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October 01, 2008

Doug Brown, UMass Memorial Health Care's General Counsel, speaks with David Harlow about transparency and systems improvement

I spoke with Douglas Brown, General Counsel of UMass Memorial Health Care in Worcester, Massachusetts earlier this week about his institution's experience with reinventing its cardiac surgery program.  The Medical Center voluntarily suspended operations of the program in 2005 after it became clear that its CABG mortality rate was twice the statewide average (though it was equivalent to national averages).  Doug wrote a Boston Globe op-ed piece on this issue that ran last week, and I wanted to hear more about the self-examination and reinvention of the program.  The team of experts brought in to review the situation came up with 70 recommendations, and the medical center has worked to implement them.  The system improvements in cardiac surgery have had a beneficial effect on other programs across the hospital as well.

The audio file of my interview with Doug Brown runs about 18 minutes and is available for download/podcast.  A transcript of the interview is available for download as well, and is reproduced at the end of this post.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Douglas S. Brown, General Counsel, UMass Memorial Health Care
September 29, 2008

David Harlow:  This is David Harlow at HealthBlawg and I have with me today Doug Brown who’s the general counsel at UMass Memorial Health Care.  That’s the UMass Memorial Medical Center and affiliated organizations.  Thank you for joining us today, Doug.

Doug Brown:  My pleasure, David, good to be with you.

David Harlow:  Doug, I am interested in speaking with you about the efforts around transparency, which is one of those big buzz words these days, transparency at your institution that was brought on in part by some incidents with cardiac surgery.  This is something that you wrote about in the Globe a couple of weeks ago.  I understand that there were some untoward events a few years ago in the cardiac surgery program that prompted an interesting reaction at your institution.  I wonder if you would tell us about that.

Doug Brown:  Sure.  I’m happy to talk about it.  It was in the fall of 2005 and is, as I’m sure you know, the state had started to publicly report on certain cardiac surgery results.  The specific procedure was CABG, Coronary Artery Bypass Graft surgery.  And we were, to make a long story short, we were notified right before the release of the second annual report that UMass Memorial was going to be an outlier in this report.  That’s never a place that a hospital wants to be.  We – our adjusted mortality rate was about four percent which, while about average for the nation, was double the state average of two percent.  And it was determined by DPH that that was a statistically significant amount and so we had several conversations with DPH and ultimately decided that we would suspend the program at that time until we could really get a handle on exactly what was going on.

David Harlow:  And this was – so my understanding is that that was not a requirement from the Department of Public Health but something that was initiated by the medical center.  Is that correct?

Doug Brown:  Yeah.  The Department of Public Health, we had some very productive conversations with them at the time.  They – there was no requirement imposed on us but they were making some strong suggestions that we looked very seriously at it and, you know, we had a decision at that time.  Do we want to fight this, challenge the data, you know, as many other hospitals had done around the country when faced with similar situations, or do we want to do what we thought was the right thing at the time.  And so we chose to voluntarily suspend the program.  So you know, as I noted in my article, we took kind of an interesting course.  We made a very conscious attempt to be as transparent as possible within the organization and within our community.  We felt that as painful as it was at the time, over the long term it was critical that we be open and honest and transparent with the organization and to the community because we felt that, you know, in the long run that would serve the institution best.  And as you can imagine, it was not – in hindsight, of course, that that worked out great and seems like it was a wonderful decision.  It was a lot harder in real time because, as you know, there are important protections that we as lawyers like to invoke and often for the right reasons.  Obviously, there were peer review issues.  There’s certainly attorney-client, you know, privileges that we’re concerned about, and in the end we really erred in the side of being open and transparent.  We made this – as I said in the article – the first thing we did was we hired some outside experts, some of the best cardiologists and cardiac surgeons we could find that were from other organizations and they came in and did an extensive review of the program.  They reported directly to the Department of Public Health.  They had, basically, free rein of the facility and the individuals and they issued a detailed report with 70 specific recommendations.  And we made that report actually publicly available to our community.  And again, it wasn’t the most flattering report, as you can imagine.  The report basically noted that while there were no smoking guns, there were a number of red flags, all of which were addressed in these recommendations.

