1. Elizabeth A. Martinez, MD, MHS Johns Hopkins Medical Institutions September 10, 2008 Organization of Care and Outcomes in Cardiac Surgery AHRQ grant 1K08HS013904-01A1 Building a Health Services Career

3. Background Interest in research as a senior resident and fellow Stepping stones ♦ Became involved in ongoing projects ♦ Took advantage of “evening” classes in research

4. Life prior to the K Stayed involved in multiple projects ♦ NO theme ♦ NO expertise ♦ NO advancement ♦ NO likelihood of independence I did have a mentor

5. Building a Health Services Career Personal Career Goals: 1.Develop and conduct the proposed research ♦ Define area of interest ♦ Develop the research protocol and grant ♦ Core curriculum required 2.Develop into an independent investigator ♦ What does it take? 3.Become a leader in Health policy

6. Building a Health Services Career How to achieve the goals: Define area of interest ♦ Define your passion ♦ What links your experiences? ● Clinical ● Research ● Personal

7. Life prior to the K Further focused my clinical and research area of interest ♦ Became more involved in performance improvement and patient safety projects in cardiac surgery Identified sub-areas of interest/potential research questions Further recognized my limitations especially when it came to measurement, analysis and transforming care. Participated in the GCRC grant review committee

8. Applied for University Support Recognition of limitations Interest in pursuing an advanced degree ♦ Precedence in our department Encouragement of my chairman and mentor Johns Hopkins University ♦ Sought to gain local support first Johns Hopkins Clinician Scientist Award

9. Life prior to the K One of the courses included “grant writing” ♦ Helped with focusing thoughts and first iterations of the development of my abstract for the eventual grant. ♦ Broke it down into manageable pieces Overwhelming at first Made the psychological commitment to complete the grant ♦ Johns Hopkins University Clinician Scientist Award first ♦ If it were easy, everybody would be doing it!

10. Life in K-Limbo Resubmitted the grant twice to AHRQ Challenging to wait for funding ♦ Some delays in funding with a “fundable” score ♦ Proposed project most appropriate for AHRQ Some experience with NIH and couldn’t find a home for this type of grant proposal Started to (needed to) consider alternative career path

11. Life during the K Meet with advisors ♦ High rate of attendance! ♦ Taken seriously with the award— Reflects hard work to get there (writing the grant!) and quality of the planned project – The process of writing the grant (and, of course, resubmitting it!) DOES improve it Pursue advanced coursework in Health Services

12. Building a Health Services Career How to achieve the goals: 1.Develop and conduct the proposed research ♦ Define area of interest ♦ Write the research protocol and grant ♦ Core curriculum required 2.Develop into an independent investigator ♦ What does it take? ♦ How the K08 facilitates this 3.Be a leader in Health policy

13. Building a Health Services Career How to achieve the goals: ♦ Core curriculum required Epidemiology and Biostatistics Health systems Organizational and behavioral change Leadership change

14. Why formal training? Health services and outcomes research is very complex ♦ Need to be an expert in epi, biostats ♦ Need to be able to be address biases ♦ Measurement in outcomes research remains a challenge Need sophisticated background to develop independence and a leadership role

15. Develop into an Independent Investigator Formal training additional importance ♦ Just like lab researchers ♦ Very complex systems that are being evaluated ♦ Need to be an expert in many fields ♦ Form professional relationships Skills in project management Gain experience outside of the proposed project and coursework ♦ National professional societies ♦ Research conferences Broaden professional relationships

16. Life during the K Member of national committee for professional society to develop quality measures for anesthesia Have been asked to represent the American Society of Anesthesiologists in development of national guidelines And, of course, the grant work……

17. Organization of Care and Outcomes in Cardiac Surgery 700,000 cardiac surgical cases in US Hypothesis: Differences in the processes of postoperative care contribute to differences in mortality in low-volume and high-volume hospitals. Primary goal: ♦ Identify the structure and processes of the perioperative management of patients undergoing cardiac surgery that impact their mortality.

18. Organization of Care and Outcomes in Cardiac Surgery Variation in Care ♦ Cardiac ICU physician staffing ♦ Cardiac ICU nurse staffing ♦ Cardiac ICU mid-level provider staffing ♦ Protocols Link variation in care to outcomes

19. Life during the K Completed preliminary site visits to explore current practices in cardiac surgery Developed pilot survey ♦ Iterative process ♦ Survey development course Piloted survey ♦ Lessons learned

20. Life during the K The importance of pilot testing It’s true! Found significant issues with questions ♦ Despite reviewing while visiting sites ♦ Outline a plan to remedy Explore contributors Revise the survey Re-pilot!

21. Impact of research on Healthcare Delivery Significantly advance our knowledge of how cardiac surgical patients are managed postoperatively and how the differences in organizational characteristics are related to their outcomes. Identify strategies to reduce mortality in low- volume hospitals and to decrease variation in mortality within all centers.

22. Become a Leader in Health Policy: Professional societies ♦ Inform/develop quality measures for cardiac surgery Inform insurers whether cardiac surgery should be included in the volume or intensivist measure Prioritization of efforts to improve cardiac surgical care

23. Thank you. Elizabeth Martinez emartine@jhmi.edu