Part-2: A career in patient safety research
Dr. Holl, M.D., Mary Harris Thompson Professor, Professor of Pediatric and Preventive Medicine. Institute for Public Health and Medicine (IPHAM) –Director, Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine .
We recently sat with Dr. Holl for an in-depth and extensive discussion about her career trajectory, her research in patient safety and future directions. This is part 2 of 2. For part 1 please click here.
There is a lot that needs to be studied about the US healthcare system, what treatments work, for which patients, and how to really change health behaviors. We need to understand the trade-offs between cost and quality of healthcare. Current measure of quality are not very satisfying. They don’t really tell us when we are delivering the best healthcare. There is a tremendous amount of work to really understand what is high quality care and to truly assess meaningful outcomes. Only then can we understand the true “value” of care. This field, while still in its infancy, is highly impactful as the research has the potential to immediately affect patient outcomes. – Dr. Holl
How did you begin your current work in patient safety research?
Dr. J.H: During the Bush administration, there were no major initiatives in health policy. Around this time, Dr. Peter Budetti, director of the Institute for Health Services and Policy Research where I was working, had received funding from the Agency for Healthcare Research and Quality, and a young applicant (Donna Woods) to the fellowship came to me. Donna was working on her PhD in health policy with a focus on patient safety. I acknowledged to her that I had little or no experience in the area. I had never delved into the topic. She said that it was going to become a very important topic, that there are a lot of medical errors occurring in the US healthcare system. Nobody was looking at medical errors in children. She thought this was going to become a very important area of research. So, I agreed to mentor her and we began working together. She completed her PhD, working in collaboration with some very well-known patient safety researchers, including Dr. Troy Brennan, who had already written very important papers in the field.
We published an interesting paper in which we estimated the actual number of medical errors when a child is hospitalized in the United States –that is the average number of medical errors per child and it was substantial. The paper was published in Pediatrics and actually, we have been continuing this line of research since that day. It probably now is my most permanent area of research: patient safety and healthcare quality. I have taken the methods and I developed them during the early years in the field of pediatrics and now, I have expanded them and applied them in emergency medicine transplant surgery, labor and delivery, family planning, stroke, a variety of other settings and conditions. The point, which has become abundantly clear to me, is that medical errors occur in all of these settings and in all of these conditions and that the mechanisms are often very similar and so you can use very similar methods to reveal, identify, and also to fix them.
Can you share with us a bit of the back story on how you became director of Center for Healthcare Studies?
Dr. J.H: So Dr. Peter Budetti was the founding director of the Institute for Health Services and Policy Research at Northwestern. Originally, the institute was actually based on the north campus and it was established by Kellogg, called J.L Kellogg Graduate School of Management at the time and directed by Edward F. X. Hughes, MD. In 1995, Dr. Budetti founded the Institute for Health Services and Policy Research, as a collaboration between the Feinberg School of Medicine, Kellogg, and the Law School.
By the time I arrived at Northwestern in 1998, they had just opened an office downtown on the medical school campus and so I came downtown. It really was Dr. Budetti’s vision to try and expand collaborations with faculty in medical school departments. So, it was, as part of this institute, that I did my work on welfare reform and began all this work on patient safety. Following Dr. Budetti’s tenure, Dr. Kevin Weiss became the director and then, when the Dr. Weiss left to become the President and CEO of American Board of Medical Specialties, I was recommended to become interim director. Subsequently, after a national search, I was selected to be director.
As Director what has been your agenda and vision for the center for pediatric studies?
Dr. J.H: Since becoming director, we’ve expanded both in the number of faculty and the scope of our research. I view the Center for Healthcare Studies as being pivotal for interdisciplinary collaborations focused on health services and outcomes research, as well as, understanding the impact of the healthcare delivery system and its outcomes. Many projects have focused on patient safety, but also in the context of transplant surgery. As an example of recently collaborations, Dr. Michael Abecassis, who is the division head of solid organ transplant in the Department of Surgery, reached out to me to understand more about health services research and transplant surgery. It became abundantly clear that patient safety and quality of care was a huge issue for transplantation. For a living donation, live donors/perfectly healthy individuals undergo major surgery to donate an organ or a piece of an organ. From a public relations perspective, you don’t want any errors because these people are undergoing a surgery for purely altruistic reasons.
As part of our collaboration, we recruited two new faculty members: Dr. Daniella Ladner, MD MPH and Dr. Elisa Gordon, PhD MPH who have been here since 2008. The collaboration has been around health services and patient safety in the transplant arena. Initially, we took advantage of funding that Dr. Abecassis had secured for a project funded by the National Institute of Digestive and Kidney Disease (NIDDK), focusing on adult living liver donor transplantation.
