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THE QUALITY GAP: MEDICINE'S SECRET KILLER Transcript

OPEN:

ANNOUNCER:  This program is part of the PBS Democracy Project.

b-roll: ambulance lights/EMT’s tending patient in home:

EMT 1:  I understand that you’re having some chest pains?

EMT 2: OK.  We’re gonna take your blood pressure here.  

LUCA FRESIELLO:  I thought it was just a bad dream.  I really couldn’t believe anything could, could happen like that. Really.

EMT 1: And the strap’s gonna to go under your arms.

VALERIE KENNEDY:  I’d never been in the hospital.  Gee, I was the healthiest, you know, woman walking around. . .

b-roll:  stretcher into ambulance

EMT 3: Let’s go.

VO/OC

JAY LUBBERS:  It’s something like falling off a cliff and you don’t know when you’re going to hit bottom. 

Cue music

b-roll: pov - ER hallway

ER Nurse 1: Are you still having chest pains?

ER Doctor:  Can you just describe the chest pain for me? Was it a sharp pain? Was it a dull pain?

NARR:  ALL OF US.  WE’RE ALL AFRAID OF WHAT WILL HAPPEN WHEN OUR HEALTH FAILS.

b-roll:  pov – ER exam room

ER Doctor: Alright.  What’s his vital signs right now?

NARR:  WITH SO MUCH AT STAKE, JUST HOW GOOD IS YOUR HEALTH CARE?

ARTHUR LEVIN:  Medical errors kill between forty-four thousand and ninety-eight thousand people a year in the United States.

MIKE McCONNELL:  If the insurance company denied anything he could die.

MARK CHIPPS:  It’s money.  It’s cost over care.  Cost over care.

MARK CHASSIN:  As a consumer, you’re highly likely to be the victim of a quality problem, and not know it.

title logo

NARR:  CRITICAL CONDITION WITH HEDRICK SMITH

ANNOUNCER:  Principal funding for Critical Condition was provided by

The Robert Wood Johnson Foundation.

Making grants to improve the health and health care of all Americans.

Major funding provided by

The California Healthcare Foundation.

Additional funding provided by

The Rockefeller Brothers Fund

And the Charles E. Culpeper Foundation.

Title/bumper

Dip to black

STANDUP:  HELLO, I’M HEDRICK SMITH

AFTER THE REVOLUTION OF MANAGED CARE, AMERICANS ARE ANXIOUS ABOUT HEALTH CARE AS NEVER BEFORE.

 WITH SO MUCH FOCUS ON COST, WILL THE RIGHT CARE BE THERE FOR YOU WHEN YOU NEED IT MOST?  WHAT HAPPENS IF YOUR MOM HAS A STROKE… YOUR CHILD IS CRITICALLY INJURED…OR YOU GET CANCER?

IN THIS PROGRAM, WE TAKE YOU INSIDE OUR SYSTEM TO SEE JUST HOW GOOD IS YOUR HEALTH CARE IN THE CRUNCH ?

THE QUALITY GAP IS HUGE, EXPERTS SAY. … NORMAL MEDICAL PRACTICE IS RARELY BEST PRACTICE …..OUTRIGHT ERRORS KILL TENS OF THOUSANDS OF PEOPLE EVERY YEAR.

AND AS A HEALTH CONSUMER WHAT DO YOU THINK QUALITY MEANS? AN ENDLESS ARRAY OF DOCTORS TO CHOOSE FROM? CONVENIENT OFFICE HOURS? POLITE SERVICE?

WHAT DO YOU KNOW ABOUT YOUR CHANCES OF LIVING OR DYING?   LIKE WHICH DOCTOR OR HOSPITAL HAS THE BEST SURVIVAL RATE AFTER OPEN HEART SURGERY? OR CATCHING PNEUMONIA BEFORE IT KILLS?

YOUR BEST HOPE MAY LIE WITH A NEW BREED OF QUALITY CRUSADERS BENT ON CLOSING THE QUALITY GAP. AND THEIR BIGGEST CHALLENGE IS CHANGING THE OFTEN HIDEBOUND, SECRETIVE WORLD OF DOCTORS.

NARR:  IT WAS A MEDICAL ERROR THAT KILLED KOREAN WAR VETERAN CLAUDIE HOLBROOK. . .   

nat sound/b-roll Holbrook family on front porch:

Sandy Reynolds: Dad was good to people. I mean, he was very, very talkative, um, boisterous personality. Loved to joke. But, he was extremely honest. He talked a lot and cursed a lot.

Reynolds: Here’s some pictures whenever he was in the service...

NARR: HOLBROOK DIED AFTER THE LEXINGTON, KENTUCKY VETERANS AFFAIRS MEDICAL CENTER MISTAKENLY SENT HOME THE WRONG CONCENTRATION OF HIS BLOOD THINNER, HEPARIN.

SANDY REYNOLDS (o/c):  And so one day, h- -- Dad goes to the Lexington VA hospital, and he goes to get his Heparin, same as prescribed -- 10,000 units per milliliter -- and they send 'im home with the big bottles. 

SANDY REYNOLDS: This is the correct medicine.  And this right here is the incorrect medicine.  It's one tenth of the power of this medicine.  

NARR:  THE LARGER BOTTLES OF HEPARIN WERE A FRACTION OF THE STRENGTH OF THE SMALL BOTTLES - NOT STRONG ENOUGH TO STOP HOLBROOK’S BLOOD CLOTTING.

SANDY REYNOLDS:  From there, he got the wrong strength of medicine, and everything went downhill.

NARR:  HOLBROOKE DIED FROM A BLOOD CLOT.  AND TO ADD TO THE TRAGEDY, IT WAS HOLBROOK’S YOUNGEST DAUGHTER SANDY REYNOLDS WHO PAINSTAKINGLY GAVE HIM TWICE DAILY SHOTS OF THE WRONG MEDICINE .

SMITH:  Did you feel that you-all had done anything wrong, that there was something here you could have done differently?

SANDY REYNOLDS:  I did.  I can't speak for the rest of the family, but I did.  Immense guilt.

SMITH:  Why did you feel guilty?

SANDY REYNOLDS:  Because I was the one that gave 'im his injections that killed 'im.

music/OR b-roll montage

NARR:  A BUNGLED PRESCRIPTION. . . THE SLIP OF A SCALPEL . . . A BOTCHED LAB TEST . . . A MISSED DIAGNOSIS . . . THEY HAPPEN ALL ACROSS AMERICA . . .  MEDICAL ERRORS . . . OFTEN FATAL.

. . . THE INSTITUTE OF MEDICINE REPORTS THAT NATIONWIDE MISTAKES KILL 44,000 TO 98,000 PEOPLE EVERY YEAR . . . MORE THAN CAR ACCIDENTS . . . BREAST CANCER. . . AND AIDS.

ARTHUR LEVIN:  Since the Institute of Medicine Report on Medical Errors, I think the genie’s out of the bottle.