David Harlow:  Are there a handful or, you know, sort of a top ten list of issues that might be generalizeable to other programs, other surgical programs?  We hear a lot about, for example, certain approaches through checklists and the need to take timeouts in surgeries.  Were things like that part of the issues that were identified by your outside experts?

Doug Brown:  I think those were definitely part of a report but I’d say the key aspects were issues that I noted in my op-ed piece.  I think the most significant one was that one is they recommended that we cohort patients.  So cardiac surgery patients were being treated by nurses who were more like generalists and it was a suggestion that we took and followed that we really separate all these patients together so that all of the clinical staff could really develop some expertise, understand their needs, and really focus on their needs.  The other key thing that happened, as I mentioned, you know, we recruited key leaders after that and, of course, you know, one thing probably more important than anything I have learned in my role here for five years is that leadership makes a huge difference in the likelihood of success of a program or an institution.  And we had already at that time recruited a guy named Rob Phillips as head of our heart and vascular services.  And with Rob’s help we went out and found a fabulous chief of cardiac surgery, a guy named Lynn Harrison who would come from LSU and kind of – it was fairly fortuitous that it was right after Hurricane Katrina and he was having a lot of issues down here and was looking to move on, and it just happened to be an opportunity for us.  So Rob and Lynn really revamped the entire program and they approached it with a lot of humility.  And one of I think that the most important things they did is they truly brought a team approach to care, and so they did rounds together with all of the clinical staff.  There was really no hierarchy with the department.  Everyone had a voice to add to the conversation.  And they developed a sense of pride and teamwork within the department that is a great model for our organization.  And, you know, they truly become, you know, as I like to say, they’ve gone from worse to first and you can kind of see this transformational impact that’s had staff who, you know, three or four years ago the morale was very low.  Of course, when something like happens, it’s never, you know, good for the morale of the department.

David Harlow:  Sure.

Doug Brown:  But to see that go now from a group that is just so proud of the work they’re doing and, of course, the recognition that they’re receiving is just helping to build on itself and it really – it’s just really – it’s been a great story. 

David Harlow:  So do you see these effects percolating through the other departments, other parts of the institution?

Doug Brown:  We sure do.  You know, it’s just a great model of what focus and attention can really do and how it can make a difference and so – it’s happened in a number of ways actually.  I mean we’ve seen it start to spread to other clinical departments and there are a number of other areas who are really – have achieved, you know, national recognition in certain efforts.  Critical care is probably the most notable example where they have incorporated, you know, the checklists that you mentioned.  And, through the electronic ICU have done some phenomenal results.  Also, even within the heart and vascular area.  So one of the things we did was to create this heart and vascular Center of Excellence where we put essentially all of the heart and vascular services under one umbrella reporting to this Rob Phillips and that was certainly a different way of organizing thing from what we’ve done before.  And so it allowed a lot of the gains to kind of spread through the area.  And right now in, you know, cardiology and other areas, our door-to-balloon time is really some of the best in the nation.  And, you know, it’s – we’ve been able to spread it kind of in that way.  The other thing we’ve done is we also – from the things we learned through this experience, we developed some interesting initiatives in other areas.  One was a risk assessment effort which I chair, and it’s really a form of enterprise risk management throughout the organization that we focused on bringing all of the so-called risk functions, legal, internal audit, compliance, risk management under one umbrella together to look at risk a little bit more holistically and to try to be much more proactive.  So, you know, one of the key lessons we learned from cardiac surgery was that there were, in fact, staff members who knew that there was a problem but for whatever reason didn’t feel comfortable speaking about it.  And so we’ve learned painfully well this lesson that it’s critically important to encourage all staff at all parts of the organization to feel comfortable speaking up about their concerns and to raise issues.  And so part of that effort is, this risk effort, is to try to be more proactive, to try to encourage what we’ve called the discipline of speaking up.  And it’s really had great results.  And then we similarly launched a governance initiative and  that’s focused on trying to get ahead of all of the scrutiny that is coming down on nonprofits in general, nonprofit hospitals in particular, and again trying to get a little bit more proactive about addressing some of the key issues in that area.  Community benefit, executive compensation, governance, conflicts of interest, and things like that.  And by bringing the group together, attacking those issues, we’ve developed some annual goals and try to really promote best practices in the whole organization. 
David Harlow:  That’s quite a broad agenda, but it makes sense to be dealing with things like this, as you say, holistically. 

