’t have a car, so think nothing of whizzing down to Sainsbury’s with my trolley bag. But despite frequent trolley dashes, there’s a big but – my big butt, in fact! I’m lucky that I’ve always been a healthy weight, but it’s starting to creep up, the muffin top is rising steadily and there’s no way I’m going to fit into my dream 40th birthday dress again, at least not the way things are going.

My fear of exercise means I’ve never liked the gym or classes. It’s the classic ‘I was always the last to be picked’ for the team at school. It’s made me a tad anxious in sporting environments.

But that all changed a few weeks ago. As part of a work feature, I tried a yoga class for the first time with my work colleagues. And I could see the attraction of exercising as a group. In fact, I rather enjoyed it. And so, Tina tries… was born. It’s a week by week log of my mission to get fit - and get me back into that party dress.

My first stop was the Health Check at Nuffield Health at their flagship centre at London’s Cannon Street (it’s really more hip hotel than soulless gym). All members go through checks before starting their fitness plan.

Nuffield Health’s senior wellbeing adviser Katarina Berceliova took me through my body MOT, checking my BMI, resting heart rate, blood glucose levels (all healthy) and quizzed me about my sleep patterns (fine) and lifestyle habits (cholesterol and alcohol quotas not so fine). Generally, at 5ft 5in and 9 stone 3lb, my BMI at 21.2 is very good and my blood pressure spot on. But I know I need to do something about my fitness levels – I’ve reached the age where you can’t take anything for granted. 

I came away feeling optimistic with three main Wellbeing Action points: to monitor my blood cholesterol, up my water consumption and increase my activity and fitness levels.

Come back next week to read about my first ever session with my personal trainer. I have to admit, just those words make me nervous…

A Reflection on the Meaning of Labor Day

As our country celebrated the hard work of the American people during the Labor Day holiday on Monday, many of us enjoyed the three-day weekend which has also come to symbolize the unofficial end of summer. But, Labor Day is also an opportunity for us to reflect on what we have accomplished and will continue to achieve, and to thank the people that make our health system and our country strong because they go to work every day and put their best efforts toward serving a need. At GBMC, we are fortunate to be able to meet the important need of helping others by delivering to everyone the care that we want for our own loved ones.

And as I reflected on the true meaning of the Labor Day holiday, I realized how thankful I was for the efforts of the entire GBMC staff - from the doctors, nurses, and technicians to our food services workers, environmental service staff and parking attendants.  Every individual at GBMC is an important part of the collective team and I see the great efforts our team puts forth to provide the very best care to patients every day.

I also reflected on what it means to have a job, especially with the way our economy has been over the past six years or so. Now that I have four children who have graduated from college, I see how hard it is to find a good job that you love. I am grateful for my job, which I competed for and was delighted to get. GBMC is a great organization with a great vision and a great future. I know what it means to love what you do and I am honored to work with such dedicated individuals.

I have been talking a lot about standard work, processes and systems, but as we celebrate Labor Day and look ahead I need to remind myself that what makes a healthcare system truly outstanding is not the technology or the facilities, but the people.

Is Refined Carbohydrate Addictive?

[Note: in previous versions, I mixed up "LGI" and "HGI" terms in a couple of spots.  These are now corrected.  Thanks to readers for pointing them out.]

Recently, a new study was published that triggered an avalanche of media reports suggesting that refined carbohydrate may be addictive:

Refined Carbs May Trigger Food Addiction
Refined Carbs May Trigger Food Addictions
Can You be Addicted to Carbs?
etc.

This makes for attention-grabbing headlines, but in fact the study had virtually nothing to do with food addiction.  The study made no attempt to measure addictive behavior related to refined carbohydrate or any other food, nor did it aim to do so.

So what did the study actually find, why is it being extrapolated to food addiction, and is this a reasonable extrapolation?  Answering these questions dredges up a number of interesting scientific points, some of which undermine popular notions of what determines eating behavior.

Read more »

Gluten-free cooking made easier

By Norma McGough

If you’ve been diagnosed with coeliac disease, adapting to a gluten-free diet can seem daunting at first, but with a few ingredient switches, you can still enjoy your favourite recipes. Try these…

* There’s a lot of gluten-free pasta available now, so you can still enjoy spaghetti bolognese and lasagne if you also use cornflour for your cheese sauce and buy a gluten-free bolognese sauce.

* Try alternative cereals such as quinoa and teff. Quinoa is nutritious (it contains protein, fibre, iron and folate) and ideal as a basis for salads – and teff adds a delicious nutty flavour to biscuits. 

* If you’re ever stuck for ideas in the kitchen, branch out into different cuisines: Mexican meals include a lot of corn and rice, which are both naturally gluten-free cereals, so you could maybe go for corn tacos with chilli, guacamole and salsa; Indian and Thai curry sauces, also served with rice, are usually made with combinations of onions, garlic, ginger and fresh chilli with spices, maybe with coconut milk or ground nuts, so are often gluten free, too. 

* A bit of experimentation, plus speciality flours and baking aids (including gluten-free baking powder, bicarbonate of soda and xanthan gum) can make gluten-free baking a success. It’s the gluten that gives your bread, cakes and pastry the right texture and provides structure, which is why gluten-free bread can be dry and solid, and cakes and pastry a lot more crumbly. But there are many speciality flours available in supermarkets that work perfectly well in your favourite recipes.

Want more help or information? Visit Coeliac UK’s website. Whether you’ve been diagnosed, are seeking a diagnosis or need information to support friends and family with coeliac disease and dermatitis herpetiformis, Coeliac UK is there to help. It provides a range of member services to help you understand more about coeliac disease and the gluten-free diet, including access to its Recipe Database, electronic Food and Drink Directory and Venue Guide.