Leading Medicine with Houston Methodist

Leading the Houston Methodist Department of System Safety, Quality and Service | Quality Time with Dr. Schaal

• Houston Methodist

Share episode

In this episode, Dr. Shawn Tittle discusses his transition from a working as a highly specialized cardiothoracic surgeon to serving as the senior vice president and system chief quality officer of system safety, quality and service at Houston Methodist.

Expert: Shawn Tittle, MD, senior vice president and system chief quality officer for the Houston Methodist Department of System Safety, Quality and Service

Notable topics covered:

  • Culture of safety
  • Principles of high reliability
  • Vizient Inc. scorecard and national benchmarking
  • Houston Methodist Quality, Safety and Well-being Institute

Links:

♪ ♪

DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist leading medicine podcast. I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist, and I serve as the Chief Physician Executive of Houston Methodist, located in the world-renowned Texas Medical Center. I passionately believe that quality is the heart of health care and a commitment to quality is essential for every health care system. Join us each month as we discuss the latest advancement in quality in health care with clinicians, researchers, physicians, industry experts, and thought leaders who are as passionate as I am. I am pleased to welcome today, Dr. Shawn Tittle. Dr. Tittle is a cardiothoracic surgeon who currently serves as Senior Vice President and Chief Quality Officer for the Houston Methodist system. He oversees all aspects of safety, quality, and patient experience for both inpatient and outpatient care. Prior to this, Dr. Tittle was the Chief Medical Officer and Chief Quality Officer for Houston Methodist Baytown Hospital. Welcome, Dr. Tittle.

DR. SHAWN TITTLE:

Thank you, Dr. Schaal. It's a pleasure to be here.

DR. SCHAAL:

Tell us a little bit about yourself.

DR. TITTLE:

I grew up in Michigan, I grew up in Detroit. I went to medical school at Wayne State, which is in the city of Detroit. I did my residency in Connecticut and was there for about 18 years before I came to Houston Methodist. The story of coming to Methodist was fun for me. The person who recruited me was my chair, the Chair of the Department of Surgery at Norwalk Hospital in Connecticut where I was before. He called me and he said,"There's this really amazing health care system in Texas." And I said,"I'm not moving to Texas." And he said,"They're amazing people. I really think it's worth you taking a look." So, I came down and he was completely right. It's an amazing system. It's unlike any experience I've had in a health care system previously. And later that year, we moved to Texas.

DR. SCHAAL:

Fantastic. And so, why -- you know, why dive into quality? Usually in cardiothoracic surgery, I don't think, you know, you spend much time learning about quality, what does it mean. And you know, in your role, you're responsible for so many specialties across the system. And after spending so much time specializing in cardiothoracic surgery which is, you know, very unique and very highly specialized, why making that leap?

DR. TITTLE:

I think there's a lot there to unpack. Honestly, I believe that more surgeons need to be involved in safety and quality. I think that's a very important thing. I also believe that there's some bias about surgeons who do administrative work. And the historic stereotypic bias is that they must not have been good surgeons, right?

DR. SCHAAL:

You heard that? People tell you that?

DR. TITTLE:

Oh, yeah, I have. Which was more reflective I think of some preconceived notion and biases than it is the realities of the health care system that we're living in in the 21st century. I don't doubt that at some time people who struggle with clinical medicine wanted to move out of it to a more administrative job, but the role that I had before I came here, we were the highest volume robotic thoracic surgery program in the state of Connecticut. We were also the only certified center of excellence in the entire New England area. And so, we had excellent outcomes, we had an excellent program. To talk about the transition, I think I would have to go all the way back to my first job out of residency. Stanley Dudrick was my mentor. He was the first Chair of Surgery at the University of Texas when they joined with Hermann. And at the end of his career, he ran a residency program, and was the Chair of Surgery at the hospital in Connecticut where I was. He brought me back after my cardiothoracic surgery training and asked me to develop a thoracic oncology program. After I did that and we had an established program, he worked with me to develop a general surgery residency program, a de novo program. It was the first one in over 40 years in the state of Connecticut and we got ACGME approval, our RC backing. And started a program and it graduates three general surgeons a year. What I found is I really like developing programs that impacted people more than the singular operation I could do in the OR. I also tended to specialize in the thoracic oncology, and my passion is care of cancer patients. And so, through practice experience over years, what I determined is it's not just an individual practitioner that makes the biggest impact, it's a system, a coordinated system of like-minded individuals who have a set of shared goals and objectives that they live up to in order to provide the best care to the patient. Extrapolating that out past just clinical cancer care, you begin to see how the entire health care system and the delivery of care to patients is really dependent on the ecosystem. It depends on everybody. It's not the hero culture where it's just one person who comes in and saves everything. It has to be everyone who is a hero all the time. And I found that I really loved building that part of health care is --

