National Leader Charles Macias, MD, MPH, Leads Innovative Campaign for Quality at UH Rainbow Babies & Children's

Innovations in Pediatrics | Spring 2022

Knowledge management, evidence and analytics, innovation and teams & collaboratives: four pillars of success

What does it take to be a healthcare system that learns? That’s the question driving the ambitious approach to quality improvement and safety at University Hospitals Rainbow Babies & Children’s Hospital.

Charles Macias, MD, MPH

“Learning healthcare systems identify problems and use analytics to understand how to solve them broadly,” says Charles Macias, MD, MPH, Division Chief of Pediatric Emergency Medicine and Chief Quality Officer at UH Rainbow Babies & Children’s Hospital. “They have clear measurement around quality and safety initiatives. They pilot quality improvement strategies, and they make a decision based on the results to take that across their system, or to redesign the interventions. At UH Rainbow, we are operating as a learning health system.”

This is foundational to a five-year strategic plan for quality and safety for improving outcomes and enhancing systemness in pediatric outreach across Northeast Ohio. It’s a large, complex undertaking, by necessity. One focus is on knowledge management, using both digital and in-person education to teach the science of quality improvement, available not only to physicians but also to nurses, respiratory therapists and other clinical staff. Residents and fellows at UH Rainbow also have specific training rotations and conferences devoted to quality improvement.

“Knowledge management is how we are looking at quality and safety competencies and how we're building those competencies for our stakeholders across our culture,” Dr. Macias says. “We're seeing much more participation in quality improvement initiatives that aren't driven by our office, but are really coming from within the clinical departments and the divisions. And that's really exciting to see.”

The four-month quality curriculum in place at UH Rainbow, in fact, has expanded beyond the hospital to other healthcare systems.

“We are embedded in national efforts and opening up our quality curriculum to others from outside our organization,” Dr. Macias says. “We’re excited to have such a robust quality curriculum go national and support several networks.”

In concert with this focus on knowledge management is a single-minded emphasis on evidence and analytics. Teams from across UH Rainbow have produced an exhaustive list of clinical and evidence-based practice guidelines for nearly every conceivable condition or clinical situation – all with the goal of achieving the challenging task of standardizing evidence-based care across the large UH health system. New guidelines, and updates of existing guidelines are always in the works.

The next step, Dr. Macias says, is to align these guidelines with healthcare’s increasing emphasis on value-based care.

“Where we're headed with that work is a focus on outcomes-based payment models; when we look at value-based care strategies and how we are reducing cost of care by improving quality of care, especially for management of chronic diseases,” he says.

In terms of analytics, Dr. Macias has assembled a team of data scientists, data analysts and informaticists to harness the voluminous clinical data within UH Rainbow Babies & Children's to detect patterns and possible areas for quality improvement, while monitoring the successes of such interventions. One project is employing artificial intelligence and predictive modeling to identify patients at risk of developing sepsis.

“We’re not just saying, ‘What do we see in our population, but can we predict what we're going to see?’ Who's going to have onset or worsening of those diseases and how do we prevent that from happening? So it's using artificial intelligence to help you identify those most at risk in your patient population.”

Another analytics effort is focused on building systemwide pediatric disease registries for chronic diseases like asthma and diabetes.

“In creating these registries, we're able to learn about our populations across venues of care, across continuums of care, and across communities,” Dr. Macias says. “And we've begun to apply equity measures to those efforts so that we also understand within those populations, are we getting the same outcome for all patients? Are Hispanics, Blacks, and white patients showing improvement at an equal rate or are there other factors that we should consider? Integrating that work into our equity dashboards has been important because it allows us to be transparent in the way that we're delivering care on an equitable basis.”

Another essential element in the quest to drive quality at UH Rainbow is innovation. The hospital collaborates closely with UH Ventures, the technology-transfer engine for the UH system, to identify opportunities to further develop ideas originating within the hospital system, as well as worthy collaborations with outside entities.

One important theme, Dr. Macias says, is digital technology. To that end, UH Rainbow has collaborated with Inside Out Care, an electronic portal that helps patients plan and track their care – one of just two children’s hospitals in the U.S. to do so. So far, 35 different modules across 20 different UH Rainbow departments and divisions have been created for patients and their families.

“One of the most innovative uses of that has been the way that we manage amblyopia with ophthalmology and actually being able to do a number of those management processes from home without a visit to the clinic,” he says. “We've also developed tools through Inside Out that help us give COVID information back to families specific to their own testing. It has created a tremendous amount of efficiency because those tested in the emergency department find their answers and/or guidance through Inside Out Care. Especially important at a time when staffing is so critically short across the country; that’s allowed us to redirect care in an innovative fashion that doesn't consume nursing time.”

The last essential element in becoming a learning health system, Dr. Macias says – and perhaps the most important – is an emphasis on empowering teams and collaboratives. Joint efforts improve the quality of care, he says, whether the team is local, regional or national.

“The teams can be as small as a local level project working in one department or division, like improving patient satisfaction in the emergency department, or it can be across the hospital, like reducing central line bloodstream infections,” he says. “Or it can be participation in national collaboratives because improving outcomes requires partnerships with other institutions, such as participation in the Improving Pediatric Sepsis Outcomes collaborative.”

His job, he says, is to provide teams within UH Rainbow and clinicians who are part of regional or national efforts with the support they need to successfully solve difficult clinical problems and improve outcomes for patients.

“We help support them with coaching, with analytics and if necessary, helping them develop evidence-based guidelines or evidence-informed protocols for the work that they're doing.

“Our NICU has been CLABSI-free for well over a year,” he says. “Our PICU is just a couple of months from being completely free of any central line bloodstream infections. We're just so very proud of that work, but that just illustrates how we support a team, arm them with the right quality improvement principles and ultimately improve outcomes.”

For more information about the Four Pillars approach to quality at UH Rainbow, please email Peds.Innovations@UHhospitals.org.

Contributing Expert:
Charles Macias, MD, MPH,
Division Chief of Pediatric Emergency Medicine and Chief Quality Officer
UH Rainbow Babies & Children’s Hospital
Clinical Associate Professor of Pediatrics
Case Western Reserve University School of Medicine