NARR:  HEALTH CONSUMER ACTIVIST ARTHUR LEVIN SAT ON THE  INSTITUTE OF MEDICINE PANEL THAT ISSUED THE ERROR REPORT: 

LEVIN (o/c):  The American public knows there’s a significant problem, uh, in injury and death that’s caused by medical error. Now is that best addressed by covering it up?  Or is it best addressed by being open and honest and showing people in, letting them in and saying this is what we’re doing to make things better?

NARR: THE HOLBROOK FAMILY FEARED THE WORST.  AFTER THEIR FATHER’S DEATH THEY BRACED FOR A SECOND TRAUMA. . . A BATTLE WITH THE V.A.:

SANDY REYNOLDS:  I thought they was gonna try to sweep it under the rug and was gonna lay it, like, in my lap.  They was not gonna -- they were going to deny it.  And I was ready for a battle.  I was ready to fight.

NARR:  AND FIGHTING IS THE TYPICAL ROUTE.  HOSPITALS CLAM UP AND COVER UP.  DOCTORS GO FROM HEALERS TO ADVERSARIES…FAMILIES FILE SUIT . . .

GINNY HAMM:  Families go through years of hell, doctors go through years of hell in a lawsuit.

nat sound: 

Hamm:  Office of regional counsel

NARR:  FOR THE HOLBROOKS THE FIGHT FOR JUSTICE MEANT CONFRONTING THE LEXINGTON V.A.’S ATTORNEY, GINNY HAMM:

HAMM:  It’s a very ugly process.  It’s not near as much fun to doctors and laypeople as it is to lawyers. 

NARR:  BUT IT TURNED OUT THE HOLBROOKS DIDN’T HAVE TO BATTLE HAMM.   SHORTLY AFTER CLAUDIE’S DEATH, HAMM MET WITH THE FAMILY AND MADE A STARTLING CONFESSION:

HAMM (o/c):   I told the Holbrook family that we had made the error that we believed contributed solely to his death.

SANDY REYNOLDS:  She said, ‘You were right, Sandy, you know, we were the, we were the ones that killed your dad. It was our fault."  I don't remember the exact words, but it was plain -- very plain.  "We were the ones responsible for killin' your dad."  I -- I started cryin'.  I had to leave the room -- didn't I?

DEBBI PRESTON (o/c):  . . . Yeah. It really got emotional after a few moments of just shock.

b-roll:  Lexington VA Medical Center

NARR: THE LEXINGTON VA’S CANDOR . . . IN STARK CONTRAST TO STANDARD HOSPITAL SECRECY . . . DATES BACK A LITTLE MORE THAN A DECADE.   IN 1987, AFTER LOSING TWO MALPRACTICE CASES TOTALING 1.5 MILLION DOLLARS, HAMM AND HER COLLEAGUES BEGAN CONFESSING SERIOUS ERRORS TO VICTIMS AND THEIR FAMILIES.

HAMM: We called it doing the right thing then.  We didn’t call it disclosure, I don’t think.  I think we just said we ‘gotta tell the family.

SMITH:  How radical a departure for this institution and for you as an attorney is this new approach?

HAMM:  People thought you were absolutely crazy if you suggested an admission of liability. 

SMITH:  They thought you were crazy. . .

DR. STEVE KRAMAN (o/c):  Yeah, they thought we were out of our minds doing this.  This was not the way, this is not the way you handle financial risks to an institution.

NARR: ALONG WITH GINNY HAMM, LOCAL CHIEF OF STAFF DR. STEVE KRAMAN LED THE LEXINGTON VA AWAY FROM ITS OLD POSTURE OF DEFEND AND DENY.

DR. KRAMAN:  The normal way of dealing with these things I, I liken it to hit and run.  Because what you’re doing is you make a mistake, somebody’s hurt, they don’t say anything, nobody else sees, you just go on and you maybe put a little money aside in case they file a suit.

nat sound/b-roll: Kraman with medical students:

Kraman:  so what happened, why did he get malignant now?

NARR:  FOR MOST HOSPITAL ADMINISTRATORS, COMING CLEAN WITH VICTIMS OF MEDICAL ERRORS IS ALMOST UNHEARD OF.  TAKE FOR EXAMPLE, THE UNIVERSITY OF KENTUCKY CHANDLER MEDICAL CENTER WHICH SITS RIGHT NEXT DOOR TO THE LEXINGTON V.A. HOSPITAL. THE TWO HOSPITALS ARE LIKE SIAMESE TWINS,  SHARING MANY OF THE SAME DOCTORS AND STAFF. . . AND EVEN PHYSICALLY JOINED BY A TUNNEL.

DR. JAMES HOLSINGER (o/c):  I believe that there are very few hospitals in America of any kind that are as open about disclosing medical errors as the VA Medical Center in Lexington, Kentucky.

NARR:  DR. JAMES HOLSINGER WAS DIRECTOR OF THE LEXINGTON V.A. BEFORE BECOMING CHANCELLOR OF THE UNIVERSITY OF KENTUCKY’S MEDICAL CENTER.

SMITH:  Is this an approach that you could now adopt here at your hospital?  And would you want to, personally?

DR. HOLSINGER:  Practically, I think it would be extremely difficult to do.  I don’t think we could afford to do it.

NARR:  ACCORDING TO HOLSINGER THE PROBLEM IS THE THREAT OF MALPRACTICE LAWSUITS:

SMITH:  Are you saying then that, that, that whatever you might want to do, that as an institution you cannot afford to be totally open both for professional and financial reasons?

DR. HOLSINGER:  That’s correct.  You cannot afford to be totally open in the, in the private sector because of the, of the litigation issue.  Uh, our attorneys would think that we had, uh, lost what little intelligence we had left if we were to, uh, to do that.  If you go first to the patient and say I think we made an error, then the usually the next thing we deal with is, is a call from an attorney.   

DR. KRAMAN:  So what? So the first, you know, we have no, we tell people to bring a malpractice lawyer. 

HAMM:  The first person I want to hear from is a malpractice lawyer.  A good malpractice lawyer understands the law, they understand the concept of damages, and you can bargain with them and deal with them without worrying about breaking down a very carefully, uh, put together relationship, a fragile relationship like you have with a family.  

SMITH:  What did Ginny Hamm say to you about getting an attorney or not getting an attorney?

SANDY REYNOLDS:  She recommended, what I thought was unusual, she recommended that we get a lawyer that was familiar with malpractice.

DEBBI PRESTON:  She was there to help us, we felt like.  You know, she was there to help us.

HAMM (o/c):  It’s not about me, it’s not about us, it’s about Mr. Holbrook, it’s about Mrs. Holbrook and about the daughters.  It’s just can’t be about us anymore once the mistake is made.  It has to go away from us.

NARR:  BEFORE COMING CLEAN WITH THE HOLBROOKS, THE V.A. FIRST REVIEWED THE CASE INTERNALLY . . . IN WHAT HOSPITALS CALL A “RISK MANAGEMENT” MEETING, LIKE THIS ONE.

nat sound/b-roll: 

Hamm:  Ah we’ve had 3 new tort claims filed in the last couple of weeks. . . I got a call from the civil chief down at the U.S. Attorney's Office.  It involves a suicide that occurred . . .

