Later this month, Kaiser Permanente Washington will welcome Rita Mangione-Smith, MD, MPH as our new vice president for research and health care innovation and executive director of Kaiser Permanente Washington Health Research Institute (KPWHRI). An investigator at Seattle Children’s Research Institute and chief of the Division of General Pediatrics and Hospital Medicine at the University of Washington (UW), Dr. Mangione-Smith talks in this Q&A about what shaped her career as a leading scientist and research leader in pediatric quality improvement.
Yes, as far back as I can remember, probably since I was 5 years old. I wanted to be a heart surgeon, but in medical school it became obvious to me that surgery was not a lifestyle I would want. I really value having a family and work/life balance.
During my rotation in pediatrics at Wayne State University, I worked with a physician named Yvonne Friday in Detroit. She had passion for teaching families about preventive care. She knew every resource in the community, and she would plug people in. I thought, this is what medicine should be about: Taking kids who have so much potential and infusing them and their families with good ideas about health—and hopefully preventing a myriad of problems later on.
I think it’s a big opportunity. Many conditions that KPWHRI has studied have their seeds in childhood. We can be thinking multi-generationally—taking into account their genetics and social determinants. We can be thinking: How do we optimize health, not only for the child, but for family members who have already passed into adulthood, and those who are elderly?
Not immediately. I want to focus on the institute’s mission and vision, asking what our strategic plan should be for the next three to five years. If time allows, I may go back to doing some clinical work eventually; it has often driven my research agenda.
When I first started, one thing that got under my skin—and I always tell people to research the things that bother you—was variation in care around upper respiratory infections. I would see one provider zealously give antibiotics every time, and another provider tell parents, “This is a virus. Antibiotics aren’t going to help.” So I started to question people in my residency: “What’s your rationale for treating bronchitis with an antibiotic?” And they might say, “That parent wouldn’t be happy if I didn’t send them home with an antibiotic.”
That led me to the literature to see who had studied parents’ and physicians’ expectations going into these visits, and what might those expectations do to decision-making? The literature had almost nothing. So in my fellowship training at UCLA, I designed my project around this. We queried parents’ expectations before their visits, audiotaped the visits—and queried them afterward about their satisfaction. We had physicians do surveys after the visits. We asked, “Did you think this parent wanted an antibiotic?” It helped us understand those connections.
My main mentor for that study was Beth McGlynn, who was at the RAND Corporation and is now vice president of research for Kaiser Permanente nationally. She said, “You realize you’re doing quality-of-care research?” That’s when I started seeing research questions all over the place.
I replicated that study in a larger group of much more racially and ethnically diverse practices in Los Angeles. We found clear communication patterns were associated with satisfaction. From this, we developed an intervention we called “DART”—dialogue around respiratory illness treatment. It worked well, decreasing prescribing significantly. And the provider reaction to the intervention is really positive. I think that comes from developing it by watching what actual providers were doing. It came from the front lines.
Yes, I understand that Kaiser Permanente has been addressing antibiotic prescribing for upper respiratory infections. And my next goal is to see if the DART intervention will translate into encounters with adults. My other work will continue to focus on implementing evidence-based quality measures on the front lines to better understand where gaps in care exist. We then do stakeholder-engaged collaborative work to develop and test interventions on those areas, aiming to understand how to change the system to improve care.
Mentoring people in my division was definitely the most rewarding part of the job. When I received a large center grant in 2011, I could bring younger investigators in and say, “Here is this cool study. Do you want to lead it? Here’s how we do quality measure development. Here’s how we assess improvement.” I saw that the more people I can train and mentor, the faster we can improve care for kids and move the quality agenda forward.
This is going to sound so simple, but it’s understanding how to listen. People would ask me, “What’s your vision of where we should go?” And I would say, “What’s your vision?” These are such smart, innovative people. I had to get stakeholders into a room and brainstorm: “If we want to shake things up and move child health forward, what should we do as a group of professionals in this field?” Creating a shared mission and vision—and strategic initiatives based on that—was some of the most enjoyable work I have done.
Of course, the real job happens after that, working with people who are really committed and holding them accountable. If I’m working with people who have commitment and passion, then I don’t have to do it all. I just say, “Here are the ideas we came up with, here’s the plan. Go!”
We’ve got a group of nationally recognized researchers who are doing such profoundly important, innovative work. We’ve got the learning health system, which is the work that I live and breathe. It’s at the intersection between research and clinical care. We can learn from the clinical side: What’s working? What isn’t? What should the research priorities be? That to me is so exciting.
People who gave me the license to try things that were out of the box, to push the edges. For example, when I was doing that fellowship study, one faculty member said, “This is ridiculous, this is not a fellow’s project.” But when I went to Beth McGlynn, she said, “You go do it!” Some other people said, “No, you’re not crazy. That’s going to be hard, but you’re going to learn a tremendous amount.” I’ve held onto that. I’ve seen that when the path is hard to get what you really need to answer a question, you do it, understanding that you may be taking a risk. If it gets the job done, it’s so worth it.
Another turning point was when I came to Seattle and met Fred Rivara, who was head of the UW’s Division of General Pediatrics—and is a longtime KPWHRI affiliate investigator. He asked, “What’s your research mission?” And I thought, “Wow, nobody has ever asked me that.” I said, “There are serious gaps in the quality of children’s health care. I want to understand those gaps and develop interventions to close them. Then I want to see if we got it right. And if we didn’t, I want to try again. Because so many children around the country are vulnerable—and we as pediatricians and researchers can make a difference.”
Then Fred said, “Write that down.” I thought, “That’s kind of weird,” but I did, and that was a lifechanging moment for me professionally. People recently asked me, “Why did you go for this Kaiser Permanente job?” I said, “Because that’s what I see myself doing, based on my professional mission.”
[Laughing.] I am very focused on eating. My father’s parents emigrated from Sicily. I remember when I was very young watching my grandmother in the kitchen and all the socializing and very loud banter around her table. So that’s been a constant. With my own family, no matter how busy our lives got, we always sat down to dinner together. My son once said, “You know, Mom, some families do sports together, some families hike together. We eat together!”
We recently went to Italy, where I learned about “aperitivo.” It’s lovely! In the early evening, you relax together with charcuterie, cheese, bread, and little bit of wine. Then you have dinner around 8. That’s what my husband and I have always done, but we didn’t know it had a name. So I said, “Aperitivo! It must be genetic!”
KPWHRI will host a reception with aperitivo to celebrate our leadership transition. The event will be held from 3:30 to 5 p.m. on Thursday, September 5 in room 1509A at Metropolitan Park East. If you would like to attend, please RSVP to firstname.lastname@example.org.
Rita Mangione-Smith brings expertise in quality improvement and health systems from leadership posts at Seatte Children's and UW Medicine.