DR. SCHAAL:

That's very insightful of you because, you know, I'm a surgeon as well, and you know, you spend so much time specializing and then the lens of the surgeon and, you know, I'm an ophthalmologist, I'm using lens, I love lenses and focus. It's really focused on, you know, what you do. You see the patient in the clinic and then you go and prepare the patient for surgery and then you do the surgery, and then you do the follow up, and then the outcome, you think, at least from my experience as a surgeon, you think it's actually you. But what you're saying is that you noticed that it's you of course, but then many, many, many other people that contribute to your success. So, how did you came out -- come up with this realization that, you know, there's a whole system? Is that by building the programs or this is another, you know, experience that you had?

DR. TITTLE:

It was primarily from building programs and understanding when we were trying to build a residency program, when we were trying to build a certified center of excellence from an outside agency, I began to understand everyone's role more clearly. As we defined things like standard work and programs, as we defined metrics for navigation, as we defined targets and key performance indicators and we thought about how effective, how efficient, how much patient satisfaction, how much patient retention was not a product of any one individual, but an entire program, it really started to open my eyes when we think about safety. Because historically, in a lot of people's minds, safety was individual-dependent and it really dovetailed with this whole idea that we came through the health care system, right? You have to be the top of your class to get into medical school, you have to be top of medical school to get into surgery, you have to be the top of surgery to get into your specialty. And all along the way it's individual, individual, individual, and we're drilled that way. And I think we do ourselves, culturally, a disservice by not understanding the context in which we operate. Can't be a good surgeon if you don't have a good circulator. You can't do good surgery if you don't have clean instruments. You're not gonna have a good experience if the anesthesia delivery is not appropriate. Thinking about all of those things too as you continue to expand it, as I thought bigger and bigger, it all came down to, well the entire system is involved. How do we fix that? How do we make that better?

DR. SCHAAL:

So, this is -- you now, I love listening to you when you say that because we really -- you know, I meet many, many people in my daily job and, you know, the majority of them are not clinician. And when I meet with physicians, they say "Well, you know, we are the most important part." And I don't doubt, and you know, certainly have high respect and high regard to physicians that have, you know, really invested their entire career in specializing and delivering the best care. But the reality is that every single person that works for health care, no matter what they do, they are important and they make really the patient experience and the outcomes better if they do their job right. Tell us a little bit about your role.

DR. TITTLE:

Referenced earlier, I oversee all aspects of safety, quality, and patient experience. And to me, those are really intertwined. If you as a patient are not safe, nothing else matters. That is the single most important part of interfacing with any health care system is,"Don't hurt me," right? And it references back the primum non nocere, right? First, do no harm. After that, it's quality, it's outcomes, and it's experience because if we put that in context, the American health care or the American medical education system wasn't even formalized until the early 20th century. We didn't have antibiotics until the 1940s. We didn't have plastic in the hospital until the 50s and 60s. So, we weren't running IV fluids, we weren't having any of the things that we've come to expect in just a generation. CMS started in the 60s. We've continued to evolve and we started talking about safety in the 70s. And I think as a reflection of an earlier time and people's assumptions, if you live and you had some sort of positive outcome, even with complications, you were better off than you were before you came in, so you should be grateful. We as an industry have been going through a painful journey to understand that it's not just the laboratory numbers, it's not just the x-ray results, it's not just the outcome of somebody going home after surgery in a certain amount of time. It's really the human experience that they have interfacing the health care system that is going to provide a better outcome for the entire population. And I think taking that even further and understanding that there are historically disadvantaged populations who have not been able to access health care the same way and thinking about things like,"How do we provide the most equitable care? How do we put people in appropriate context of their lives by understanding their social determinants of health?" Taking all of those things into account like a tapestry and bringing the best possible medical care, which I believe we have here at the Texas Medical Center, and delivering it in a meaningful way that helps people, makes them feel good about their experience and then encourages them though their positive experience to continue taking care of themselves is really what the mission is about.

