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As Black History Month draws to a close I would like to introduce you to one of my surgical heroes, LaSalle D. Leffall, Jr., MD. As surgical resident at Walter Reed in the 1970’s I had weekly grand rounds with visiting professors. The format was the presentation of interesting surgical cases followed by a discussion by the professor. It was at time of great education and great stress for us as residents as the professor would ask questions of medical students and residents on a certain disease process or surgical procedure that had been presented. We had several visiting professors who were chairmen of surgical programs from Washington, D.C., and Baltimore. The most outstanding was Dr. LaSalle Leffall from Howard University.
Following the case presentation Dr. Leffall would walk up to the podium, grasp it in both hands and ask “where are the 3rd year doctors?” (referring to the 3rd year medical students on their surgery rotation) Next he asked where are the 4th year doctors, and so on through the residency ranks. He would then dissect through the case and give us the important lessons by asking questions all around the room. I remember once when I was the chief resident that one of Dr. Leffall's quesions made it all the way around the room up to me. Luckily I knew the right answer and didn't disappoint Dr. Leffall.
One of his favorite sayings was “There are only two reasons that patients come to the doctor, pain and bleeding. Pain because it hurts them and bleeding because it scares them.” He would admonish us that “there are two diagnoses that you will never make.” Then he’d stop and look out over the conference room and restate “never make”. Then he would tell us in his precise diction, “The two diagnoses you will never make are the disease that you don’t know about, and the disease you don’t think about.”
Dr. Leffall also taught us how to say Johns Hopkins. He would say “the founder’s first name was Johns, not John. You wouldn’t say Pitt-burgh, it’s Pittsburgh”.
LaSalle Leffall was born in Tallahassee, Florida, on May 22, 1930, to LaSalle D. Leffall, Sr., who hailed from east Texas, and Martha Jordan Leffall, from northern Alabama. He grew up in the small town of Quincy, Florida. Both his parents were educators in the public school system of Florida. Dr. Leffall graduated as the valedictorian of his high school class, graduated summa cum laude from Florida A&M University, and was first in his class at Howard Medical School. He did his residency at Freedmen’s Hospital, now known as Howard University Hospital and completed a fellowship in surgical oncology at Memorial Sloan-Kettering Cancer Center.
Dr. Leffall performed his military service as Chief of General Surgery in the U.S. Army Hospital in Munich, Germany in 1960 and 1961. He then joined the faculty of Howard University College of Medicine. He was selected to be Chairman of the Department of Surgery in 1970. In 1992 he was named the Charles R. Drew Professor, occupying the first endowed Chair in the history of Howard's Department of Surgery.
During the course of his illustrative career, Dr. Leffall was awarded honorary degrees from nine universities and was the president of nine medical organizations. He was the first African-American to be elected President of the Society of Surgical Oncology, President of the American Cancer Society, both in 1978 and President of the American College of Surgeons in 1995.
He used his national positions to emphasize the problems of cancer in minorities. He held the first conference on cancer among black Americans in February of 1979. "I have tried to point out the problems of lack of access to care and the increased death rate”. In 1980, President Carter appointed him to a six-year term as a member of the National Cancer Advisory Board.
As much as he dedicated himself to the broader aspects of prevention, nutrition, and education as head of the American Cancer Society, Dr. Leffall continued to remind others that "the one thing we must never forget is that the object of our attention and affection is the cancer patient."
In 1987 M.D. Anderson Hospital established The Biennial LaSalle D. Leffall, Jr. Award. This award recognizes Dr. Leffall’s contributions to cancer prevention, treatment, and education in minority and economically disadvantaged communities. In 1989, the citizens of Quincy, Florida named a street, a path, and the surgical wing in the Gadsden Memorial Hospital in his honor. The LaSalle D. Leffall, Jr. Surgical Society was formed in March 1995; the Leffall Chair in Surgery at Howard University was established in February 1996. Dr. Leffall and his family established the Martha J. and LaSalle D. Leffall, Sr. Endowed Scholarship Fund and Endowed Professorship in Science at Florida A & M University in 1997 in honor of his mother and father. His memoirs entitled “Grace Notes—A Cancer Surgeon’s Odyssey,” was published by the Howard University Press in 2004.