NARR:  ITS HERE THAT HAMM, KRAMAN, AND OTHER KEY PERSONNEL DISCUSS POSSIBLE ERRORS MADE AT THEIR HOSPITAL. . .

nat sound:

Hamm:  . . . colon cancer surgery that allegedly was misperformed.

NARR:  AND EXPLORE WAYS TO PREVENT MISTAKES IN THE FUTURE.

nat sound:

Dr. Schwartz: There’s no question that, uh, that an error, that a medical error was committed here Kraman:. . . it sounds to me that perhaps we should have a, a standard protocol –

Hamm:  Yes.

Dr. Kraman:  -- of always calling a vascular surgeon, or general surgeon.  We could set that up as a system as well and it would be fairly easy to do.

NARR:  ALL HOSPITALS MEET REGULARLY TO GO OVER POSSIBLE ERRORS.  SO WE WANTED TO SIT IN ON A RISK MANAGEMENT MEETING AT THE UNIVERSITY OF KENTUCKY. 

SMITH:  Would you ever make your Risk Management Committee meetings open either to the media or, or to anyone in the general public?

DR. HOLSINGER:  Uh, we would not open our Risk Management Committee meetings to the public, uh, because those are the ones where we are with our attorneys, both our own internal attorneys and our defense attorneys.  And so those are privileged, uh, under the, the legal system.

NARR:  LOCKED OUT OF THE UNIVERSITY OF KENTUCKY, WE ASKED FOUR DIFFERENT HOSPITALS – EACH OF WHICH GAVE US EXTENSIVE ACCESS TO FILM OTHER STORIES – TO LET US VIDEOTAPE A RISK MANAGEMENT MEETING.  EVERY HOSPITAL REFUSED, EXCEPT THE LEXINGTON VA. 

HAMM:  You have to be brave enough to believe that your morals, your ethics, and your experience are going to serve you well.  You ‘gotta take a risk, that’s why we call it risk management. 

NARR:  DEFYING THE MEDICAL CODE OF SILENCE, THE LEXINGTON V.A. SEES OPENNESS AS A KEY TO IMPROVING THE QUALITY OF ITS CARE.  

DR. KRAMAN (o/c):  You can’t have a patient safety program if people are going to sit on medical errors.  They’ve got to report them themselves.  And in order to do that, they have to feel safe; that they’ll be treated, not that they’ll be absolved, but they’ll be treated fairly. 

NARR:  BUT WHAT ABOUT THE MALPRACTICE SHARKS CIRCLING HOSPITALS . . . WAITING TO POUNCE ON THE SLIGHTEST ERROR?  UNDER THE  LEXINGTON V.A.’S NEW POLICY, ITS LEGAL DAMAGES ACTUALLY WENT DOWN.

HAMM:  We feel that you don’t lose money being honest.  We can’t prove you save a lot of money but we know you don’t lose a lot of money.  It does not, in our experience, expose you to huge verdicts.

DR. KRAMAN:  You know, the, most patients understand that doctors can make mistakes.  Um, what they can’t understand is lying to cover ‘em up. 

NARR:  WHICH BRINGS US BACK TO THE HOLBROOK FAMILY:

SANDY REYNOLDS:  If they hadn't've come forward, I would have wanted millions.  I would have wanted to rip them apart.

SANDY REYNOLDS (o/c):  I would have wanted their head on a platter with a apple in their mouth if they hadda done it any differently.

NARR:  BUT WHEN THE LEXINGTON, V.A. CAME FORWARD AND ADMITTED ITS MISTAKE, THE HOLBROOKS QUICKLY SETTLED FOR $50,000.

SMITH: What’s your reaction to this kind of approach?

SANDY REYNOLDS:  I'm much better off the way it happened, 'cause anger woulda just ate me up.  And it would've affected me and my family.  It wouldn't affect -- (chuckling) -- the VA.  It would've affected my life.

DEBBI PRESTON:      The guilt would've n- -- just, um, consumed you.  There would never have been a c- -- a closure to it.

SANDY REYNOLDS: You know, it's -- it's like it's -- it's -- they defused it.  They just -- you know, you -- you say, "Okay" -- you know, "Okay." 

STAND UP:  MEDICAL ERRORS LIKE THE ONE THAT KILLED CLAUDIE HOLBROOK GRAB THE HEADLINES.  BUT THERE’S EQUALLY LETHAL PROBLEM THAT PLAGUES AMERICAN HEALTH CARE . . . AND YOU KNOW ALMOST NOTHING ABOUT IT.  IT’S THE QUALITY GAP:  MEDICINE’S SECRET KILLER.

nat sound/b-roll:  Luca Fresiello o/c and being rolled on gurney, beeps

LUCA FRESIELLO:  I haven’t been feeling good lately. I’ve been very tired lately. Recently I had been getting these pains in the esophagus - like indigestion pains and it really took me by surprise.  When I found out, you know, that I had clogged arteries, okay, then a leaky mitro valve. . .

NARR:  NEW YORKER LUCA FRESIELLO IS HEADING FOR OPEN HEART SURGERY. 

FRESIELLO: I was shocked. I couldn’t believe it, I thought it was just a bad dream, I really couldn’t believe anything like that could happen like that to me. Really.

NARR:  FRESIELLO’S CHANCES ARE RIDING ON WINTHROP UNIVERSITY HOSPITAL, IN THE TOWN OF MINEOLA ON LONG ISLAND.  HE WAS SENT HERE BY HIS CARDIOLOGIST.

FRESIELLO: I’m going to go in this thing with my eyes closed, that’s it, ya know, just hope for the best. 

nat sound/b-roll:  ER

NARR:  EYES CLOSED . . . HOPING FOR THE BEST. . . THAT’S THE WAY NEARLY ALL OF THE 600,000 AMERICANS WHO HAVE HEART BYPASS SURGERY EACH YEAR GO THROUGH IT:  IN THE DARK. 

ARTHUR LEVIN (o/c):  I think American consumers know almost nothing about quality of care that they receive. 

NARR: THAT’S A REAL PROBLEM BECAUSE THERE ARE VITAL DIFFERENCES IN PERFORMANCE, ACCORDING TO QUALITY IMPROVEMENT EXPERTS.

DR. MARK CHASSIN (o/c):  The level of quality is really quite variable both within hospitals, between hospitals, within physician practices, and between them.

DR. DON BERWICK: Care could be a lot better than it is.

DR. BERWICK (o/c):  I am surprised at how little the public seems to understand about the gaps in the quality of care they're getting.

LEVIN:  The history of medicine has been secrecy.  I think the dirty little secret of medicine, maybe not so little, has been one that there’s a lot of error and two that there’s tremendous variation even without error and how well people do in treating various conditions.  I don’t think anybody wanted to talk about that publicly. 

NARR: IN 1990, NEW YORK BROKE MEDICINE’S CODE OF SILENCE WHEN IT BECAME THE FIRST STATE TO PUBLISH DEATH RATES FOLLOWING HEART BYPASS SURGERY . . .  HOSPITAL BY HOSPITAL. 

NARR:  BUT UNDER PRESSURE FROM THE MEDICAL ESTABLISHMENT, THE STATE DECLINED TO RELEASE THE PERFORMANCE OF INDIVIDUAL SURGEONS.

