Image: Calie Santana (General Internal Medicine), Assistant Professor and Associate Director of Quality
In response to increasing demand for higher quality of care from regulatory and accreditation bodies, patient groups, and payers, Dr. Calie Santana (General Internal Medicine) has been recruited as the Einstein-Montefiore Department of Medicine’s Associate Director of Quality.
In this newly created role, Dr. Santana, who joined the Department in August 2008, will assess clinical divisions' needs, evaluate local research translation efforts, and help create a quality improvement agenda. Additionally, Santana is a Montefiore Comprehensive Health Care Center (CHCC) clinician, where she precepts Primary Care and Social Medicine program residents.
A graduate of Cornell University and Harvard Medical School, Santana discovered her interest in quality improvement following her internal medicine residency at Weill Cornell Medical College. In her first year of faculty practice, she was surprised by her diabetic patients’ health measures. “I saw the results of my patients’ blood pressure control, cholesterol, and sugar levels and realized I wasn’t practicing nearly as well as I’d thought I was,” she said.
Knowing that her own performance was part of a much larger picture, Santana began to examine different primary care clinic models and their effect on the quality of care provided. She went on to complete the Robert Wood Johnson Clinical Scholars Fellowship Program at Yale University, focusing intensively on factors that drove certain clinics to outperform others, particularly in settings of care for the medically underserved.
Treating diabetic patients prepared Santana well to launch and support a multifaceted healthcare improvement initiative. As an attending, she learned first-hand the complexity of clinical inertia in insulin prescription, including issues of physician reluctance, patient resistance, and system-level barriers. As a fellow, she participated in the Fairhaven Community Health Center’s implementation of a promising diabetes screening and prevention program that offered nutrition counseling and exercise classes to at-risk families. By capitalizing on the immigrants’ social networks, the clinic’s initiative raised awareness and multigenerational support of healthier lifestyles, provided employment, and helped the community grow. However, it also revealed the clinic’s areas of need, including staff to conduct glucose tolerance tests and provide individual counseling and education. Watching the clinic struggle to realign and respond, she learned how even the best-intended endeavors can strain limited resources, especially in underserved population settings.
Working with immigrant patients in Boston, Ithaca, New Haven, and New York City has given Santana a vantage point for localized healthcare trends. In Boston, she was struck by patients’ loyalty to particular hospitals or institutions, Patients in the Bronx have a similar commitment—more so than Manhattan, she thought—though Montefiore’s longstanding relationship with the community likely plays a significant role. Regardless of the geographic area, quality improvement issues are the same: overwhelmed doctors and nurses, the impetus to see outpatients quickly, and an increasing complexity in patients’ conditions.
“I’m more of a lumper than a splitter—I tend to step back and look at the interaction between patients, providers, support staff, administrators, and other parties involved,” said Santana. "I’m always looking for an alternative explanation for the different ‘waves’ of healthcare, and I look to the next layer up to find it.” She believes that a strong, well-organized system is fundamental for quality improvement; even the most qualified, altruistic individual providers cannot serve as a sole arsenal of a system’s quality.
In her first months, Santana’s mission is to discover precisely where and how Einstein-Montefiore can better serve patients. She is collaborating with Dr. Rohit Bhalla, Montefiore’s Chief Quality Officer, to identify in-need areas of inpatient care, specifically within the Department of Medicine. Acute coronary syndrome and chronic heart failure will be among those first to be addressed. Through site visits with outpatient offices and clinics, she will evaluate current initiatives, identify the most critical areas, and create an agenda for quality improvement. Conversations with residency program directors will help her determine the gaps in systems-based learning. As a preceptor for the Primary Care and Social Internal Medicine program, she aims to further residents’ knowledge of quality improvement from a top-down perspective. “Most residency curriculum focuses on treating specific conditions and working with patients in a deep one-on-one context,” she said. “But residents also need to know how their system of care can support what they do, and how healthcare quality initiatives can help them set better goals for their own performance.”
She has a few ideas already—including forming interdisciplinary task forces to improve patient care performance measures—but knows that she needs to gather more information first. “Even if I had all the answers, I would still need to proceed cautiously. Endeavors that have succeeded elsewhere need to be tailored to our local reality. Montefiore has both a large inpatient system and many small provider settings, and each operates differently, so the incentives that work for one won’t work for all,” she said. “I’m excited to figure it out—it’s a great time for me to be here.”