In addition to his professorship at Howard University, was the chairman of the Susan G. Komen Breast Cancer Foundation; the President’s Cancer Panel; the Board of Directors of the National Dialogue on Cancer. Dr. Leffall and his wife Ruth have one son, LaSalle, III an honors graduate of Harvard College and the Harvard Law and Business Schools. He is the Executive Vice President and Chief Operating Officer of the National Housing Partnership Foundation in Washington, D.C.. Dr. Leffall is an avid tennis player and supporter of jazz music. Because of his long-standing and close relationship with Julian “Cannonball” Adderley, Dr. Leffall represents an important link with one of the most imposing figures in modern jazz.
Meet LaSalle D. Leffall, Jr., MD, FACS in this video clip from the Washington Post.
http://www.washingtonpost.com/wp-dyn/content/video/2006/08/29/VI2006082900628.html
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In thinking ways in which to provide the best care possible to our patients at GBMC, I came across one recently that looks promising.
If there was a new product on the market that could reduce the rate of major complications in patients undergoing surgical operations by 36% and mortality rates by 47% would it be worth the investment? With 30 OR’s and 32,000 surgical procedures per year and a NSQIP mortality rate of 0.68% and an HSMR rate of 0.65%, perhaps we don’t need this new product. With healthcare reform still somewhat in the works, this new product might not be cost effective. Besides we have other priorities, such as showing that our EMR meets all the meaningful use criteria set forth by the federal government, making sure we can provide access to the newly insured and keeping a strong bottom line. But, just what is this new product? Perhaps we should make this investment, but what will it cost?
It turns out, it costs almost nothing. It’s the World Health Organization’s Surgical Safety Checklist. Published just over a year ago in the New England Journal of Medicine why hasn’t the surgical world embraced a tool that has been shown in a world-wide study to reduce morbidity and mortality? The answer is probably, us, the surgeons. It’s just not our culture. After spending a recent Sunday afternoon reading Atul Gawande’s new book, The Checklist Manifesto, I was 
struck, not only by his usual engaging review of the origin and use of checklists in other industries, but by his personal journey from skeptic to advocate. From the B-17 flying fortress that was felt to be too complex to fly, to the construction of modern skyscrapers, to the operations of a restaurant’s kitchen, Gawande shows that complex tasks can be completed with ease when managed by the use of checklists. Checklists help us not to forget the important things. They need to be simple and embraced as important tools to perform complex activities, like landing a jetliner or performing surgery.
For the past six months I have been using the WHO Surgical Safety Checklist in my OR’s, just to try it out and see how it feels. It’s different from our usual “time-outs” in a couple of ways. First it is divided into three parts: before induction of anesthesia, before skin incision, and before the patient leaves the operating room. It is a structured communication tool. It fosters teamwork as each member of the team, stops and introduces himself or herself by name and states their role. We use first names, like the airlines. It allows for communication between the surgery and the anesthesiology teams that is all too frequently absent. Besides checking for the proper patient identification, verification of the site of the procedure and consent, we confirm the proper functioning of equipment, the risk of excessive bleeding, review the critical steps, anesthesia concerns, and confirm the administration of prophylactic antibiotics as well as thromboembolism prevention. This 19-step checklist process takes less than sixty seconds to complete.
In order to ensure lasting adoption of this tool we are working to develop a process that will emphasize the results that can be gained with its use and align the most resistant members of our surgical teams so that they can become checklist champions. We will also look for other areas in the hospital, both in patient care settings and in operations where checklists will allow us to, as Gawande says: “get the stupid stuff right”.