DR. CHASSIN:  From a political perspective the success of this program depended on the collaboration and cooperation of hospitals and doctors.

NARR: DR. MARK CHASSIN IS A FORMER NEW YORK STATE HEALTH COMMISSIONER:

DR. CHASSIN: The hospitals were cooperating from the beginning.  And for the doctors to continue to cooperate, uh, we did not think it was time to release the physician information.

LEVIN:  It was a tremendous battle, and both the state and the medical profession did not go willingly down this path.

NARR: IT TOOK A LAWSUIT BY LONG ISLAND NEWSPAPER, NEWSDAY, TO PRY OUT THE PERFORMANCE DATA ON SPECIFIC SURGEONS.

NARR: JOSH BURACK IS A NEW YORK HEART SURGEON.

DR. JOSH BURACK:  I think when the system first came out, everyone -- every surgeon I know was terrified.

nat sound:

Burack:  So I see the retractor’s still in?

NARR: TO THIS DAY, THE REPORT REMAINS CONTROVERSIAL . . . DR. BURACK SPEAKS FOR MANY NEW YORK SURGEONS WHEN HE COMPLAINS THAT THE DATA ISN’T GOOD ENOUGH TO BE TRUSTED.

DR. BURACK (o/c): I think that you're able to open up a "Consumer Reports" and pick the best toaster. Um, There's nothing like that in -- in medicine.  Uh, however, medicine doesn't lend itself to measurement as easy as, uh, appliances do.

SMITH:  What do you say to doctors who say these are not accurate statistics?

DR. CHASSIN (o/c):  It is the best model statistically speaking that’s ever been developed. And it actually predicts mortality even at the very highest levels of severity, with extraordinarily precise accuracy.

nat sound/b-roll: Dr. Scott at x-ray:

Dr. Scott:  . . . Osteo right’s tight, left main’s about a 70 percenter…

NARR: AND SOME DOCTORS LIKE LUCA FRESIELLO’S SURGEON WILLIAM SCOTT CONCEDE THAT STATE OVERSIGHT HAS FORCED PROGRESS.

Dr. WILLIAM SCOTT (o/c):  Doctors are probably about as good at policing themselves as lawyers and politicians and everyone else. Ah, But, but they’re being pushed into it. And that’s the good part about the state department of health’s holding us accountable, if you will.  It pushes us to deal with the issues.

DR. CHASSIN:  Making information public on a proactive basis about how they’re improving.  That’s got to be a major part of every health care’s delivery systems mission in the year two thousand. 

NARR:  BUT SOME NEW YORK SURGEONS ARE WAGING A GUERILLA WAR AGAINST THE REPORTING SYSTEM.  DR. BURACK, IN A 1997 SURVEY OF HIS PEERS, FOUND THAT MANY SURGEONS GAME THE SYSTEM.

DR. BURACK:  Doctors can change diagnoses, can alter operations to avoid public scrutiny. Doctors can quickly transfer patients who've had surgery that hasn't been successful to other institutions, and thereby a- -- avoid reporting a bad outcome. 

NARR:  SOME SURGEONS TOLD BURACK THAT THEY NOW AVOID HIGHER RISK CASES TO TRY TO BOOST THEIR GRADE. 

DR. BURACK:  I think that it has affected my decision-making as a surgeon when I approach patients who more than likely not gonna survive.  You have to think twice about performing operations on those patients.

nat sound/b-roll:  operating room

Dr. Scott:  . . . needs a whole volume of oxygenated blood...

NARR:  BUT AN AUTHORITATIVE STUDY HAS SHOWN THAT OVER ALL, THESE PEOPLE ARE NOT BEING REFUSED SURGERY IN NEW YORK. . . SUGGESTING THEY ARE GRAVITATING TO DOCTORS WILLING TO HANDLE HIGH RISK PATIENTS AND AWAY FROM LESS SKILLED SURGEONS…  WHICH MAY SAVE LIVES. 

DR. SCOTT:   There are some institutions and some physicians who shouldn’t do high risk cases because they don’t get good results in high risk cases.  So I think that the self sorting process is a good thing. . . 

NARR: IN FACT, SINCE NEW YORK BEGAN PUBLISHING DOCTOR AND HOSPITAL RECORDS, THE DEATH RATE AFTER HEART BYPASS SURGERY DROPPED DRAMATICALLY.  

DR. CHASSIN (o/c):  The program of publishing data brought down the mortality statewide over fifty percent and to the point where New York had the best performance in the country.

NARR: DESPITE THESE POWERFUL RESULTS, THE MEDICAL ESTABLISHMENT ACROSS THE COUNTRY CONTINUES TO RESIST THE NEW YORK SYSTEM.   ONLY TWO OUT OF 49 OTHER STATES - PENNSYLVANIA AND NEW JERSEY – HAVE ADOPTED NEW YORK’S PUBLIC REPORT CARDS ON HOSPITALS AND DOCTORS.

NARR: IT’S THE LOWER PERFORMING HOSPITALS - THOSE IDENTIFIED IN THE REPORTS WITH ONE STAR - THAT COME UNDER PRESSURE TO IMPROVE.

DR. CHASSIN:  When a hospital’s at the very bottom of the list, there’s a fair amount of both external and internal pressure that’s generated to do something about it.

NARR:  THAT’S WHAT HAPPENED AT THE BROOKLYN HOSPITAL OF THE STATE UNIVERSITY OF NEW YORK, ACCORDING TO LOCAL SURGEON JOSH BURACK.

DR. BURACK:  One year this institution was an outlier when the reporting system first started, and it was a shameful year.  It's a -- a time when you are not proud of your -- your career, your institution, uh, and you really, you know, have a difficult time of it.  Everybody in the city knows about it.  Everybody talks about it within our field. 

NARR: WINTHROP UNIVERSITY HOSPITAL WAS ALSO EXPOSED WHEN THE FIRST REPORT CAME OUT IN 1990…SHOWING THAT TEN PER CENT OF WINTHROP’S HEART BYPASS PATIENTS WERE DYING AFTER  SURGERY . . .  

SMITH: Out of the 30 in the state doing open heart surgery, where did Winthrop fall at that point?

DR. SCOTT:  Initially?

SMITH:  Yeah

DR. SCOTT: At within the bottom couple of hospitals.

SMITH: It was right near the bottom.

DR. SCOTT:  Correct.

nat sound/b-roll: OR

NARR:  EAGER TO STOP PATIENTS FROM DYING AT SUCH A HIGH RATE . . . AND WANTING TO BUILD A LUCRATIVE HEART BYPASS BUSINESS, WINTHROP HIRED SURGEON WILLIAM SCOTT AWAY FROM HIS WORK AT YALE-NEW HAVEN HOSPITAL TO TURN ITS PROGRAM AROUND.

DR. SCOTT: There was a, a lack of leadership here previously such that the systems weren’t in place to take care of patients in an appropriate fashion.  Especially the sicker patients...

SMITH:  I gather you’re suggesting some of the doctors may not have been trained to handle the most difficult cases…

DR. SCOTT:  Well certainly there were some physicians who were not appropriate to do the cases they were doing.