DR. SCHAAL:

Yeah, so you're executing on really three major domains, which is safety, quality, and then experience. Let's unpack these three for just a little bit for our listeners. What does safety mean, and you know, what is your team doing to ensure that our patients are safe?

DR. TITTLE:

Safety is the first priority always. We have conversations every day about safety. We talk about different aspects of safety. The correct patient, the correct care, the correct medication, the correct documentation. Everything that is a key step in this complex ecosystem of delivery of care with all these moving parts, they have to function appropriately. And like any system that is primarily human-dependent, there is expected error. Our goal is not to pretend that there are no errors, our goal is not to expect that there are no errors. Our goal is to build a system that's so resilient that errors are caught before they reach the patient.

DR. SCHAAL:

What are we doing here to do that?

DR. TITTLE:

We do something called, "Stop the line." So, if anyone is uncomfortable with any part of the process that doesn't appear the be going according to how it's planned, it is our sacred duty to raise our hands and say,"I'm not comfortable that this is safe." And then the process is reexamined, and we make sure and verify that these things are appropriate, and then we proceed with care. We celebrate people who stop the line. We celebrate people who are brave, people who want to make sure --

DR. SCHAAL:

How do we celebrate them?

DR. TITTLE:

Oh, we give them awards, we recognize them in front of the board, we were able to celebrate on an annual basis our greatest catches. And really, that is a great way to think about it. However, it's not the only way to think about it because at the end of the day, we don't want everyone to have to be a hero, we wanna build the systems such that the error rate is incredibly low. And that involves a lot of thought, a lot of engineering, a lot of designing so there are multiple fail-safe points, so someone you love doesn't get the wrong medication and have a terrible outcome.

DR. SCHAAL:

So something -- you know, somebody spoke up, somebody stopped the line, there was a great catch. Do we follow up? Do we do anything after that? Or what do we do here?

DR. TITTLE:

When we find these errors, we have process engineers, we have safety specialists, we have data analytics, we have a whole team of people who can come in and unpack these processes and say,"We're not doing this right. Let's get together and figure out a better way to do this." And it could be as simple as delivering the wrong meal to a patient who's diabetic. And we have great ideas from the staff who is delivering the meals to say,"You know, I think we could do this better." And it is our job as leaders, I believe, to hear everyone's ideas, work on the ones that make the most sense, and standardize them around the system so people get these resilient processes.

DR. SCHAAL:

And so, your responsibility and your team's responsibility is really to share these best practices all across the system but also say, this is the best practice today, and tomorrow, we may have, like, a brilliant idea from one of our frontline people that we can do it even better. Is that correct?

DR. TITTLE:

That's absolutely correct. We have to listen as leaders. We have to listen in safety because anyone's concern about safety in and of itself is an issue that we need to address. If someone isn't seeing the whole process and feel it's unsafe, then we can educate them. If someone has appropriately identified we have an unsafe process, we need to value their opinion, we need to celebrate their bravery. We need to foster and increase psychologic safety so we have more of those feedbacks and then we need to address the underlying problem.

DR. SCHAAL:

So, that's safety. Now let's move on to quality. Always when -- you know, I speak with different chief quality officers here at Houston Methodist, but also, other areas of the country, people start, kind of, blurting all these metrics. What are these metrics about and how do we, at Houston Methodist make sure that we are on top of all of this?