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GBMC is in to its sixth day of Yellow Alert (essential staff remains on site) facing back to back super storms. No sooner had the snow from the Super Bowl weekend storm been cleared, forecasters called for a second severe snowstorm to drop 1-2 feet with blizzard potential. The medical center has been fully operational throughout with full surgical schedules Monday and Tuesday. In anticipation of the second storm beginning last night over 200 staff stayed at the hospital. Many came packed for three or four days. Putting staff up in empty patient rooms was not an option since the house was full. As the supply of cots ran low the Maryland Emergency Management System was put to use.
Dan Tesch, GBMC's Emergency Management Director, uses the hospital's Ham radio system to talk with other members of the Baltimore County Radio Amateur Civil Emergency Service (RACES) group during the beginning of the second snowstorm. In short order 100 extra cots came from the Baltimore County Emergency Management Task Force supply at Towson University. The cots were quickly delivered to designated sleeping areas for staff.
Mike Forthman, VP of Facilities unloads the cots as Dan Tesch readies the cots for use.
Jody Porter, RN - Senior Vice President Patient Care Services and Chief Nursing Officer, and Jill Wheeler, RN - Nursing Administration, plan staff accommodations in GBMC's Hospital Command Center.
Our Civiletti Conference Center has been converted into a staff dorm, filled with cots. Staff that are staying for several nights are instructed to store their linen for the next night as the night shift comes in to get some rest.
Throughout, the GBMC Command Center remains on high alert. At 5 a.m. this morning George Bayless, VP of Finance, took over for overnight incident commander, Eric Melchior. Steve Cohen coordinates volunteer drivers and prioritizes staff pick-ups. Four staff handle phone calls as Dan Tesch, Michelle Tauson and Donita Dietz of Emergency Management, advise the Incident 
Commander.
The Command Center includes an information board with the roles of all important personnel outlined. The individuals fulfilling each role are place on the board with their contact and cell phone numbers. To the left of the board are pre-arranged binders that outline the duties of each position with an action plan set out for the first 96 hours of any emergency.
Incident Commander George Bayless surveys the storm from the Emergency Department entrance. Area weather reports are reporting blizzard like conditions with wind gusts between 40-60 mph. Six volunteer drivers are still out this morning and we will assess the conditions as they return. As conditions worsen we may have to stop transporting staff altogether. Physicians are rounding on our telemetry patients to see if any patients can move to med/surg beds to alleviate a back up in the ED.
Surgical cases from our three OR’s were consolidated in the general operating room. All of the first case patients were here and on time. Only four patients called to cancel. We will do 26 cases today and have 68 scheduled for tomorrow. Our pharmacy, laboratory and radiology departments have remained fully staffed. There is a great spirit of teamwork throughout the organization.
There will be plenty of lessons learned with these storms. Our Command Center keeps a running list of items to be discussed in an after-action session, so that we can be better prepared in the future.
Plow and the “Gator” in the front parking area. Same area twenty minutes later.
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The GBMC Command Center is a buzz with activity dealing with a huge snowstorm that dropped between 2-3 feet on our hilltop campus. Our emergency operations began Friday evening just as the first flakes of snow began. The medical center immediately went on Code Yellow with all staff remaining in place. As the snow accumulated during the night two trees went down temporarily blocking our main entrance. We had a full complement of patients with fairly full ICU’s and telemetry units.
Eric Melchior our EVP and CFO ably took command. Staffing, supplies, snow removal, transporting staff from home, finding places for staff to sleep, feeding the staff, coordinating with the county and state emergency teams were all items of priority. Jody Porter, Senior Vice-President for Patient Care Services and Chief Nursing Officer and her team spent the first 48 hours ensuring that patients and staff were well treated.
Two and a half feet of snow is difficult to remove, but when it’s on a confined hilly campus the problem is compounded. Where do you put all the snow? Mike Forthman, VP for Facilities and his crew were in action all through the night, plowing, salting, and clearing downed trees. By Sunday morning the campus was fully cleared. Special thanks to all of Mike’s staff; Bud Butler, who kept the roads clear, Steve Cohen who coordinated 4-wheel drive volunteers who transported over 130 staff, and Jim Duerr who kept the supplies coming into the center.