NARR: SCOTT BUILT NEW SURGICAL TEAMS, IMPROVED TRAINING FOR DOCTORS AND NURSES, AND UPGRADED EQUIPMENT.

nat sound: 

Doctor:  This is the left ventricle and this is the abnormal mitro valve that’s leaking. 

NARR:  THE PAYOFF FOR WINTHROP PATIENTS LIKE LUCA FRESIELLO IS PRICELESS - A BETTER CHANCE OF LIVING AFTER SURGERY. UNDER DR. SCOTT’S LEADERSHIP, WINTHROP HAS DRASTICALLY SLASHED ITS DEATH RATE.  

nat sound: 

Smith: How’d it go?

Dr. Scott:  It went fine, procedure had some complications, not complications, but it was a little more difficult than it might ordinarily have been. Nothing, nothing way out of the ordinary.

NARR:  LUCA FRESIELLO CAME THROUGH HIS SURGERY WELL, AND HAS RETURNED TO LIFE AS A CONSTRUCTION SUPERVISOR AT A LOCAL COLLEGE ON LONG ISLAND.

STANDUP:  IN SUM, EXPOSURE SPURRED IMPROVEMENT AT WINTHROP… AND SO WE WANTED TO SEE WHAT WAS HAPPENING AT THREE OTHER HOSPITALS, ALL IN MANHATTAN AND ALL SHOWING HIGHER THAN AVERAGE DEATH RATES IN THE NEW YORK CARDIAC REPORT.

BUT OUR REPEATED EFFORTS TO FILM AT LENOX HILL AND SAINT VINCENT’S RAN INTO A BRICK WALL.  AND AT ST LUKE’S HOSPITAL, ITS PARENT COMPANY, CONTINUUM HEALTH PARTNERS, REFUSED TO LET US FILM A SURGERY AND BARRED ITS SURGEONS FROM EVEN TALKING TO US ON CAMERA.

LEVIN (o/c):  What you’re seeing are the traditional walls that have been erected, uh, around this big secret that not every doctor is as good as the next doctor, not every hospital can do this surgery as well as the next hospital.  

DR. BURACK (o/c):  If you've got a batting average of 400, you're gonna be walking down the street with a, you know, a strut.  If your batting average is 207, well, then, you know, you're gonna stay in the locker room and not come out a- -- a- -- and meet the press.  And I think the same thing was true for cardiac surgery.

NARR:  NOT LONG BEFORE NEW YORK ISSUED ITS FIRST REPORT, A FEDERAL RATING OF HOSPITALS SPARKED A SIMILAR FIRESTORM OF PROTEST FROM THE MEDICAL ESTABLISHMENT. CHIEF CARDIAC SURGEON BILL NUGENT OF THE DARTMOUTH-HITCHCOCK MEDICAL CENTER IN NEW HAMPSHIRE.

DR. BILL NUGENT (o/c):   We were defending ourselves from what we saw was out -- as an outside threat from the Health Care Finance Administration, um, invading on our private data.

NARR:  THE BOMBSHELL WAS THIS:  DEATH RATES AT HOSPITALS NATIONWIDE VARIED WIDELY ON SEVERAL DIFFERENT PROCEDURES, INCLUDING HEART SURGERY.  DARTMOUTH EPIDEMIOLOGIST GERALD O’CONNOR.

DR. GERALD O’CONNOR (o/c):  And a few people in each town would have the reaction, “gee, our results are worse than would have been expected and we don’t believe it. We don’t believe the data. They did it wrong. Or our patients are older and sicker, and so the comparisons aren’t fair.

NARR: DETERMINED TO DISPROVE THE FEDERAL REPORT, NEW ENGLAND HOSPITALS ENLISTED O’CONNOR TO DO A REGIONAL STUDY.  BUT THAT EFFORT BACKFIRED.

DR. O’CONNOR:  We found that the mortality rates, that is the death rates across the region after heart surgery, varied substantially.  In the lowest center, they were about 2 percent.  That is two out of a 100 patients dying.  And in the highest, they were about six out of a hundred.  We realized, right away, that it was not differences caused by differences in patients.

NARR:  SO THE FEDERAL REPORT WAS RIGHT, AFTER ALL.

DR. NUGENT:  My initial response was terror, and I think that initial response was echoed throughout the cardiac surgical community.

SMITH:  What were you afraid of?

DR. NUGENT: Actually, the exposure associated with knowing your mortality rate, or other people knowing your mortality rate, and the helplessness of not knowing what to do about it.

SMITH:  Afraid you'd lose patients?  Afraid --

DR. NUGENT:  Lose patients, lose patient credibility, lose market share – um, be exposed.

DR. NUGENT (v/o and o/c):  It was a helpless, helpless feeling; because you had no clue what to change.  You were already doing as well as you could do.

DR. O'CONNOR:  We went through all of the reactions --anger, denial, bargaining, and then we finally got to collaboration,

nat sound/b-roll conference

Woman:  . . .When we look at the data are we doing surgeon specific . . .

DR. O'CONNOR:  And we said we've got--we've got to find a way to capture the lessons that are being learned around the region.

NARR:  O’CONNOR TURNED TO QUALITY IMPROVEMENT EXPERT, DR. DON BERWICK, FOR HELP: 

DR. BERWICK (o/c): At that point, I think they faced a choice.  They could have deep sixed it.  They could have--there was no particular reason they had to do anything further with it than ignore it….instead, they decided to use the information. 

nat sound/b-roll: conference

Dr. Nugent:  But you’ve got to involve the nurses, you’ve got to involve profusion, and they’re the ones that get the work done . . .

DR. BERWICK: They decided they could learn from each other.  And I think that was incredibly courageous of them.

nat sound/b-roll:  conference

Woman:  When you split out the group of patients that fell below twenty...

NARR:  SHIFTING FROM COMPETITION TO COOPERATION AND SHARING DATA AND EXPERIENCE WAS A BOLD DEPARTURE FROM THE CLOISTERED SECRECY AND CUT-THROAT RIVALRIES OF THE MEDICAL MARKETPLACE.   

DR. BERWICK:  Once one starts to ask the question how am I doing, and could I do better, and is anyone doing better at this than I am, that's pretty closely connected to your own self-image and identity.  So, so, there's a form of personal stakes in this wh -- when a doctor starts to say, "I'll bet I could get better if I study what I do and try to learn from others."

NARR:  HEART BYPASS SURGERY IS AN INCREDIBLY COMPLEX PROCESS, PERFORMED NOT JUST BY ONE HEROIC SURGEON BUT REQUIRING CLOSE TEAMWORK FROM SCORES OF PEOPLE.  YET UNDER THE OLD SYSTEM,  DIFFERENT PLAYERS WORKED IN NEAR ISOLATION.

DR. NUGENT:  It used to be surgeons talked to surgeons, and nurses talked to nursh- -- nurses, and never the two talked together.

NARR: BUT THE NEW MANTRA OF COLLABORATION OPENED UP NEW LINES OF COMMUNICATION WITHIN EACH HOSPITAL.  