Doug Brown:  It is a broad agenda and, you know, I raised it because I do think that both of those initiatives, while far afield from cardiac surgery, were really given their impetus and momentum as a result, you know, in the wake of this cardiac surgery experience.  And so it kinda comes back to, you know, incredibly painful to go through at the time, but in my judgment, one of the most transformative events that has happened to this organization because it’s – you know, we truly have gone through that and see the world differently in a whole bunch of ways. 

David Harlow:  Well, it’s great to hear how that can really improve things for the better.  One last area that I wanted to ask you about which is how you see this experience as relating to the development of value driven purchasing – value based purchasing in health care and whether you feel that these sorts of initiatives have helped the medical center position itself for those negotiations or experiences or whether you see this as more discrete.

Doug  Brown:  Yeah, it’s a very good question, and I’m sure you’re aware of what Geisinger is doing which is basically offering a fixed rate for cardiac surgery procedures and they’re, you know, guaranteeing the outcome and that’s – and they’ve had a lot of success with doing so, so that’s certainly generating a lot of positive discussion.  You know, I think that public reporting is certainly gonna speed up the whole notion of value based purchasing, and the reason is because it’s just another way that consumers and other stakeholders in the health care field are gonna truly understand and become more informed about the results and exactly what’s going on.  And, as you saw, I say in the article, I think that’s very positive for all parties involved.  And I think this kind of drive toward value based purchasing is, you know, it’s been coming for a while and it’s gonna continue.  You know, the one caution I’d say is that, like many other things, you know, public reporting can certainly go too far as well and I think one of the lessons from this is that when the state got together with, you know, really under the great leadership of Paul Dreyer, who, you know, I didn’t say in my article, but Paul was one of the early individuals I, you know, sought out and Paul has always been a key advocate of improving quality—

David Harlow:  Yes.

Doug Brown:  In hospitals as you probably know.  And I mentioned Tom Ryan, my father-in-law, that one of the advantages that he had was that he had actually worked with the State of New York in doing this.  But when they approached this public reporting, they took a lot of time and a lot of care in making sure that they could have ways of ensuring that the data was appropriate and that that really couldn’t be challenged in the end.  And that’s why it took, you know, several years before – from the time that the initial legislation was passed that I mentioned in the article and the time that they actually reported.  Now, some have questioned whether, you know, a two year delay, which is what it is in the reporting, it really make sense, but I think that’s a sign of how much care these folks took in making sure to get it right.  You know, I think that one caution we all need to have as we, you know, go headfirst into this, you know, public reporting world, is to just make sure that when we do so, the same care is taken to all publicly reported results.  Because if that isn’t done, you could see how devastating it could be to an organization and, boy, if these data were not correct, you know, I noted in my article, this, we calculate, it – this experience had about a 25 million dollar price tag for us.  And, of course, we are large enough and could sustain that but not without a lot of pain.  For a lot of smaller organizations, that can be, you know, the difference between keeping their doors open or not.   So it’s very serious, the implications that it can have, and I think it’s just important that the same care that was brought to cardiac surgery be brought to other areas. 

David Harlow:  Yes, absolutely.  It must be very gratifying to see recent numbers crediting your institution’s program with a terrific track record.

Doug Brown:  It is, you know, and I mean, I had to say, going through it, we remain very humble and, you know, again as I’ve concluded from all these, you know, humility really is so critical.  And I think if you talk to our chief of cardiac surgery, it gives no one – there’s no one resting on our laurels.  We certainly have plenty of challenges ahead.  We’re very proud of this accomplishment but I think we know now that we can always get better and we always need to stay really focused on doing so and continue to learn from others, you know.  And we’re just delighted if something we’ve done can be a lesson to others as well and we just hope we can continue to do that. 

David Harlow:  Terrific.  That’s another element of transparency we keep talking about.

Doug Brown:  It sure is.

David Harlow:  Well, thank you very much, Doug.  I’ve been speaking with Doug Brown, General Counsel at UMass Memorial Health Care in Worcester, Massachusetts.  This is David Harlow on HealthBlawg.  And again, Doug, thank you very much for joining me today.

Doug Brown:  My pleasure.  Happy to do it, David.

David Harlow:  Thank you.


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