Throughout the storm, the medical center continued to operate. An ambulance taking Torina McQueen of Owings Mills who had gone into labor and her fiancé, Saeed Hill, got stuck on the way to GBMC. The couple eventually made it to the hospital and safely delivered their first child - a boy named Tyson.
So many individuals worked tirelessly throughout the weekend. , COO Keith Poisson and Finance VP George Bayless, helped Eric Melchior throughout the weekend. Sunday morning Mark Thomas, VP of Human Resources took over command with Tressa Springmann, VP and CIO as liaison officer. In the Command Center Dan Tesch, GBMC Safety Officer, along with Michelle Tauson and Donita Dietz of Emergency Management and Safety were the guiding forces.
GBMC’s heroes are all of our staff, especially Cate O’Connor-Devlin (proprietress of the O’Connor-Devlin Bed and Breakfast), Kim Bushnell, Kathy Tracey, Sue Bowen, Eileen Skaarer, Michelle Patchett, Kara Lundberg, Kathy Lowerer, Sandra Scherer, Keith Jackson and C.J. Marbley who brought in DVD’s to show in the back of the cafeteria for the off duty staff. Dietary staff led by Keith Sappington, Matt Miller and Jennifer Christman fed our patients and staff. Their staff has been working non-stop for three days. Heath Jenkins’ Environmental Services with Mary Moise, and Transport Director, Judie Kusiolek with Chris Broadway have kept the hospital clean and functioning. Duke Bowen and his Patient Access staff kept patient registration up and running. Other heroes include: Joan Powers Smith from ED, Valerie Tighe from PEDs, Gretchen Bell, Jen Norris, and Janis Radcliffe from MNH, Genia Friia from M/S, Mark Kern and Jerry Mlinac from Pharmacy. Marketing’s Michael Schwartzberg and Kim Davenport have been posting messages on gbmc.org along with Twitter and Facebook. The “Gator Cam” on GBMC’s Facebook is worth a look.
On Saturday evening it was decided to pay staff that were required to say an hourly stipend while they were off shift and sleeping. Throughout this ordeal our staff has stayed positive and exhibited great team cooperation. One of our staff wrote:
“I just wanted to give my gratitude to how you handled the code yellow this weekend. I was stuck here at the hospital during the storm. I know I personally appreciate the fact that our meals were taken care of and we had a comfortable place to sleep on our unit. And finally, the fact that we are getting compensated for staying longer than our scheduled hours is great. I don't know if it was a legal issue or not, but it was the right thing to do. Everyone that I have talked to seems happy and appreciated.”
We are very proud of our staff for their efforts. More snow expected in two days!
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"The best time to plant a tree is twenty years ago. The second best time is now." This African proverb comes to mind as GBMC embarks on an organizational performance improvement plan. We have chosen the Toyota Production System – Lean. We are doing this at the second best time in our organization’s history, now.
Under the able guidance of Tressa Springmann, Vice-President & Chief Information Officer, GBMC has begun laying the foundation by first educating the executive staff and getting their commitment. We trained fourteen of our staff to become Performance Improvement (PI) Masters in order to facilitate the process. This week we took 150 of our managers and directors to a two-day off-site training program on Lean. We wanted to give them a working knowledge of Lean tools so that they can work with our front-line employees begin to identify improvement areas, to drive out waste and to be ready to support kaizen events when they occur.
The Toyota guiding principles, particularly fostering a culture that enhances and respects employees fit nicely with our greater behaviors of respect, excellence, accountability, teamwork, ethical behavior and results. Lean focuses on our employees; the ones closest to the work as those who can provide the best solutions for improvement. Our job is to give them the tools to make their work more meaningful and efficient. Studies of bedside nurses show that they spend less than half of their time in direct patient care. All too often they are caught up in spending time, clarifying orders, documenting items looking for things or just waiting. Our staff deserve a well-ordered workplace, that is clean and uncluttered, where everything that is needed easily accessible, to allow them to do the things that really matter to them and that is their passion for choosing to work in health care.