KEN DIXON (o/c):     And we're all there in a very congenial atmosphere to carry out what can be a very scary thing for the little person laying on the bed . .

nat sound: 

Nugent:  “Looks good, huh?”

DIXON:  It's not like having your tonsils taken out or having your -- you know, your hair cut or something.  It's a -- it's a life-threatening thing.  So, if you can decrease the level of interpersonal friction and things that occur in other environments, it just runs so much more smoothly.

nat sound:

Dixon: The trick question is . . .

NUGENT (o/c):  But now, surgeons talk to nurses, nurses talk to perfusionists, perfusionists talk to anesthesia, surgeons talk to anesthesia -- believe it or not -- surgeons talk to surgeons.  And -- and each acknowledges the relative role that each of us play in -- in -- in facilitating somebody's, um, recovery –

MARY BETH MENDUNI (o/c): Before, we were all like, working like we were warming up in a symphony. We were each practicing our own instruments.

MENDUNI:  And now we really sound like a great symphony.

DR. NUGENT: I began to recognize how important communicating your needs and your roles are within the greater context of the program itself.

NARR: TEAMS FROM MEDICAL CENTERS IN VERMONT, MAINE AND NEW HAMPSHIRE BEGAN MAKING SITE VISITS TO THEIR COMPETITORS, LEARNING FROM EACH OTHER’S PRACTICES:

DR. O’CONNOR (o/c): And when we went around the region, we realized that there were vastly different ways of doing the same thing, each of which grew up in its own place and you said, "they are doing it a better way then we're doing it.  We've gotta fix ours, and have it look more like that, because we'd be doing a better job if we did.”

DR. BERWICK:  Those cardiac surgeons, didn't have a silver bullet.  There was, there was not a single thing they discovered.  It was many, many lessons learned.  It was the process of visiting each other, watching each other operate, sharing data, going deep into their data and learning step-by-step many, many improvements, dozens of things.

nat sound/b-roll:  cath conference

Doctor:  So the angiogram was done four or five weeks ago now and you can see in this view sequential L.E.D lesions

NARR: COLLABORATION HAS YIELDED CONCRETE CHANGES . . . 

nat sound/b-roll:  Nugent at Cath Conference: we’ve got a 1 percent mortality risk versus a .3 percent with tcpa . . .

NARR: FROM HOW PATIENTS ARE WORKED UP PRIOR TO SURGERY . . . TO THE WAY BLOOD IS TRANSFUSED DURING THE OPERATION . . . TO THE HAND-OFF FROM THE OPERATING ROOM . . .

nat sound/b-roll:  OR

Ken Dixon:  We have Mr. Berthiaume for you.

NARR: TO THE INTENSIVE CARE UNIT. . . 

Menduni: “And his last antibiotic?”

NARR:  AND THAT HAS PRODUCED PHENOMENAL GAINS FOR PATIENTS.

DR. O'CONNOR:  We saw this 24 percent reduction in mortality rates.  That means that one out of four deaths was prevented.  The difference between this expected mortality rate line and the observed line is 74 deaths.  People who didn't die, who would have died.

DR. NUGENT:  Statistics don't lie.  Fewer people are -- died after open heart surgery in Northern New England and I feel confident that it's in  -- at least in part, if not almost totally because of our regional involvement.

nat sound/b-roll conference: 

Dr. Nugent: There’s very good evidence that Northern New England is the best place to have chest pain in the country right now …

NARR:  BILL NUGENT HAS COME FULL CIRCLE . . . FROM SKEPTIC TO QUALITY CRUSADER: 

DR. NUGENT: I’ve been accused of being a preacher. And -and to be a believer of this concept of clinical collaboration, um, this is my holy war; this is my Jihad.

SMITH:  You’re talking about a chance in culture and the people who practice medicine.

DR. NUGENT: Absolutely, It’s an absolute change in culture…

DR. NUGENT:  I'm talking about a reflection of where we came from.  The fact is that when I went to medical school to be a clinician, it was to take care of my patients, it was a calling.

nat sound/b-roll: surgery

Dr. Nugent:  Okay, here’s atrial I think…

DR. NUGENT:  And as we see it as clinicians and physicians as a calling/ then the pressures for market share and for economic success becomes secondary to improving the outcomes of our patients, doing the best we can.

NARR: BY GETTING COMPETITORS TO TRUST EACH OTHER WITH ACTUAL RESULTS, THE NORTHERN NEW ENGLAND COLLABORATIVE HAS ACHIEVED ONE OF THE LOWEST BYPASS DEATH RATES IN THE COUNTRY.

NARR: BUT UNLIKE IN NEW YORK, THE PUBLIC HAS BEEN KEPT IN THE DARK ABOUT DEATH RATES AND HOSPITAL PERFORMANCE .  ALL SPECIFIC DATA IS KEPT SECRET SO DOCTORS WILL OPEN UP TO THEIR PEERS.

DR. NUGENT:  If you're gonna use this data for improvement,  all right, then you need to drive as much fear out of it as possible.  It -- it needs to be shared, and it is sensitive data.

DR. BERWICK (o/c):  We need an environment which encourages exchange, learning, relationship, uh, and a commitment to continuous improvement.  I do not believe that's going to happen by creating an environment whose fundamental characteristic is fear and surveillance.

nat sound:

Dr. Nugent:  Um, what we have done as a group, not just what we’re doing as an individual institutions...

NARR:  WHEN BILL NUGENT AND HIS PEERS CARRY NEW ENGLAND’S QUALITY SUCCESS STORY AROUND THE COUNTRY, OTHER DOCTORS ARE SURPRISINGLY SLOW TO ADOPT THEIR APPROACH.

SMITH:  When you run into resistance, what are the obstacles you have to overcome?

DR. NUGENT:  Basically it’s fear of one another.  They must overcome their fear of each other and they must build trust in one another as clinicians.

NARR:   THAT MIGHT WORK IN NEW ENGLAND BUT NEW YORK’S QUALITY CRUSADERS DON’T SEE MUCH HOPE IN WAITING FOR DOCTORS TO CLOSE THE QUALITY GAP.  

DR. CHASSIN (o/c):  I think the chances of the Northern New England Collaborative approach working in New York City are about as close to zero as you could measure.

SMITH:  Why?

DR. CHASSIN:  Because they are too many institutions, they are too many egos, there’s too much competition among them, uh, there’s too much worry about getting together and doing collaborative, uh, collaborative projects.

LEVIN (o/c): We’re where we are today with a tremendous problem with errors, tremendous variation in performance because medicine, the hospital industry never took quality seriously.  We have no reason to trust they will in the future.  I believe the only lever for change is public disclosure and public accessibility of information like coronary artery surgery reporting in New York State.

NARR:  BUT UNTIL AMERICANS DEMAND PUBLIC OVERSIGHT TO SEE JUST HOW GOOD THEIR DOCTORS ARE, CLOSING THE QUALITY GAP WILL BE LEFT TO ISLANDS OF REGIONAL REFORM IN PLACES LIKE NEW ENGLAND.

NARR: ,…AND UTAH.

nat sound:  ER sounds, etc.