DR. TITTLE:

That's a big question. There are a lot of metrics and they are continuously evolving in health care. I think early on when we were talking about the history of quality and the development of quality in the American health care system, there was a lot of challenges with data, and attribution, and how people felt about metrics and being measured, and this independent streak that we have in practitioners that didn't want to be compared to other people. We've moved past that, I believe, overall, as thought leaders in American health care. And we understand that we have to measure things that really matter. So, hospital acquired conditions. If you get a catheter placed when you're in the hospital and you get an infection from that, that's really due to a failure of the process. And so, we measure complications of care, however you want to define it, all the way down the line, outcomes and efficiency, effectiveness. We're starting to measure things about social determinants of health because we do understand that that affects patients quite dramatically. And the metrics that we're using I believe are only going to expand. And in the coming AI era, I think the entirety of everyone's stay is going to be assessed regularly. Now, we use Vizient, which is our true north balance score card. It's very comprehensive. Probably the best in the United States right now, that's what we believe. And so, we measure all of our hospitals against Vizient. And I'm very proud to relay that as a system, we are one of, if not the highest performing systems in the United States on the Vizient score card, and it is extremely stringent. It covers all aspects of safety and equity.

DR. SCHAAL:

Yes, and I think that every single employee knows that, you know, we are measuring, and the measurement and also the comparison of ourselves to national benchmarks helps us get better, helps our patient get better care, and also helps us in these large meeting of Vizient we learn from others. We share our own experience and we learn from others. And you know slowly, slowly we evolve. I would like to also touch on patient experience. A lot of times when I talk to physicians, they say,"Well, you know, I need to say tough things to my patients because they really need to be on top of either their medications or their habits, they need to stoop smoking. So, I need to, kind of confront them with very tough information. So, I would like to ask you about patient experience. What is it exactly and is it really about making people happy with you?

DR. TITTLE:

What an interesting viewpoint. I think that the perception is making people happy is not the same as experience. Experience comes back to what we talked about, people, I believe, wanna feel safe. People want to feel like they're involved with a high quality institution. People are entrusting their lives and the lives of their loved ones to us. They wanna know that people care. They wanna feel it. There's an emotional component to being sick. There's an emotional component to recovery and we can't underestimate that. There's also a strong desire, I believe, in most patients to want to know that their health care team is talking to each other. They wanna see them, they wanna talk to them, they wanna ask questions. I don't think people are going to have a bad experience when they learn difficult things as long as the difficult things are explained to them in a respectful, meaningful way. And so, a lot of the coaching that we've had with any of the physicians that we've worked with in the past has not been,"Don't tell them the difficult truths," but tell them the difficult truth in a meaningful way, in a respectful way, in a way that they can hear you. I've had the blessing and the responsibility through the course of my clinical career to tell a lot of people that they had cancer. There's a way to do that that accepts and appreciates and values the gravity of that situation because I may have told four people that day that they have cancer, but for each one of them, it is a life-changing event that they will remember for the rest of their lives. I need to respect that and I need to use words and speak to them in a way that reflects my understanding of what they're going through at that time, and also shares with them the options, the treatment, and gives them a meaningful way forward in each one of those situations. Now, to me, that's what a keystone of the patient experience is.

DR. SCHAAL:

Another aspect of patient experience in the modern world is that medicine became so complex and so subspecialized that in order to take care of patients, and you gave an example of a cancer patient, it's really not one physician. It's multiple specialties, you know, specifically in cancer, you have, you know, imaging, and you have people that are oncologists, and you have the surgical team. And they all come to see the patient but sometimes, from the patient point of view, it's like,"I -- who is the boss?" And that creates really a challenge. What are we doing here to make sure that all our hospitalists, our specialists, and people who are taking care of the patients, including nurses who are not physicians, they are all on the same page and they are all, you know, delivering one message that is highly informed by, you know, all the opinions?

DR. TITTLE:

Yeah, you're exactly right. Everybody wants the right hand to know what the left hand is doing for lack of a better analogy. There's a lot of logistics behind this, there's a lot of culture behind this, there's a lot of change behind this. And I think everyone who's worked in a complex health care system can appreciate that communication, while we have more and more channels with which to communicate, can be more challenging. I have to confess, I just saw a Teams message from Monday because I haven't checked Teams chat because there's 50 other ways that people communicate. And it can be difficult. So, we try to approach this from a common sense, logistics standpoint where we simplify the channels of communication. We have the medical staff agree on a platform that they're going to use to communicate. We simplify call schedules so people can know who the specialists are who are available. We try to coordinate care under the auspices of the hospitalist who is primarily responsible for the patient when they're in the hospital. We need to make sure that there are appropriate hand offs from inpatient care to outpatient care. So, the primary care physician who has seen that patient 80, 90% of the time is fully informed as to what happened during their stay. It's a lot of moving parts, it's a lot of complexity, but at the end of the day, one of the beautiful things about it is all of us really do care, and all of us really do want the best care for our patients. And so, breaking down the obstacles to good communication is part of our role, very specifically.

