Accountable Care Organization

Episode 56: Natisa Dill on Patient Safety and Care Variation

January 2024

Unwarranted care variation is often discussed in terms of its impact on cost. But there’s another dimension to care variation that is perhaps more important: its impact on patient safety. In this episode, MaineHealth Medical Group’s VP for Quality and Safety, Natisa Dill, discusses variation’s profound impact on safety and steps to mitigate it.

Mike: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Mike Clark. My co-host Heather Ward is away this month. So, we're kicking off the new year by bringing you a new perspective on, wait for it, unwarranted care variation reduction. We often look at care variation through the lens of cost savings but turns out there's a strong relationship between variation and patient safety. Coming up, MaineHealth Medical Group's VP for Quality and Safety joins us to make the link.

Mike: The reduction of unwarranted care. Variation is a pretty hot topic here at BACON, and a major focus of the MaineHealth ACO this year. Why you ask? Well, because unwarranted variation can lead to increased cost of care with no appreciable benefit to the patient. And sometimes care variation can lead to real patient harm. Here to talk about this aspect of care variation is Natisa Dill, the MaineHealth Medical Group's VP for Quality and Safety. Natisa joined MaineHealth in 2022 after more than 19 years at Kaiser Permanente in California. She holds a PhD in executive leadership, an MBA, and numerous certifications in patient safety and health care quality. This is truly her area of passion. Natisa spoke to our producer, Paul Santomenna.

Paul: So, Natisa, tell us a little bit about your work as the VP for Quality and Safety for the Medical Group. What's your mission? What's your primary mission?

Natisa: Well, thank you so much for having me. And as the Medical Group VP for Quality and Safety, I was really hired to create a structure and build and develop a team to drive quality and safety throughout the Medical Group that are really help improve patient outcomes in the workflows and systems for our care team members, physicians and APPs. And so, simply put, I was hired to help us work together to make our communities the healthiest in America because, as you know, working together as a medical group is still new. And I would say we're in our toddler years. So as a Medical Group leader, my work spans across all three regions, into the state of Maine and into New Hampshire. And we have a little over 300 practices. When I was looking back for fiscal year 23, we saw about 100, excuse me, 1.7 million unique patient visits. And so, I really love that my team and I have the opportunity to impact so many lives. You know, our patients, including our care team members, physicians, APPs. And so, I just really love the work that I do.

Paul: So you're plenty busy, I would imagine. Yes.

Natisa: Most days.

Paul: Okay, well, I wanted to shift over to care variation, which is, you know, a current priority of the ACO. And I think also for you. What do you see as the links between care variation reduction and quality and safety?

Natisa: So unwarranted care variation has a potential to cause medical errors and adverse events, meaning unwarranted care variation can cause patient harm and exacerbate health care disparities. So when I was looking back and reviewing the Joint Commission 2022 Sentinel event data and Sentinel events are the really bad medical errors that caused severe, temporary or permanent harm up to patient death. When I was looking at that, all of the reports for 2022, the second cause of all reported Sentinel events was due to unwarranted care variation, not following, you know, defined standards and just multiple unwarranted care variation. And 20% of these resulted in death of patient. So there's a pretty significant link between unwarranted care variation and quality. And safety care variation can have significant implications on patient morbidity, mortality. There was a study published in Jama surgery that examined the impact of unwarranted care variation on mortality rates in patients undergoing major cancer surgery, and the study found that hospitals with greater variation in care had higher mortality rates compared to hospitals with more standardized practices, so your variation can contribute to increased morbidity rates due to inconsistent adherence to best practices and guidelines. And, you know, for example, there was a, um, systematic review that was published in PLOS ONE that found care variation in the treatment of acute myocardial infarctions was associated with higher rates of complications and worse patient outcomes. And I can go on and there are many studies. And patient safety is really a passion of mine. But there's a significant link between unwarranted care variation in the outcomes of our patients.

Paul: Yeah. I wanted to talk a little bit about how you define unwarranted care variation and maybe how the ACO has, um, so, you know, the ACO kind of defines it in financial terms as a way, as sort of low value practice or procedure that's performed by a provider habitually when a higher value option is available. So like prescribing an expensive medication when there's an equally effective but less expensive one available. But what you're talking about is a little bit different, right? It's not about a procedure that isn't efficient. It's about care variation almost. I would describe it as going sort of variation is sort of going off the rails completely. So can you, can you talk about the different ways to interpret what care variation really is?

Natisa: Yeah. So I look at it as, um, variation in care outside of established best practices and are not related to a patient's specific medical need that has a potential to cause harm to our patients. So unwarranted care variation can really increase the likelihood of medical errors. And when health care providers follow different practices, there's a higher chance of mistakes, misdiagnoses, and inappropriate treatments that lead to adverse patient outcomes and complications, infections. You know, inconsistencies in care can result in inadequate monitoring, delayed interventions, suboptimal treatment choices, really putting our patients at risk. So care variation can really exacerbate health inequities as certain patient populations receive inconsistent or substandard care based on factors such as socioeconomic status, race, ethnicity, geographic location. These can lead to disparities in health care outcomes and patient safety. Unwarranted care variation can lead to increased health care costs, right inefficiencies, redundant tests, unnecessary treatments arising from inconsistent practices that can escalate health care expenses without providing additional benefits, and really, I know we're focusing on patient safety, and I just want to underscore the importance as well as the increased cost, because the patient population that can't afford healthcare costs is growing.

