A Conversation with Dr. Charles Macias

UH Research & Education Update | September 2021

For more than 20 years, Charles Macias, MD has dedicated his time to caring for pediatric patients and developing local and national pediatric clinical standards and disaster preparedness and response strategies. We had the pleasure of speaking with Dr. Macias to learn about him and the invaluable work he does to improve the quality of care for the pediatric community. In addition, UH R&E congratulates Dr. Macias on his recent $48M HRSA grant, the largest grant in University Hospitals’ history.

Q: Can you tell us more about yourself, where you grew up, and when you knew you wanted to become a physician?

Charles Macias, MD

A: If I were to describe myself with the highest priority first, I am the father of nine-year-old twins, Rachel and Jacob. We moved here about two years ago from Houston, Texas, where I lived for 22 years. So it was definitely a big move. I lived in various locations throughout the country and have spent only about three years in any given city, but most of that time was in various cities in Texas.

When did I know I wanted to be a physician? The interesting thing about that is that I never wanted to be a physician; I always wanted to be a pediatrician. I didn’t want to be a doctor; I wanted to be a doctor that took care of kids. I think a lot of it stemmed from my interactions with my own pediatrician when visiting his office. He was a very calming person and very good at his craft, and I was enamored with the thought of being able to help heal sick children and to support their families.

Q: You are widely recognized as an accomplished national leader in the field of pediatric emergency medicine, healthcare quality and patient safety. Are there any mentors or inspirational figures that influenced your career, and what experiences shaped you into the physician-scientist you are today including your interest in health services research?

A: There were multiple mentors throughout my career, but there is one mentor in particular that shaped my interest in pediatric emergency medicine. He is widely regarded as one of the grandfathers of pediatric emergency medicine. He carved out new ground to help create the sub-specialty and was an enormously talented clinician. However, what was so powerful about his mentorship was his ability to look at the future and create sustainability and a strategy for the pediatric emergency medicine space - the discipline as a whole, and create opportunities for me within that transformation.

As an example, he coedited a textbook on pediatric emergency medicine, and as he began working towards retirement, he prepared me over several years to take over his role as co-editor of that textbook. I valued his mentorship and learned to pay it forward. He taught me to be forward thinking and strategic about building organizational structures and leveraging relationships within the societies and federal bodies that influenced our work, in order to advocate for transformational improvements.

I think the experiences that have shaped my passion for health services research came from the recognition that changing lives, one at a time, is powerful, but changing lives systematically by creating infrastructure changes is enormously powerful. Being able to quantify and define that improvement drove my interest in health services research.  I was interested in optimizing the outcomes of the intersect in science and operations and learned to conduct research in the segment of health services research related to quality improvement or improvement science. When I first became interested in this kind of work, quality improvement and improvement science didn't exist as a label. The country was heavily focused on quality assurance, mostly related to regulatory issues, but there were leaders that were bringing attention to research in improvement science under the umbrella of health services research.

We've come a long way since then. We recognize that the impact of improving systems of care is to more reliably generate improved outcomes. Still, we need more research in improvement science to understand where, when, and how these changes in healthcare systems should be adopted or adapted. And we need to more quickly and nimbly disseminate best practices. My personal story stems from that epiphany of the need to improve systems of care. I was working one night in the emergency department and saw a patient with an asthma exacerbation that I had seen three times in the past six months (always on an overnight shift). This was a working family whose livelihood depended on their daily presence at their jobs, and it was a challenge for them to leave work to take their daughter to a doctor’s office during the day. Embarrassingly, the interaction I had with these parents began with my thinking that somehow they failed to follow their prior discharge instructions…until the child’s mother handed me a folder with six different asthma action plans, all from different providers and venues in our healthcare system. They all had different instructions for how to manage the child’s asthma exacerbation. I realized that this family was working hard to do the best they could for their child. Still, we, our healthcare system, weren’t doing the best we could for their child. We needed to understand how our system functioned as a system, not just how emergency department care or primary care was functioning. I had to ask the question, “What does our system as a whole do to improve asthma outcomes?” It wasn't easy to decipher that. That was about 15 years ago. And it was then I realized what a gap there was in healthcare, not just for asthma, but for all diseases. So this concept of improving systems of care became a critically important goal for me. And studying the structures, processes and outcomes led me to health services research.

Q: You left Baylor in 2019 to come to University Hospitals to be the division chief for pediatric emergency medicine and chief quality officer for UH Rainbow Babies & Children’s Hospital. What influenced your decision to come to UH and tell us more about the two roles that you play here?

