Welcome to eFocus. Our goal is to provide you with timely, informative and useful short summaries and links about UM UCH related news, issues, or events. Feel free to contact us if you have news to share, story ideas or any other feedback. As always, your comments are welcome.

eFocus, December 2022 topics include:


It's the start of the holiday season and we have great reason for growing optimism. We have seen some inspirational success with our Back to Basics initiative,  healthcare-associated infections are tracking on target with a composite score of 5 total infections, and UM UCH is also leading UMMS in clinical pathway adoption for CHF, COPD and sepsis. We will have challenges ahead with the respiratory viral illness season that includes flu, COVID and RSV and capacity. The only solution is to run as efficiently as possible to promote early and safe discharges for our patients. This is why the SCORE survey and our High Reliability journey is so important. We will begin the work of developing action plans based on our survey results. Providing safe and high quality care for our patients is our north star and becoming an HRO is how we will get there. Happy holidays, everyone, and we will see you in 2023!

Fermin Barrueto, Jr., M.D., M.B.A.
Senior Vice President/CMO
Medical Staff Affairs


A Patient's Letter of Thanks

My name is Steele Glenn. I volunteer as a Spiritual Companion at the University of Maryland Upper Chesapeake Medical Center. However, that is not why I am writing you. Please permit me the opportunity to express what an outstanding hospital you have, and to say thank you.

Last Friday, October 28, I came to your emergency room and was ultimately diagnosed with a minor stroke. By the grace of God there were no residual effects. As one person said, “Someone was watching over you.”

Many people had come that day for treatment and the staff was obviously being pushed to the limit, yet they were efficient, friendly, and comforting. My wife is a retired critical care Nurse Manager for the ICU, Step Down Unit, and Burn Center at the Johns Hopkins Bayview Center. She asked me to include her very favorable impressions of the Emergency Department.

I spent two nights in the Critical Decision Unit, and these people were amazing. I could mention the names of some nurses, but it would be unfair as they all performed at an exceptional level. I must mention Nurse Practitioner Tonya Appleby who was comforting, timely, and epitomized in my humble opinion the exceptional qualities of a care provider.  A lady named Anna served all my meals cheerfully and with a sense of humor. She tolerated my attempts at Naval Academy German that I studied over 49 years ago.

Allen Siegel spent a lot of time with me on a Saturday while I was in the CDU. Allen is always a source of wisdom and inspiration in my volunteer work. I greatly appreciated his being there.

Finally, please recognize a lady in the MRI unit who got me through a traumatic experience that Saturday. The Technologist mentioned in the report was Christine M. Greene, and Supporting Staff was Jennifer Ireland. In his book The Wounded Healer, Henri Nouwen talks about the importance of telling a patient, “I will be waiting for you.”  I believe it was Christine who kept her hand on my shoulder and said, (I am right here, I will be here the whole time). I have 1000 hours in the F-4 Phantom as a Marine fighter aviator and spent five years traveling remote spots in South America. I was never afraid, even though there were times I should not have come home.  Yet the thought of an MRI was petrifying. Whoever it was standing there helped get me through it. 

In conclusion, I love volunteering at UCMC and, to me, it is a privilege. Being on the other side of a patient experience will enhance my conversations as a Spiritual Companion. May God’s peace be with you,

Steele Glenn


Patient Experience UpdatesPlease review the latest physician communication graph below as well as the AOP overall rating score for PX.



Mortality Reviews - Learning from Every DeathAs a part of our effort to update the mortality review process, we are currently developing a 3-4-minute electronic survey to obtain insight from the frontline team for inpatient deaths. It will be sent out to relevant TMs electronically soon after a death. The survey will ask about contributing factors relating to unexpected deaths. No chart review is required. 

Our theme is learning from every death. The focus is on systemwide issues; it’s not to place blame but to find opportunities to improve quality of care. In order for this to be a beneficial tool, we ask for your cooperation and participation.


UMMS Sepsis ProgramUMMS continues to take action within its member hospitals to standardize the System’s response to sepsis, which a 2020 study reaffirms as one of the leading causes of mortality in hospitals worldwide. UM UCH is working with the rest of UMMS hospitals within the Sepsis Program to develop a consistent practice across the System to decrease morbidity and mortality secondary to sepsis. Current focus areas are: 1-Timely Antibiotic Administration, 2-Infection Management, 3-Diagnostics. 