Natisa: And when we're not excellent financial stewards, it impacts patients. And working people cant afford to pay their health care bills. You know, last year I got Covid for the first time, and I had to go to the E.R. and as a former E.R. nurse, I was basically forced to go to the E.R.. I was passing out, I couldn't breathe, I was having shortness of breath, all these different things. And um, after I left, I was welcomed with a $1,500 bill from the E.R.. And for some patients, that's their rent, right? Their rent is $1,500. So now they're deciding, do I pay my rent or do I pay this bill? I also earlier this year, I had injured myself from working out and had to get an x ray. Well, then I was blessed with a $400 bill. So some people are living paycheck to paycheck. Some people can't even they don't even have enough with their paycheck. And so really care variation, increasing costs is significant. And so sometimes patients are afraid to even come in to see us because of the bill. So I just wanted to underscore that significance as well.

Paul: Yeah. Thanks for mentioning that. That part of it. Yeah. So what are some key steps you think that the that a health care system can take and providers can take to, to reduce unwarranted care variation.

Natisa: So I think the most important thing is enhancing communication and collaboration. I know I had mentioned those Sentinel events before, the really bad medical errors, and number two was unwarranted care variation. But the number one root cause for those errors were ineffective, inadequate, or lack of communication. So one of the most important things we can do is have, enhance our communication, collaboration, have a common language in which we speak to each other, in which we can provide psychological safety, in which we can stop the line if someone is deviating from a standard of care. And I'm excited that at the beginning of the year we're going to be rolling out TeamSTEPPS, specifically CUS, it's an acronym. It's a communication tool that stands for "I'm concerned, uncomfortable, this is a safety stop." So really looking at how can we improve our communication and collaboration across the Medical Group. And then another thing is standardization and evidence-based practice. And I know that standardization sometimes can seem like a four-letter word, but really, its removing unnecessary variation, you know, standardizing of clinical pathways, developing, implementing standardized protocols that can help ensure consistent and evidence-based care across the health care setting. And so, these thse pathways outline the optimal sequence of interventions for specific conditions, reducing unwarranted variation in the practices. So enhancing communication and collaboration, standardization and evidence based practice. And then also continuous quality improvement. So our CQI. So implementing CQI processes allows for ongoing monitoring evaluation improvement of health care practices. And this involves collecting and analyzing data, identifying areas of care variation, and implementing targeted interventions to standardize and enhance patient safety. And finally, just utilizing our electronic medical record a little bit more. Leveraging a EHRs and health information exchange systems can improve communication, care coordination and data sharing. So those are the main things.

Paul: Great. I was going to ask you to get specific about what what MaineHealth is doing. But you just did that. So that's that's fantastic. What's going to be deployed in the near future. I guess as another question, more on a more kind of individual level is, you know, what could an individual provider care team member? Is there some kind of behavior that they can change or that they can, you know, adopt to improve care variation, you know, is there like an immediate thing that I could do, say as a provider?

Natisa: I think. Be informed and be aware of protocols, evidence based practice, uh, understanding that we are a medical group so we don't have to recreate the wheel. You don't have to work in a silo. You can reach out and phone a friend if there is some sort of patient condition that's presenting that seems a little foreign. You know, again, knowing our protocols, evidence based practice within the different medical specialties, those are pretty significant. And then also just acknowledging that we are a team and that one person is not responsible for anything. So remaining humble, asking questions when without proceeding in the face of uncertainty is something that we can do as well.

Paul: Yeah, that's a that's a good reminder to have if you're if you're feeling uncomfortable to just stop and look for help. Right. Okay. Anything else you want to add? Um, while we have you here on BACON.

Natisa: Uh, yes. On BACON, uh, making me hungry. So yes, I wanted to just share some of the exciting things that we're working on that's going to impact care variation reduction. And so last year we focused on building out an infrastructure, building out a team for quality improvement, side of quality of performance improvement side of quality. And now we're going to be focusing on safety, patient safety. So really excited. We are building out a structure across the Medical Group. So across over 300 practices to really streamline how we do things. And so part of that is developing a no harm index for the Medical Group. So really, really exciting. We for the first time we have a database that looks at our opportunities and near misses within the practices specifically so we can proactively fix our system before it actually causes harm. And we're seeing some trends where there is some unwarranted care variation. So it's exciting that we have opportunity to fix the system right before it actually harms any of our patients. So building out that safety structure, building out the no harm index, really getting to be a proactive organization as a medical group so we can really fix the system before it causes any harm.

Natisa: Also really excited. We are continuing to build out our team so we are fostering black belts. We have more black belts, more people that are more educated. We have some standardized chronic conditions care that's coming out. So evidence based practice on how to manage chronic conditions, specifically in hypertension, diabetes, cancer screening that's going to be rolled out at the beginning of the year. So that's also going to help reduce ambiguity, especially for our care team members. Right. There's be some protocols. So some standard orders that they can take, action in, and really remove as much as many things as possible so that the physicians and APPs are free to do what only they can do. So it's really exciting and really awesome because that frees them up to give more personalized care. It's not exclusive, like standardization really puts the infrastructure in place so that the physicians and apps can give that more person centered care. So really exciting. Some of the things that we have coming up that's going to impact our care team members, physician apps, our patients and really help with that unwarranted care variation.

Paul: Super. Well, thanks very much, Natisa, for your work, your team's work, and for joining us today.

Natisa: Thank you so much for having me.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page And if you have questions, comments or suggestions, we'd really love to hear from you! Please email us at That's Bacon is produced by the MaineHealth, the Accountable Care Organization. Thanks for joining us. We will see you next time.