DR. SCHAAL:

Yeah, so kind of limit the options of channels of communication, and then really, because we communicate so much online by text and written messages, maybe also, maybe you can speak about that. Have an opportunity to come together, different specialties by the bedside and discuss the patient, you know, as a team. Talk a little bit about that. What are we doing here?

DR. TITTLE:

Oh, you're getting right into the area that I love so much. In this era of digital communication, I personally feel like we are losing a little bit of the beauty of face-to-face communication. And the human contact aspect is an irreplaceable component of health care. Bedside nursing, could you imagine hospitalizations without bedside nursing? Can you imagine health care without somebody to hold your hand when you're going through a difficult time? That can never be replaced. There is nothing that takes -- there's no substitute for that. I believe that people do very well when they sit down face-to-face with their health care provider team and have conversations. And one of the things that we did at Baytown when I was there, is we instituted a program where every day, on every unit at the exact same time, the physician, the nurse, the social worker, the case management, the pharmacist, the physical therapist, and sometimes the specialist walked around as a team from patient to patient room. The patients knew what time it was going to happen, the families were invited, they came in with lists of questions, and we met with every patient face-to-face, and that's still going on today. At the end of the day, I think that that is an irreplaceable component of health care and we're encouraging the expansion of that program at Houston Methodist all around.

DR. SCHAAL:

That's wonderful, and I think it's so important. And again, I absolutely agree with you that, you know, as we have more and more machines, more and more artificial intelligence, there's also a very important spot for natural intelligence, and also, you know, emotional intelligence that machines cannot give us yet. Tell us a little bit about high reliability. I know you're leading an effort for Houston Methodist to become a high reliability health care system. What does that mean and what does that entail?

DR. TITTLE:

I believe that we are already well down the pathway of high reliability at Houston Methodist. I believe that there are further developments that we can go into on the high reliability. And I understand that it's a bit of a corporate catch word at this point, and some people view high reliability as just the latest flavor of the month.

DR. SCHAAL:

What is it?

DR. TITTLE:

It's really designing a human-based system to learn from mistakes, re-engineer processes so they are less prone to errors, and to emphasize the expertise of people on the frontline. So, at the end of the day, you would take something like the airline industry which had crashes, and we use this analogy all the time, right? When's the last time there was a commercial airliner that crashed in the domestic United States? I think it was something like 16 or 17 years now. That did not happen by accident. That is not just because the machines are better. It's because there are checklists, and there are reviews upon reviews. Simple things like is the landing gear down? There are multiple fail-safe checks for that. And it's been a culture change for us to incorporate those sorts of things in our medical practices, but at the end of the day, we all know that if we use a checklist and we go through itemized review of surgically appropriate issues prior to the operation, we have less complications, we have less wrong site surgery, we have less wrong patient issues. There are a number of different things on that, but it's a mindset, it's a culture, it's a group of people who have bought into organizational behavior that is really at the edge of organizational psychology, science. How do we get groups of people to perform highly? We use high reliability principles.

DR. SCHAAL:

So, you believe that we can become like the airline industry and really decrease, you know, medical errors to almost reach or maybe reach no harm?

DR. TITTLE:

I believe we have to. I believe that all of us listening, all of us talking, all of us here, all of us everywhere are eventually going to be patients. And it is our duty, our highest duty as physicians, as health care providers to make safety our first priority. And so, using whatever available science we have to get there including psychology and organizational behavior, it's our responsibility to do such a thing. And the only appropriate target is no harm.

DR. SCHAAL:

Fantastic. Thank you so much for leading this for us. Let's talk about the Quality and Patient Safety Institute that we are launching at Houston Methodist. Why do we need it and what do we aim to accomplish?