Please see our FY23 UM UCH compliance data on timely antibiotic administration below. 

Also, soon we will be distributing to all nursing units at UCMC and HMH a flyer that was developed by your colleagues in an attempt to simplify most of the elements of sepsis bundles. Learn more about the UMMS Sepsis program


Telehealth Utilization: Did you know that UM UCH averages 150 telehealth consults each month? And, this last month, most of them were focused on an infectious disease issue or concern? You can nowreview our latest telehealth numbers and updates, as well as learn of UM UCH's future plans.

UMMS TeleportUMMS Teleport is the new telehealth video conferencing technology for UMMS. Teleport provides a simple, app-free solution for patients to connect with their healthcare team in both the inpatient and ambulatory settings. For more information on the inpatient Teleport platform please watch this 2 minute video, or check out the UMMS Teleport site on SharePoint.

Pediatric Skills Sessions: Dr. Megan Cobb and pediatric specialists recently held two pediatric skills sessions at UCMC for clinical team members. During the skill sessions, they demonstrated pediatric resuscitation, inserting airways, pediatric code cart, IV access, OG/NG tube placement and catheterization. Their goal was to get staff more comfortable in all areas (OR, anesthesia, hospitalists, ED staff, etc.) in caring for our pediatric patients. 


Just Culture Training“Just Culture refers to a values-supportive system of shared accountability where organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner.  Employees, in turn, are accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.” -Outcome Engenuity

If requested, be sure to complete your UMMS Just Culture training and save this algorithm and toolkit for your records and teams!

Celebrating Our Providers for the HolidaysThank you for celebrating! At this time of year, it is a privilege to reflect on the support we have given each other and our patients. The UM UCH Medical Staff Holiday Party was a return to celebrating all that has been achieved together. We hope you enjoyed this time to connect with friends and colleagues. 

Send photos of your team celebrating to Lindsay.mcmurdie@umm.edu to be featured on the Medical Staff Lounge screen.



Mason Nance Safety Award RecipientWendy Hutson, our latest Mason Nance Safety Award recipient, is a Pharmacist with UM UCH and exhibits a commitment to providing safe, quality care for our patients. Recently, she exhibited some key safety culture elements including preoccupation with failure, personal accountability, and effective communication. Upon learning of an inpatient’s need for chemotherapy for which there was not an appropriate order, Wendy worked with the nurse and ultimately the provider to troubleshoot the problem and provide instruction for entering the order. Once the order was entered, she continued her diligence and identified that the ordered chemotherapy agents dosage was inconsistent with the original treatment plan. Wendy proactively communicated with the provider to confirm the proper dosage, which indeed needed to be reduced. Wendy then came in before her scheduled time to prepare the chemotherapy for the patient. Her actions ensured that the appropriate safety checks were leveraged prior to the patient receiving high risk/high alert medications. Wendy is exemplary in her knowledge and implementation of current polices and safe practices. 

Do you know someone who creates a culture of safety by improving teamwork and communication; inspires positive change to processes that directly affect patient care; speaks up when something is not right and has had a direct impact on the safety of a patient; and practices our must-have behaviors and holds others accountable to these behaviors as well? Then nominate him/her for this meaningful award. Learn more about the award as well as its namesake, Mason Nance.


Journey to Zero Harm: Please review below our current HAI composite score graph and falls with fracture numbers.


What Changed After the Second Back to Basics Retreat?: Leaders: Please share this message with your frontline teams and B2B retreat attendees.

Thank you to you and your teams for participating in our second B2B retreat on August 2, 2022. As promised, here are a few examples of what improved as a result:

  1. Unit based quality scorecards are now being updated by the PI team monthly. Frontline teams are proudly showcasing their work and B2B core group is periodically rounding on the units to provide support and remove barriers for the team.
  2. Steady improvement in unit huddles and shift change handoff.
  3. HRO culture. Our nursing and wound care teams reinforced the basic practices for HAPI prevention during the month of November. We have noted a steady improvement in our patient safety indicators (PSIs) over the past 2-3 months.
  4. Culture of gratitude: Number of UrMUCH recognitions given have gone up from 600s to the 1200 range. 

Our work is not done. That’s why we will gather for our third quarterly retreat on December 6 at 12:30 pm (Brass Mill). We look forward to your partnership.