Taking on the System

Tina Schade Willis, a pediatric ICU doctor and winner of the UNC Fuller Award, works to improve teamwork among hospital staff to benefit patients and their families.

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All doctors and nurses are in the patient-care business for a reason – they want to help heal those in need. But sometimes, complex health care systems can get in the way, resulting in inefficiencies as well as confusion among patients and their families.

As Tina Schade Willis, MD, devotes herself to pediatric patients in need of critical care, she also works hard to improve the overall quality of care at the N.C. Children’s Hospital. Her team’s results have been impressive, including a dramatic drop in the rate of non-ICU cardiac arrest in the Children’s Hospital. For her work, Schade Willis earned the H. Fleming Fuller Award, which the UNC Health Care System Board of Directors gives to a member of the medical staff who demonstrates dedication to the highest standards of patient care, teaching, and community.

We sat down with Dr. Willis to discuss why she got into pediatric care and quality improvement, and what her team has achieved at the N.C. Children’s Hospital.

5q-book2Why did you pursue a degree in science and what was the driving force behind you going to medical school?

I grew up in a fairly rural area in Nebraska, a small college town called Kearney. No one in my family had been to college, and there weren’t a lot of medical professionals other than community doctors. But I’d always wanted to go to medical school; I don’t remember a time when I didn’t. I majored in biology and minored in music at the University of Nebraska at Lincoln. I bought a lot of books about how to get into medical school and talked about it with as many people as possible.

When I got into med school [at the University of Nebraska Medical Center] I had no idea what kind of medicine I wanted to do; I just knew I wanted to be in health care.

5q-crossWhy did you focus on pediatrics and then pediatric critical care medicine?

As I started doing clinical rotations, I loved all the procedural rotations; surgery was fantastic. And I loved critical care; I loved helping patients in intensive care units. So I knew I wanted to be an intensivist before I knew what type. That was late in my third year of medical school.

During my fourth year I took every intensive care unit rotation possible. I toured seven different ICUs – geriatrics all the way to the neonatal ICU. That’s when I realized I wanted to be a pediatric intensivist, because you do everything. You work with babies, you take care of 18-year olds, trauma patients, heart surgery patients. You take care of nearly everything you could possibly think of. So the variety of patients you get to help is great.

5q-clipboardYou are an associate director for the new UNC Institute for Health Care Quality Improvement. How did you realize you wanted to become an administrator dedicated to the overall quality of patient care?

I did basic science research in a lab all through medical school in the department of pharmacology and through residency [at Creighton-Nebraska Universities Foundation], which was four years, and my fellowship, which was three years [at the University of Texas Southwestern Medical Center].

But during my last two years of my fellowship, I started realizing how hospital systems work. I saw lots of errors, waste, and inefficiencies. The systems in place for improving quality around patient care weren’t great back then. But I had seen great examples during residency in a few very small areas of cardiac surgery; the care in those areas was done very differently; it was a team-based approach. They were constantly looking and relooking at outcomes and seeing how we could improve.

I think that helped me realize that things could be done better and differently. I started learning about how I could get training in patient safety and quality improvement. It was all very new. Not a sexy field at all. People would ask me why I wanted to get into that. They’d say, “You’re not going to be able to get grant money, and it’s not all that academically interesting.”

But when I came to UNC as a faculty member almost ten years ago there were groups of people actually working to improve quality of care. I received training here at UNC, at the Cincinnati Children’s Hospital, and through the Institute of Healthcare Improvement, [a not-for-profit organization based in Cambridge, MA.]

Now, I spend 40 percent of my time working in the pediatric intensive care unit and about 60 percent of my time leading and studying improvement initiatives.

Working in patient safety and quality improvement fits the personality of ICU doctors; we’re very impatient. We want to see rapid change for the better. And when we do, it’s a rush.

One of our improvements involved the pediatric rapid response system, which is a team of professionals that get pulled together – like a code blue team – but they get called as soon as a part of the hospital staff or a patient’s family member sees any deterioration in a patient. The team comes together fast to assess and treat the patient with the goal of preventing cardiac arrest.

After we put that in place we had a 70 percent decrease in the cardiac arrest rate in children at the N.C. Children’s Hospital. And that’s been sustained since 2005. We had an entire calendar year – 2012 – with no inpatient cardiac arrests outside of the ICU. We used to have one every six weeks before the team was launched in 2005.

5q-heartIn 2010, the DHHS Agency for Healthcare Research and Quality awarded your research team $574,523 for TICKER. What is it and why is it necessary?

That’s a grant we received to put in place patient-centered practices to improve patient safety and quality of care. It was aimed at a very vulnerable patient population – those 200 to 250 children who have heart surgery every year at our Children’s Hospital. These are patients with a relatively high mortality rate. If you’re going to improve things for patients, that’s a great target population to work with.

Basically, it’s a foundation of teamwork training with an overlay of standard evidenced-based guidelines and clinical pathways. Part of the problem was that when patients come in, they may be treated by four different silos of care areas that may not work in concert throughout the patient’s stay. They start with an initial neonatal ICU team, and then they go to operating room with the surgical team, followed by a postoperative stay in the pediatric ICU; then, when well enough, patients go to another unit on the floor; that’s another team.

With all these different transitions and different teams working separately, errors can happen. Care can vary. Families can get confused. Even though we need all these different groups caring for children, we finally got all of them together and did teamwork training for everyone so we have a common language and standard clinical pathways. Essentially we turned all these separate teams into one big functional team. Now, everything is predictable for patients and families about what will happen next.

The novel part of what we did is putting teamwork training in place first and having patient families design things with us as equal team members.

We finished in October. Program TICKER is now a permanent infrastructure in the pediatric congenital heart program at UNC.

We’ve seen a significant changes including statistically improved teamwork in all four areas of care. We also participate in the Society for Thoracic Surgeons database and have seen early improvements in length of stay and mortality in one of the highest-risk categories.

Part of the grant requirement was to have a toolkit at the end. Providers at another institution can click on our toolkit on our website to see how they could do this in their hospital.

5q-teamWhat’s the most rewarding part of your job?

In my quality improvement work, the best part is starting something new and seeing it take off, and then mentoring other people to do the same things. When I came here I was the only one doing quality improvement work in this division. Now, nearly half of the faculty does this sort of work. So it’s been incredible to see that transition over time.

As for working in the ICU, the best part is the patients themselves. Caring for a critically-ill adult is vastly different than caring for a critically-ill child. There’s a different pace, different ways you have to talk to families. Child patients are more resilient. It’s just incredibly rewarding. Often, we think a child may die and we’re proven wrong. That’s the amazing thing about this job. You see miraculous things every single day.

Tina M. Schade Willis, MD, is an associate professor in the Department of Pediatrics in the UNC School of Medicine, and she is an associate director of the UNC Institute for Health Care Quality Improvement.

Media Contact: Mark Derewicz, (919) 923-0959, mark.derewicz@unch.unc.edu

 

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