DR. TITTLE:

This is a real passion project for me and a lot of people here. I know it's a passion project for you. It's -- the whole idea is we have to train people. We have to pass the knowledge along. One of the challenges that we have in organizations like this, I believe, is something that we see in a lot of organizations where you have that one person who has all the knowledge in their head, and we go ask them. And we don't have institutional knowledge, we don't have documentation that's periodically updated. We're reliant on oral history and tradition being passed from one group of people to the next. And there's always some loss in that. There's not a perfect transfer of knowledge down. So, building an institute where we use those highest levels of organizational knowledge, documented, reviewed, taught in a constructive way, bringing everyone in in a spirit of inclusivity to make sure that the nurses, the physicians, the medical students, the techs, everyone who wants to access the cutting edge, state of the art quality theory can join us and can learn that we also do research. And I heard an incredible comment about that. There's a lot of excitement about biomedical research and nanotechnology and gene therapy. That's great. What's also great is safety research and understanding organizations and how they function. Safety research, the great Dirk Sostman said,"We can take to the bedside tomorrow." So, there's an immediate return on that investment of time, money, and effort to say,"We can make this safer tomorrow." So, there's the teaching aspect, the research aspect, and there is the organizational development aspect. So, we're training the next generation to not only be as good as we are today but really giving them the foundation to move past us and make the next iteration of this a superior one.

DR. SCHAAL:

It is a passion of mine specifically, because you know, you and I work together, and we see that when we want to appoint quality officers and even when we do national searches, still today there's a paucity of individuals that actually have a background in what does it mean, you know, the science in quality and patient safety simply because we don't learn about it. I do highly believe that this is going to change in the next decade where medical schools are going to teach that in their curriculum. We already see residency programs mandating quality education, quality project -- quality improvement project as part of the residency program. So, we here at Houston Methodist, I believe are positioned in a unique way to be a leader in that so we can teach the next generation, publish research about it and then, you know, share the knowledge. You know, I've been in academic medicine my entire life and I see that when you teach and when you talk about anything, you actually learn, and you improve, your students improve, the world becomes a better place. So, I highly believe in that. And so hopefully you know, next time when we sit here in a podcast maybe a year from now, this is gonna be a reality, we just kicked that off. I would like to ask you a question that I ask all my guests here at the podcast, and this is what does quality mean to you?

DR. TITTLE:

This is the most fun question of all because everyone has a different answer on the podcast that I've heard. And I think that I've actually struggled with this thinking,"When I'm on the podcast, how am I going to answer it?" And I can tell you that I'm no closer to an answer than I was before. I believe that teaching a class about quality, I used the whole first session to have a discussion about what does quality mean. And everyone approaches it differently. I think that at the end of the day, quality means different things for different people all the time, and we have to respect that. What quality looks like for me is a very specific viewpoint of cardiothoracic surgeon who's Assistant Chief Quality Officer. And so, my perspective is going to be different from, say, someone in the community who comes in and accesses this. My goal is to make their version of quality come true for them. And so, at the end of the day, quality of health care is people can access it, people are safe, people get appropriate therapy without errors, and they have an enriched life afterwards where they are more apt to access health care and be the best versions of themselves. How to build that is really the great mystery that we're all working on. What is in everyone's mind? What is in everyone's attitude? What is in everyone's spirit, you know, when they come to work? Are -- does everyone have the same goal to produce that? This is where we are with quality I think in the 21st century.

DR. SCHAAL:

What I loved about your definition, and you're absolutely right, everybody gives me a different definition, and that's why I also love this question a lot. But what I loved about your definition is that you mentioned the life afterward. So, sometimes we forget that people actually do not want to be in the hospital. They don't enjoy being in the hospital. They have to. You know, this is an episode in their life but they wanna live and they wanna live without being in the hospital. So, that's part of the quality definition, to allow them to be the best selves after this hospitalization episode. So, thank you very much Dr. Shawn Tittle for that. We learned a lot from you today, and I very much enjoyed our conversation.

DR. TITTLE:

Thank you, Dr. Schaal.

DR. SCHAAL:

And thank you for listening. Quality Time is part of Houston Methodist's"Leading Medicine" series of physician-led podcasts. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. If you enjoyed our conversation today, please consider rating this episode and sharing it with your colleagues. I appreciate your support. Thank you, and until next time, I am always listening.♪ ♪