The RO1 funded research has been, I think, extremely impactful. It identified two major areas of high risk for medical error that, prior to the research, not a single transplant surgeon or anyone involved in transplant surgery in the United States thought were potentially areas of harm or risk. One is donor pain management. It turned out that donors were experiencing a fair number of untoward events related to post-operative pain management. The other was related to the positioning particularly of patients on the operating room table.
These are very lengthy procedures and patients are obviously asleep and sedated and their arms are outstretched on the table. It seems that they can sometimes experience a peripheral nerve injury from being in this position. What was interesting is the clinicians involved in these surgeries sort of accepted that these were just a complication of surgery. They didn’t really think of them as a medical error. This is not uncommon. Many times, clinicians just assume that the outcome cannot be avoided, it’s just a consequence of needing healthcare.
What are some on the innovations that have come out of the Center?
Well, I think we have really excelled in the patient safety arena in our investigation of potential failures in the processes of care and in exploring the underlying causes of error. We started with a single methodology and we’ve expanded our methodologies so that we really gather data in a 360-degree evaluation.
We think that this approach helps identify risks or barriers to high-quality care that no one else has ever thought of or described. For example, one novel method that we developed is called ‘In-situ simulation’.
We create a high-fidelity, clinical scenario to simulate care that way that it occurs in the real world and we ask clinicians to provide care, just the way they would for any patient. The reason for doing simulations is so that if an error occurs, it’s a very safe environment. The patients are typically mannequins and clinicians provide the care as they would for a real patient. Even if something doesn’t go quite right, no one is hurt. We’re able to video tape it and therefore go back and together, with the clinicians, look at it to study how care was delivered. What processes worked, what broke down?
We have used this technique in pediatrics, for example, when transferring sick children from outside hospitals to the a pediatric emergency department or intensive care unit. We have also done this when transferring women from a labor room into the delivery operative suite, for an emergency C-section or for young women who are attending a title 10 clinic, seeking contraception or inter-uterine device (IUD) placement.
In-situ simulation has become a powerful tool to detect failures in the systems and processes of care.
How do you test new “lessons” of patient safety and how has this work translated into “real time” safer practices.
Dr. J.H: Simulation can also be used to train clinicians. But, it is a labor intensive approach because the scenarios are like a movie script. But, the training can be very powerful and has been supported, in the past, by NMH.
We developed a set of simulations at NMH about systems and processes of care in labor and delivery, particularly during emergency C-sections. We videotaped the simulations and then reviewed them with the clinicians who participated. They were surprised at how chaotic the team appeared. The room was abuzz with activity, supplies needed to be found, and there was a lot of talking. As a result of the simulations, the clinicians developed a solution. It is called the Red Cap program. The solution was to have operating room charge nurse wear a different color scrub cap, a red one, in the operating room during these emergency C-sections. Everyone else is in a blue mask and gown, however the charge nurse has a red cap. All of the clinicians were trained to know that if they needed something, they should talk to her. They also reorganized the operating room and assigned a nurse to be responsible for obtaining supplies assigned another nurse to work with the anesthesiologist. We had noted in the simulations that the anesthesiologist was stuck behind the drape and needing help, but had to constantly try to catch someone’s to help him/her.
One of my colleagues, Emilie Powell, MD MPH, subsequently did similar work in the emergency department at NMH. She used a simulated patient with acute sepsis. In her work, she found that there some cognitive issues, such as clinicians not recognizing the condition or recognizing it, but somehow not acting upon it, despite evidence-based guidelines for managing these patients. As a result of the simulations, she continued to do work in this area to solve the issues that were identified in sepsis patient care management.
How much resistance have you faced in trying to translate the results of your patient safety innovations to practice?
Dr. J.H: There was tremendous resistance in the early 2000s when we began this work at what was then Children’s Memorial Hospital, now Lurie Children’s. The medical malpractice environment was still very much one of shame and blame. But, there has been tremendous change since then.
NMH has been very progressive and aggressive about exploring and fixing processes of care that put patients at risk. I feel that NMH has been very innovative and has invested substantial resources into process improvement, quality improvement, and patient safety.
I worked for almost eight years as the medical director for patient’s safety at Lurie Children’s and they have come, from a cultural perspective, a long way. The institution is in a totally different place with respect to patient safety. Both organizations really understand, that it is not about individuals. It is about systems and processes of care that individuals are a part of.
Can you tell us a bit about the collaborative, funding or training opportunities for researchers interested in patient safety?
Dr. J.H: I think a lot of the patient safety and quality improvement work has led to major collaborations within the Center for Healthcare Studies. One is with Dr. Ann Borders, who is a faculty member. She did a post- doctoral fellowship with us and I mentored her and have collaborated with her for many years. She has established the Illinois Perinatal Quality Collaborative, now funded by the Centers for Disease Control. This is a collaboration of 70 or more hospitals in Illinois involving both the labor and delivery and the neonatal intensive care units. I believe that they are in their third or fourth year of collaboration and are doing quality improvement work, using the data that each hospital reports.