Doctor: How did you happen to fall? 

Curry:  I slipped.

Nurse:  OK.  Can you take a big deep breath in?  Hold your breath, don’t breathe?

Dr. Mooers: ...oxygen level in the blood stream is a little on the low. 

NARR: FOR EXAMPLE, SALT LAKE CITY, UTAH . . . WHERE BENNIE CURRY IS BATTLING A COMMON BUT DEADLY DISEASE...

nat sound: 

Jay:  How are you doing Bennie?

NARR: AT INTERMOUNTAIN HEALTH CARE’S LDS HOSPITAL.

DR. MOOERS: This shape is that of a pneumonia.

nat sound: 

Mooers:  We’re gonna need to keep you in the hospital for a couple days.

NARR:  COMMUNITY ACQUIRED PNEUMONIA – A SIMPLE LUNG INFECTION -- IS ONE OF THE NATION’S LEADING KILLERS: 

DR. MOOERS (v/o and o/c):  If he doesn't get treated, I mean, my gosh, this guy could die.

nat sound:  ER

Dr. Mooers:  Hey, Howie. 

Howie:  What.

Dr. Mooers:  Ceftriaxin two IV in room 6.  .

NARR:  WITHIN TWO HOURS OF HIS ARRIVAL IN THE EMERGENCY ROOM, CURRY IS DIAGNOSED AND HIS PHYSICIAN, DR. BRUCE MOOERS, PRESCRIBES ONE SPECIFIC ANTIBIOTIC.

nat sound/b-roll:  Howie giving Bennie rocephin

Howie:  “Bennie, I’ve got the antibiotic for you. Ok?  It’s called Rocephin.”

NARR: CURRY’S CARE MAY LOOK ELEMENTARY. BUT IT’S NOT. IT WAS CAREFULLY CRAFTED BY A TEAM OF PHYSICIANS FROM TEN UTAH CLINICS . . . THE WHOLE EFFORT INSPIRED BY THIS MAN . . . INTERMOUNTAIN HEALTH CARE’S QUALITY GURU . . . DR. BRENT JAMES.

nat sound/b-roll: James teaching

James: We can be far better for our patients. It’s the single most important thing that we could possibly be involved in.

NARR:  EVERY YEAR, JAMES DELIVERS ONE CENTRAL MESSAGE TO THE 150-200 DOCTORS WHO TAKE HIS COURSES:  FIND AND THEN FOLLOW THE BEST PRACTICES BASED ON REAL RESULTS… AND YOU’LL SAVE LIVES.

DR. BRENT JAMES (o/c):  I see myself as a little infectious agent that takes an idea from one part of the medical system, where we know that it works and transmits it out to other parts of the medical system to show them that it works.

nat sound/b-roll:  Dr. James lecturing: 

James:  You support the team because the team came to that solution...

DR. JAMES:  I am an evangelist for quality.  No doubt about that.

James: And I hope that you picked up that vision. . .

DR. JAMES:  I believe in this, I have seen it work.  I am absolutely convinced that it will change the face of American medicine and lead us to far better outcomes than we have ever achieved before.

DR. JAMES:  I’ve seen improvements in care in which I played a role, some small role, that went far beyond what I ever would have been able to accomplish in a lifetime of practicing medicine.

nat sound/b-roll: Drs. James and Bateman:

Dr. James: How’s life?

Dr. Bateman: Fun.

NARR: . . . . SIX YEARS AGO DR. KIM BATEMAN, A RURAL  FAMILY DOCTOR WORKING IN ONE OF INTERMOUNTAIN HEALTH CARE’S CLINICS, TOOK JAMES’ COURSE . . .

nat sound:  

Dr. Bateman: You already know what a master persuader and a master teacher he is. . .

NARR:  AND BECAME A DISCIPLE. . .

DR. KIM BATEMAN:  I just caught fire.

nat sound/b-roll:  Bateman teaching :

Dr. Bateman:  You can do things in a small hospital you can’t do so readily in a larger hospital. . .

DR. BATEMAN:  The style that Brent James brings us I'd never thought of.  It changed my life.   He's the kind of guy if you talk to him for five minutes, you're a convert. And that's pretty well what happened to me.

NARR:  MOTIVATED BY JAMES’S TEACHINGS, BATEMAN INVESTIGATED HOW PNEUMONIA WAS BEING TREATED AT 10 RURAL IHC HOSPITALS . . . AND HE FOUND CHAOS.

DR. BATEMAN (o/c): Before the program it was every man for himself.  Every doc had his own idea about how to do it. And uh, there were a lot of good ways and there was a lot of waste.  We even think there were some no-- pneumonia cases being missed.

nat sound:

Dr. Bateman: Every single one of those is FDA approved to treat pneumonia.

NARR: DOCTORS WERE USING DOZENS OF DIFFERENT DRUG COMBINATIONS

nat sound: 

Dr. Bateman:  . . . biaxin .. .

NARR:  . . TO TREAT PATIENTS WITH PNEUMONIA:   

nat sound:

Bateman:  . . . cephazolin, cephtazadine. . .

DR. BATEMAN: Believe it not, we identified 68 different drugs, or combinations of drugs, being used in those 10 hospitals for the treatment of pneumonia.

DR. BATEMAN:  But wouldn't you think, if there are 68 different ways, one might be better than another?

SMITH:  Why would doctors use a whole slew of different medicines?

DR. KIM BATEMAN:  These antibiotics are sold, they're sold and they're marketed and physicians may know more about one than another because of that marketing experience.

NARR:  SO MANY DRUGS TO SELECT FROM. . . SO MANY LAB TESTS TO DO. . . MEANT DANGEROUS DELAYS FOR HALF THE PNEUMONIA PATIENTS:  

DR. BATEMAN:  They were in the hospital at least four hours before they even had a first dose of antibiotic. When you stop to think about it, that's almost ridiculous, isn't it? The only reason you go to the hospital with pneumonia is to get the antibiotic.

nat sound/b-roll:  Dr. Mooers with Curry

Dr. Mooers: Deep breath…

NARR: BATEMAN’S BREAKTHROUGH WAS TO TREAT PATIENTS FASTER BY REDUCING THE NUMBER OF LAB TESTS AND DIRECTING DOCTORS TO A SINGLE ANTIBIOTIC.

NARR: STANDARDIZING CARE THROUGH GROUP CONSENSUS...

nat sound in clinic:

Dr. Bateman: Hi, how are you?

Patient: How you doing?

NARR:. . . WAS A RADICAL BREAK FROM HOW DR. BATEMAN WAS TRAINED.

BATEMAN:  I used to be satisfied with doing things the right way--the way I was taught.  Now I want to know the outcome and I want to know how what I do stacks up with what everybody else does.

SMITH:  Is that atypical for doctors?

DR. BATEMAN:  I think so. We're a pretty egotistical group.  The world tends to revolve around us individually.

b-roll/nat sound: Howie with nursing students: 

Howie:  . . . and that was causing his cardiac problems.

DR. BATEMAN:  Medicine is now a team sport.  It's not an individual sport./So the new quality is how to work together, is how to cooperate, how to use everybody's knowledge.

