Charles Macias, M.D., M.P.H., Improving Pediatric Sepsis Outcomes collaborative co-chair, discusses the potential for improved outcomes in sepsis care when hospitals work together.
Charles Macias, M.D., M.P.H., executive director, National EMSC Innovation and Improvement, and chief clinical systems integration officer at Texas Children's Hospital is one of three national co-chairs of a collaboration among the nation's children's hospitals to defeat sepsis, the leading cause of death in hospitalized children. The multi-year Improving Pediatric Sepsis Outcomes collaborative—based on a proven improvement model—aims to reduce sepsis mortality and hospital onset severe sepsis by 75 percent. We caught up with him at the 2016 Annual Leadership Conference to get his thoughts on the importance of this work.
Why is this collaborative different, and why should a hospital be a part of this? What attracted you and your hospital to this effort?
We were attracted to this collaborative because we recognized our outcomes of sepsis mortality and morbidity were not as good as we thought. Because sepsis is hard to detect until you are engaged in the improvement science work and use analytics to define it clearly, an institution can be lulled into thinking it's doing well with outcomes, when in fact it's not. And, the cost is not a subtle gap in quality, but in lives lost or saved.
The real attraction came from the nature of the work. It gets to the core of why we do the work we do as clinicians. We want to heal sick children; we want to save lives. I don't have to wait for several degrees of separation to see the outcomes of this work for this disease. The gains are immediate. The outcome changes are powerful. It really feels transformational.
What makes this particularly powerful is that it truly is a "collaborative of collaboratives." It speaks to work and improvement in the emergency care setting, critical care setting, hematology/oncology care setting and in the hospital-based setting. The breadth of care settings will allow patient data to be captured anywhere within the continuum of a children's hospital. It's not the addition of one silo to the next. The advantages are not simply additive, they are synergistic. The potential for improved outcomes is exponential.
Why haven't hospitals been able to create these kinds of results before?
There have been pockets of success from creative and innovate approaches to improving quality or using improvement science to drive changes in institutions. But, the comprehensive and sustainable nature of what we hope to accomplish can't really be done on a small scale.
Despite the fact that we can look at some process measures that tell us we have the right things in place to likely change an outcome, when we're looking at a relatively rare prevalence of mortality, it takes a large pool of data. It's the collective data pool—the big data that we're going to be able to extract—that will make it more powerful than the parts that lead up to it.
It provides the ability to take knowledge and innovation and spread to other areas to demonstrate that the effectiveness and efficiency of such a model can be replicated. That opportunity is a great breeding ground for innovation.
How do you gain and sustain senior leadership support for an improvement effort of this size? How has your leadership shown support for your work in sepsis over the years?
Highlighting the data and human stories is critical. We need to be transparent about our outcomes and reminded of the lives lost, the harm accrued and the gaps in our outcomes. One area of support evident to me and to the teams engaged in this work in our hospital has been the willingness to recognize sepsis as a problem and a weakness within our organization. That's no small feat. When you start talking about mortality in a children's hospital, you're really admitting there is a weakness. And, that level of transparency takes a cultural leap by executive leadership.
Additionally, our leadership was willing to recognize that the solution may not just be simply operational. It required a fusion of the science and evidence, operational changes as well as understanding the financial impact and where the alignment was needed. Our executive leadership was willing to engage in a more comprehensive picture, and it was a wonderful thing to see within my institution.
One of the main components of this work is a focus on patient and family engagement (PFE). What's been your experience including families in their child's care? How can PFE impact outcomes?
We've invested a significant amount of effort into understanding the role of the family and different activities in the QI realm—it's beyond simply saying we need to understand how units are doing with patient satisfaction. This is about the complete role the patient has in being able to understand and partner in their own care.
Part of the challenge with this approach is that it's relatively new. Twenty years ago, we didn't think this way. In his writings, Don Berwick describes three eras of health care: professional dominance from beneficence in era one, business dominance in era two, and moral dominance in era three—era three demanding a greater partnership with and creation of value for our patients. And that's where we can translate this to action: patient and family engagement is the perfect example of that.
Where we see the greatest opportunities at my institution and with the IPSO collaborative is leveraging the opportunities to partner with families in the diagnosis and management of sepsis. Engaging the patient and families in early identification and surveillance for hospital onset sepsis can be critical to early detection. Families often identify the first indicators that something is not quite right. When we listen to a parent who knows their child best and then apply science to determine whether the child has a potential for sepsis or a patient is evolving to severe sepsis or septic shock, it can be very powerful. It extends beyond what we as providers can do on our own and partners the family as critical "clinicians" in the model.
What things are you most looking forward to as a leader and participant in the collaborative?
Clearly, it will be rewarding to see the work come to fruition in terms of outcomes. In the health care industry, we have been engaged in so many initiatives that were process driven, that we've become somewhat attenuated to just another process change. This work is very different because we are touching change across the continuum. We're doing intensive work in improvement science, capitalizing on prior work—bringing elements of best practice we've seen across our participating institutions, and using the knowledge our experts bring to the table. That synergism will change outcomes tremendously.
I'm excited to spread existing and newly created innovation to other hospitals across the country and across the globe until we make mortality and morbidity from early sepsis and preventable sepsis negligible. But more importantly, I look forward to saving children's lives.
What is the next major milestone for the project?
The reality is much of what we've invested in to date is building the infrastructure and making sure all the mechanisms are in place. We'll launch process changes comprehensively across all of the participating hospital partners beginning in January 2017. Preceding the launch, we have a training session in December to help bring all the participating organizations together, so that we can learn from best practices.
Why was it important for you to be involved in this work? What has driven you to continue working on this particular issue over the years?
I recognized there was a paucity of evidence and science in determining the best solutions. I've been working in sepsis for more than a decade. I had a parallel interest in improvement science and have been engaged in quality improvement for a couple of decades. It seemed like the perfect partnership—to take a best practice in one area, in one institution and identify how that could be replicated in another institution and shared across an entire collaborative.
And, I'm driven by how data and analytics can be used to support the improvement work. I'm also driven by the small, but ever growing successes in sepsis at my hospital and around the country. I appreciate the comradery with like-minded people and institutions that has developed with a shared vision to save lives with this work.
Enrollment for January 2017 is now in process. For more information, visit childrenshospitals.org/sepsis.