A: I think the biggest driver was my recognition that there was an excitement for healthcare transformation at UH--lots that was happening in this environment. Dr. Marlene Miller had been recently recruited as the Department Chair for Pediatrics and she was known for her expertise in quality improvement. Similarly, Dr. Peter Pronovost had been brought into the system to drive healthcare transformation. I knew of his work and publications and was excited to work with him as well.

At the same time, the system was looking for quality transformation at UH Rainbow as a system within a system. The very creation of the role of a Chief Quality Officer for Rainbow that would oversee quality and safety across the pediatric system of care was evidence of that effort. The role would influence the Rainbow Emergency Services Network, which has a footprint in all of the UH hospitals and their partners, the Newborn Network (multiple nurseries across the system), the Rainbow Primary Care Institute and the hospital. For me, it represented an opportunity to help create a model system; to bring together all these wonderful silos of work to align under a single Rainbow system strategic plan for quality and safety, and focus on outcomes: better health for the families and children across northeast Ohio. If we're genuinely going to improve healthcare outcomes, we have to look at all of the upstream and downstream factors in our care delivery model. We have to be able to work with community partners. We have to understand what families and children want. We have to be attentive to the provider's wellness. And we need to grow a culture of quality and safety. I had the opportunity to do much of this type of work in my prior role in Texas, with many successes, but this was an even bigger opportunity to help transform healthcare far more comprehensively across a large geography.

Q: In addition to patient care, you are dedicated to the quality of improvement and establishing those standards. You are also interested in developing the clinical standards for pediatric sepsis. What inspired you to dive deeper into these issues, and did your efforts in developing critical standards for sepsis evolve into broader interest in overall quality issues?

A;  A timely question as this is sepsis awareness month. Sepsis piqued my interest because it is the leading cause of death in children worldwide—causing even more deaths in children than cancer. I don't know that this is widely known to the public. There are many public-facing and provider-facing sepsis campaigns working towards better recognition and better management of sepsis--both in adults and children. But there are many more validated tools for early identification in adults than there are for children. The greatest improvement in sepsis outcomes in children over the last decade have come from quality improvement strategies, and not from breakthroughs in bench research. With the average cost of a hospitalization for severe sepsis and septic shock between $65,000 and $85,000, there’s also a great opportunity to reduce the burden of sepsis to the healthcare system. I’ve been fortunate to co-chair a national QI collaborative through the Children’s Hospital Association (Improving Pediatric Sepsis Outcomes-IPSO) that has driven reductions in mortality across the country. We’ve published much of what we have learned about improving healthcare systems to drive better outcomes in sepsis management, adding to the health services research literature. And now we’re doing this work locally.

Our sepsis guidelines, and frankly, all of our guidelines work emanated from a deliberate quality and safety strategy designed to improve outcomes by minimizing unwanted variation in practice. It’s a fundamental tenet of quality improvement. Standardization around evidence based practice helps to drive value by improving diagnostic accuracy and therapeutic effectiveness.

Q: You and your colleague, Dr. Deanna Dahl-Grove, PIs of the Eastern Great Lakes Pediatrics Disease Center of Excellence (EGL), were recently awarded the $2.35 million expansion grant from the Assistant Secretary of Preparedness and Response (ASPR). Can you tell us a little bit more about this consortium and the overall grant?

A: The ASPR has a goal of creating a national model for pediatric disaster preparedness for the nation. This particular investment in the Pediatric Disaster Centers of Excellence began in 2019 to help further identify, curate and disseminate best practices through the two pediatric disaster centers of excellence. The other center that was funded is based out of California and has affiliates across the Southwest and the West Coast. We work collaboratively with that center.

The EGL COE operates through a hub-and-spoke model partnering with the children's hospitals in Ohio and Michigan: Cincinnati Children's, CS Mott Children's Hospital, Children’s of Michigan, Helen DeVos/Spectrum Health, Nationwide Children's Hospital in Columbus, and UH Rainbow, of course, where we are anchored.