Chinese philosopher Lao-tsu said “the journey of a thousand miles starts with the first step. We have taken our first step.
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Welcome to HospitalRounds.
Today I became the interim President and CEO of the Greater Baltimore Medical Center (GBMC). My appointment was totally unexpected. After five years as Chief of Staff, I was planning to begin work as the VP of Clinical Effectiveness and Patient Safety. But things change.
When I was Chief of Staff I have communicated with GBMC’s 1200 physicians by a biweekly newsletter. Now as CEO I thought I’d emulate Paul Levy, the CEO of the Beth Israel Deaconess Medical Center, whose blog Running a Hospital was touted as an example of communication and transparency by the IHI Patient Executive Training course I attended last December.
My purpose in this blog is to communicate with the GBMC community – the staff, nurses, physicians and patients. For those outside this great state of Maryland, GBMC is an independent, community teaching hospital in Towson, Maryland just north of Baltimore City. It has 308 licensed beds, 60,000 annual ED visits, 32 operating rooms in which we perform 32,000 surgical procedures per year and deliver about 4,800 babies. It was formed in 1965 by the merger of the Hospital for the Women of Maryland, Baltimore City and the Presbyterian Eye Ear Nose and Throat Charity Hospital. We have residency training programs in Internal Medicine, Ophthalmology, Otolaryngology - Head and Neck Surgery and Obstetrics and Gynecology. The last three are part of Johns Hopkins Medicine. Also part of GBMC Healthcare is Gilchrist Hospice Care which serves surrounding counties with nearly 500 enrolled patients with a 34 bed on-campus facility and Greater Baltimore Medical Associates, a nearly 200 member multispecialty physician group.
This blog has a few rules to be followed. As with all hospital CEO’s I will not comment on any individual or legally confidential patient or employee matters though I’d be happy to refer individuals to the proper hospital personnel who can assist them. I am happy to answer any thoughtful questions about medicine or hospitals and look forward to sharing with the community the successes of GBMC.
As Black History Month draws to a close I would like to introduce you to one of my surgical heroes, LaSalle D. Leffall, Jr., MD. As surgical resident at Walter Reed in the 1970’s I had weekly grand rounds with visiting professors. The format was the presentation of interesting surgical cases followed by a discussion by the professor. It was at time of great education and great stress for us as residents as the professor would ask questions of medical students and residents on a certain disease process or surgical procedure that had been presented. We had several visiting professors who were chairmen of surgical programs from Washington, D.C., and Baltimore. The most outstanding was Dr. LaSalle Leffall from Howard University.
During the course of his illustrative career, Dr. Leffall was awarded honorary degrees from nine universities and was the president of nine medical organizations. He was the first African-American to be elected President of the Society of Surgical Oncology, President of the American Cancer Society, both in 1978 and President of the American College of Surgeons in 1995.
In 1987 M.D. Anderson Hospital established The Biennial LaSalle D. Leffall, Jr. Award. This award recognizes Dr. Leffall’s contributions to cancer prevention, treatment, and education in minority and economically disadvantaged communities. In 1989, the citizens of Quincy, Florida named a street, a path, and the surgical wing in the Gadsden Memorial Hospital in his honor. The LaSalle D. Leffall, Jr. Surgical Society was formed in March 1995; the Leffall Chair in Surgery at Howard University was established in February 1996. Dr. Leffall and his family established the Martha J. and LaSalle D. Leffall, Sr. Endowed Scholarship Fund and Endowed Professorship in Science at Florida A & M University in 1997 in honor of his mother and father. His memoirs entitled “Grace Notes—A Cancer Surgeon’s Odyssey,” was published by the Howard University Press in 2004.