Similarly, Dr. Karl Bilimoria, who is a surgeon, has a large grant from Blue Cross Blue shield of Illinois and has created the Illinois Surgical Quality Improvement Collaborative (ISQIC). He brought together a large number of Illinois hospitals, some of which were not yet participating in the NSQIP reporting system of the American College of Surgeons (ACS) National Surgical Quality Improvement Program. The purpose of the project is to help institutions begin participating in NSQIP but also to learn how to use their data and engage in actual quality improvement.
Dr. Kevin O’Leary and the Department of Medicine created the Academy for Quality and Safety (AQSI), a six month program for small, interdisciplinary teams of clinicians to engage in quality and safety projects. AQSI includes formal didactic training around methods for quality and safety improvement and experiential training.
We now also have a Master’s (MS) and Ph.D. program in Healthcare Quality and Patient Safety. The MS degree, which is celebrating its 10th anniversary, was the first in-person degree in quality and safety in the US and has been highly successful. The first graduate of the PhD program trained in the Healthcare Quality and Patient Safety track and graduated last year. And, eight years ago, I helped to create an MS in Health Services and Outcomes Research. All of these programs moved into the Center for Education and Health Sciences. The goal of creating a single center dedicated to education, was to take advantage of having multiple programs learning from one another and to share resources. I was lucky to be asked to become the director of the Center for Education Health Sciences about 4 years ago.
What do you see as the future of the Center?
Dr. J.H: We have a couple of ongoing collaborations at the moment. We initiated a collaboration with the Branstad Family Foundation, where we’re seeking to redesign primary care and are working with a large US corporation. While we have seen substantial reform of the healthcare system with the Affordable Care Act, it probably won’t get us to where we need to be with respect to cost savings with the healthcare system. Remember, we’re still essentially a ‘pay for service system’ and I’m not sure that insurers are really positioned to make any radical changes. I doubt that the government will be able to make the necessary radical changes either. At the end of the day, large American corporations are paying for healthcare for their employees. So we have begun to think that some reforms may need to come from US corporations.
I have also been collaborating with a faculty member of the University of Chicago, Melissa Gillian, MD, MPH. She is an obstetrician/gynecologist and leads the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health (Ci3) at the University of Chicago. We have been trying to reduce the barriers to contraception in the income, minority populations, particularly among young African-American women. We focused on Intrauterine devices (IUD) using our patient safety methodologies. We found that a major barrier to young women getting an IUD was the way Medicaid was reimbursing clinics for the device. Medicaid required women to come for at least two visits before getting one. For these young women, taking time off from work or school was difficult, so many missed the second visit and did not get any contraception.
Any final thoughts:
Dr. J.H: One of the things that is so shocking to me in the United States, is that we have excellent treatments for common conditions, such as hypertension, that we simply do not or cannot deliver appropriate care to the many people who need it. For example, most adult patients who come to an emergency department have their blood pressure taken. Among those who have high blood pressure, about half are either unaware or aware but have not gotten treatment. To me, this is shocking. A condition for which we have effective treatments, left untreated. And with the potential for devastating outcomes, such as a stroke. Our healthcare system doesn’t deliver healthcare treatments equitably. Another example is patients with diabetes. One of my colleagues who is a health economist, Dustin French, PhD, evaluated the disparities in care for low-income patients with diabetes, particularly with respect to ophthalmologic care. Losing your eyesight as a result of your diabetes is terrible, a terrible disability, and impairment. We know how to care for these patient, yet the disparities in access to high quality care are significant.
This has always been my issue for the United States. While we have some of the best healthcare in the world, we do a terrible job of providing basic healthcare for many. We fail to prevent serious conditions that are highly preventable. This is a public health tragedy. Other western industrialized nations spend far less money than the US and have considerably better basic quality healthcare and better health outcomes.
Even higher income Americans have poorer outcomes and poorer quality of care than their western European counterparts.
Yet our healthcare expenditures continue to increase. As a nation, we a spending 16-17% of GDP on healthcare. This is simply not sustainable. We’re spending a lot of resources to provide care for middle aged people with chronic conditions, not just the elderly. Many of these chronic conditions are related poor health behaviors. We have a looming problem with people who have been hypertensive, obese, diabetic since their 40’s.They are going to require even more care as older adults. The demographics of US population point to tremendous stresses on our ability to provide care and contain healthcare costs.
NPHR: Thank you so much for your time Dr .Holl, I really do appreciate your time.
Dr. J.H: You’re very welcome.