This network aims to bring public, private, and professional (i.e., American Academy of Pediatrics) health entities together to develop multi-pronged approaches that address the gaps of care for children in disasters. First, I think it's important to recognize that children are not little adults. That manifests in a million different ways that extends beyond the types of illnesses that are unique to children.  For example, separation of children from their parents became a real issue in the areas devastated by Hurricane Katrina. Disaster response and recovery strategies should incorporate the need to address reunification. Additionally, equipment and supplies should be available to manage children in disasters; critically important when care is delivered in mobile units or alternate care facilities. I lived in a hurricane-prone region for 22 years before coming to Cleveland and was witness to the impact to children in disasters. I was fortunate to have worked in a system and in a city with the resources to stand up mobile triage units to mitigate the risk of those victims. The devastation of Hurricane Katrina and Harvey was profound, and long after the response phase, we dealt with recovery that included the lasting impact on the mental health of children all over the region. The solutions to these gaps in pediatric recovery were embedded in public-private partnerships. It takes more than a village, it takes a nation to build resilience for regional disasters. But there remains a paucity of best practices in disaster preparedness. We lack standardized measures to understand the effectiveness of disaster preparedness programs. We don’t have effective and highly usable analytic surveillance system with data to insights that help inform the needs of children to the same degree that we do with adults. One only has to look at the struggle schools and day cares are having with understanding the impact of the current COVID pandemic and coexistent RSV season.  Effective surveillance at a regional level could markedly improve outcomes. These are the kinds of issues the EGL COE addresses by developing pediatric readiness tools for hospitals, creating standardized measures, enhancing telehealth systems across state lines, improving health information portability…the opportunities are endless, and the need to study and disseminate those best practices is clear.

Q: Can you tell us more about the Regional Pediatric Pandemic Network (RPPN) grant that you recently received?

A:  The Center for Pediatric Everyday Readiness-Regional Pediatric Pandemic Network is a network of 5 children’s hospitals (anchored at Rainbow) integrated with the efforts of the two ASPR Pediatric Disaster Centers of Excellence and the EMS for Children Innovation and Improvement Center (under the MCHB umbrella). They will work collaboratively to improve the nation’s capabilities and capacity to take care of children every day, in regional disasters, and in global health threats such as a pandemic. The concept of pediatric readiness is critical. Eighty percent of children with acute injuries or illnesses present to community hospitals across the nation, not to tertiary or quaternary children’s hospitals. Many of these hospitals are critical access hospitals who may see fewer than 6 children per day, thus local systems may not be adequately prepared to care for children. We can’t presume we can care for children in disasters if we aren’t prepared to care for them in everyday emergencies. We will leverage the successes of the networks and the EIIC in order to create or improve upon pediatric disease surveillance, capacity and capability tracking, telehealth access, risk assessment tools, mental health resources for children, guidelines of care during disaster settings, national measures for disaster preparedness programs, trauma care, a disaster research agenda, disaster and pandemic QI collaboratives, and many other domains of work. We matrix representation and project management from many national partners including the Children’s Hospital Association, the American Academy of Pediatrics, the American College of Surgeons, and many others to align national priorities and activities in disaster and pandemic work.  Pediatric readiness makes a difference. Today, the best data tells us that pediatric readiness, as surveyed in the National Pediatric Readiness Project survey in over 4000 hospitals, has improved slightly over the last 20 years, but far from where it needs to be. We know from recent health services research that ED’s that are pediatric ready score in the top quartile of the Pediatric Ready Survey have a fourth the mortality in managing critically ill children versus other hospitals surveyed. The RPPN will drive the structures and processes that will bring pediatric readiness spanning from every day to global health threats; it will happen in hospitals, communities, prehospital systems and everywhere that risks to optimal health for children and their families exist. We will leverage existing successes to transform pediatric care across the nation through this hub and spoke model of regional exemplars.

Q: What career advice would you give aspiring young faculty interested in quality improvement and safety for pediatrics?

A: Find a mentor, not just an advisor, and nurture that relationship. Find the person who will invest in your career and holistically advise and invest in your career development. Growth of a career in quality improvement and health services research is experiential but needs to be guided. Ideally, that mentor understands the science of clinical care delivery, systems of care, business systems, payment models, technology, and quality improvement tenets that expand beyond what we're taught in medical educational institutions.  It is part of the culture we're trying to change in medical education today. It is part of how we're trying to transform healthcare to get knowledge to outcomes in a much quicker fashion, but it takes people and systems that are invested in growing the next generation of QI champions. And it takes health services researcher to help generate and disseminate the evidence.

FIVE IN FIVE!

1. Where is your favorite Cleveland restaurant? The Marble Room in Downtown Cleveland. 
2. What book do you recommend everyone to read? The New Leadership Literacies by Bob Johansen.
3. What is your favorite dessert? Crème Brule
4. What is one thing about you that would surprise people? I worked as a sous chef, and a brunch chef at a restaurant, even as recent as 10 years ago, even though I've been in medicine for 25 years. I love doing it, but I'm certainly much better at quality improvement and QI research than I was as a chef.
5. Coffee or tea? Both; hot coffee and iced tea. You can take the Southerner out of the South, but you can't take the South out of the Southerner. I’ll never give up iced tea.