Investigators at Northwestern and all over the world conduct countless studies to figure out the best ways to prevent, diagnose and treat medical maladies. There’s also a subset of investigators who develop and test innovative solutions to make sure that patients are receiving care that reflects the findings from all that research.
“This effort is about making sure that healthcare providers are actually implementing the best practices that we know about,” said Karl Bilimoria, MD, director of the Northwestern Surgical Outcomes and Quality Improvement Center (SOQIC). “Our goal is to ensure that patients get the best possible care, every time.”
With a team of more than 30 faculty members, fellows and staff, Dr. Bilimoria conducts research to elevate the quality of care patients receive, a topic he wrote about in a recent editorial and a series of studies published in the Journal of the American Medical Association (JAMA) over the past year. Here, he talks about how SOQIC tackles its broad and complex objective.
How does your center go about studying quality improvement?
We look at quality improvement in three ways: better measures, better levers and better evidence.
For “better measures,” we work with physicians, guidelines and the literature to define discrete quality measures, which are essentially statements of what should be done in certain clinical scenarios. For example, if you’re doing a colon surgery, you should give the patient the correct antibiotic prior to the surgery. You should clean the skin with a certain type of antiseptic. We develop measures like those and test them here at Northwestern Memorial Hospital or within our system and then more broadly within the state.
“Better levers” is about finding better ways to encourage clinicians to provide optimal care. We evaluate national strategies such as public reporting of outcomes or pay-for-performance initiatives to see what works and what doesn’t. Some of our findings have changed how U.S. News & World Report and others rank hospitals.
We also try to develop “better evidence” by testing different approaches to care. We do trials, but instead of randomizing patients we randomize hospitals. For example, we might experiment with two strategies to prevent patients from getting blood clots after surgery in two groups of hospitals. Maybe the ideal situation is using both strategies, but we want to learn which specific parts work best and what are the barriers to implementing them at different hospitals. Which approach is better for small hospitals versus big hospitals, or hospitals with a lot of resources versus those with fewer resources?
What are some of your ongoing projects?
In the FIRST Trial, we’re running a prospective, randomized national trial at 151 hospitals to test current surgical resident duty hour limits versus more flexible duty hour policies. The 80-hour cap is still there, but we eliminated most of the other rules, ones that limit how many hours residents can work in a row and how much time they need off between shifts.
Many clinicians believe that you can get better continuity of care with the flexible duty hours, because the doctor who knows you best can take care of you through the critical parts of your hospitalization. Continuity also results in better resident training. Earlier this year, we published a paper in JAMA showing that restrictions on duty hours imposed in 2011 had no benefit for patients.
We enrolled about 95 percent of eligible hospitals to participate in the FIRST trial, which shows us that nearly everybody in surgery thinks these limits are a problem. We expect the findings, which come out in February, to have a huge effect on a very controversial issue and to result in major future policy changes.
Another project we’re working on is the Illinois Surgical Quality Improvement Collaborative. This is a group of 55 hospitals using the same data platform to collect really detailed information about surgeries performed and their results. We’re providing these hospitals with tools – a formal curriculum, coaching and a mentor – to actually use all this data to improve.
Your research has shown that strategies meant to measure and improve quality sometimes have the opposite effect. Is there an easy solution to this problem?
Quality measures can be totally accurate, they can be a little off or they can be paradoxical and actually show you the inverse of quality. For example, we’ve seen the latter with the Hospital-Acquired Condition Reduction Program, Medicare’s pay-for-performance strategy. Hospitals appear to be performing poorly because of the way quality is measured, which leads to an unfair characterization. That’s bad for patients, because you may get led to the wrong hospitals. It’s bad for hospitals, because they focus on improving the wrong things. And it’s bad for policymakers, because they’re penalizing the wrong hospitals.
The answer to this is that hospitals and policymakers have to be nimble. You have to be able to change when you realize there are problems. We’re hoping to help inspire that change. The SOQIC team – including younger surgeons like Tony Yang, ’02 MD, ’09 GME, Jonah Stulberg, MD, PhD, MPH, and David Odell, MD MS, strong research methodologists like Jeanette Chung, PhD, qualitative researchers like Julie Johnson, PhD, and a tremendous, dedicated staff – are doing a great job so that our work can have a meaningful impact locally, regionally and nationally.
Dr. Bilimoria is the John Benjamin Murphy Professor of Surgery in the Division of Surgical Oncology, vice chair for quality in the Department of Surgery, a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University and an investigator in the Center for Healthcare Studies.