DR. JAMES:  In the past I was an autonomous individual, accountable only to God and myself. Uh I would tell you how good I was by my recall of how well I did for my patients.  The difference is, is today we are measuring it.  And we are discovering that we’re not nearly so good as we thought that we were.  And that, of course, opens doors for major improvements.

NARR:  LIKE DR. BATEMAN’S LIFESAVING GUIDELINE FOR PNEUMONIA:   

DR. BATEMAN: This, uh, small group of docs saved probably 50 lives a year in the way they were treating pneumonia.

nat sound:

James: Actively try to make it work. That’s the definition of consensus.

NARR:  UNDER JAMES’S INFLUENCE, PHYSICIANS IN THE INTERMOUNTAIN HEALTH CARE SYSTEM HAVE PRODUCED DOZENS OF CLINICAL BREAKTHROUGHS.

b-roll: lecture

DR. JAMES: …a better way of treating diabetics, a better way of managing children in our pediatric ICU, a better way of managing ventilators following heart surgery …The list just goes on and on.

NARR:   BUT EVEN WITH IMPROVEMENTS BASED ON HARD EVIDENCE, IT’S TOUGH TO GET PHYSICIANS TO GIVE UP OLD WAYS AND ADOPT NEW APPROACHES.

DR. JAMES: We’ve had some real problems with deploying the innovations that we’ve developed. In fact in a list of more than 65, only 3 deployed system wide.

NARR: KIM BATEMAN’S PNEUMONIA GUIDELINE IS ONE OF THE FEW SUCCESS STORIES. . . AND IT TOOK FOUR HARD YEARS OF SELLING THE RESULTS BEFORE PHYSICIANS WOULD ACCEPT IT THROUGHOUT INTERMOUNTAIN HEALTH CARE’S 122 CLINICS AND HOSPITALS.

DR. BATEMAN:  They all say, “I don't want to practice cookbook medicine.  I want to be--I want to be free to do what I think is best.”  And I remind them the best chefs in the world use cookbooks.

SMITH:  How do you as a doctor feel about the system deciding what you want to do?

DR. MOOERS (o/c): I am not trained to achieve a consensus.  I am trained to make my own opinion.

nat sound/b-roll: 

Dr. Mooers: A little short of breath?

DR. MOOERS: There's not one antibiotic and only one antibiotic that would work.  There are dozens of antibiotics that would work well. And so how do you get the 5 or 6 hundred doctors on our staff to agree on one or two antibiotics?  Of course it's going to be difficult.

DR. JAMES: Physicians believe that they are the experts. By definition.  That my, my excellence depends upon my own recall, my own recollection.  Yeah, they have an awful lot to lose when I suggest that maybe we really ought to measure this.   Maybe we really ought to see some data about how good you really are. . .

NARR:  MANAGED CARE COMPANIES HAVE TRIED TO IMPROVE PHYSICIAN PRACTICE BUT FOR BRENT JAMES, SUCH DISTANT EFFORTS ARE DOOMED.  HE SAYS ITS DOCTORS, WORKING AT THE GRASSROOTS, MUST LEAD CHANGE .

DR. JAMES:  No HMO has ever treated a patient.  Physicians and nurses treat patients.  The average physician works with 12 different health plans.  Each health plan sends a different protocol for a particular condition.  Each health plan wants to collect different data. It's hopeless for the physician. You know what they do with most of those?  They round file them.  They throw them away.

DR. BATEMAN: If you sense that the quality improvement program is coming from someone with a financial incentive, or from somebody with an authoritarian idea, then it's very hard to get physicians in line for this.  They want to do the right thing, and they think doctors know the right thing. 

DR. MOOERS: If I have a system that says this is the cheapest stuff, this is what I want you to use, the doctors here are going to say, "Forget it, I mean that's not the in, in the interest of the patient."  But if I have a system where a group of well-known people - locally well-known, not nationally well-known - and they say, “This is a reasonable drug” then we're gonna believe them.

nat sound/b-roll: awards dinner – James giving an award to Bateman

Dr. James: Today we’d like to honor Dr. Kim Bateman and Dr. Nat Dean for their unstinting dedication.

NARR:  EARLIER THIS YEAR, BRENT JAMES RECOGNIZED DR. BATEMAN . . .

Dr. Bateman:  Uh, thank you very much, I’ve never felt more honored.

NARR:  . . . FOR SAVING SO MANY LIVES.

Dr. Bateman: I didn’t have any idea that wasn’t first planted in my mind by Brent James.  So in my little acceptance speech I want to give honor where it really belongs and that is to this great man who has inspired all of us.  So thank you, Brent, for hosting this and for being our mentor.

DR. BATEMAN: This is one of the greatest things I've ever done to participate in something that saves multiple lives is a, is a thrill.

DR. JAMES:  There are days when you see one of these come together.  I don’t know how to describe the feeling, it’s like the universe suddenly fell into order.  And kind of rings like a bell.  It’s just pristine, it’s pure, right, and you know that you hit one.

****

FORTUNATELY, THE STUNNING IDEALISM OF THE QUALITY CRUSADERS THAT WE’VE SEEN IN UTAH, NEW ENGLAND, NEW YORK AND KENTUCKY IS STARTING TO CLOSE THE QUALITY GAP. BUT UNFORTUNATELY, THEY’RE ONLY A SMALL BAND OF GUERRILLAS FIGHTING TO CHANGE A VERY LARGE AND CONSERVATIVE MEDICAL ESTABLISHMENT.

CHANGE DOES COME… BUT VERY SLOWLY. DOCTORS AND HOSPITALS REMAIN STUCK IN THEIR WAYS… AND THEY RESENT BEING GRADED PUBLICLY ON THEIR PERFORMANCE.

STILL, AS THE STORIES OF NORTHERN NEW ENGLAND AND UTAH ILLUSTRATE, DOCTORS CAN ACHIEVE IMPORTANT REFORMS IF THEY’LL BE HONEST AND OPEN WITH EACH OTHER ABOUT THEIR SHORTCOMINGS.

BUT UNTIL WE THE PEOPLE DEMAND PUBLIC OVERSIGHT OF HEALTH CARE, WE’LL REMAIN IN THE DARK …KNOWING MORE ABOUT OUR PERSONAL SAFETY WHEN WE STEP ON AN AIRLINER…THEN WHEN WE PUT OUR LIVES IN THE HANDS OF OUR DOCTORS.

I’M HEDRICK SMITH, THANK YOU FOR WATCHING.

Dip to black

In Memoriam

Credits

ANNOUNCER:  To learn more about this program, and ways for patients to get better care, visit PBS Online, at the internet address on your screen.

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ANNOUNCER:  A presentation of South Carolina ETV.

ANNOUNCER:  Principal funding for Critical Condition was provided by

The Robert Wood Johnson Foundation.

Making grants to improve the health and healthcare of all Americans.

Major funding provided by

The California Healthcare Foundation.

Additional funding provided by

The Rockefeller Brothers Fund

And the Charles E. Culpeper Foundation.

ANNOUNCER:  This program is part of the PBS Democracy Project.

ANNOUNCER:  This is PBS.