Shining a light on cardiac surgery results

IN SUMMER 2000, the state Senate's Committee on Ways and Means had to decide whether to allow the expansion of cardiac surgery from academic medical centers into community hospitals. The House had authorized the expansion. But Senator Mark Montigny, my boss and chairman of the committee at the time, was skeptical. He was concerned about whether such an expansion would jeopardize patient safety. So he asked me, his general counsel, to research whether there was some way we could allow this expansion, but still ensure high quality care. I started by calling Tom Ryan - the best cardiologist I knew. Tom had been chief of cardiology at Boston University and president of the American Heart Association. He also happened to be my father-in-law.

Tom's response to my question was unequivocal. "Require public data collection and reporting of cardiac surgery outcomes for all hospitals in Massachusetts." No one knew how hospitals performed relative to one another, he explained, because no one collected the data. By shining a light on actual outcomes, hospitals would have a strong incentive to improve quality. Peer pressure was very powerful.

Montigny liked the idea, and an agreement was reached with the House. The expansion of cardiac surgery would be permitted. But we would also create a new "cardiac care quality advisory commission" to develop criteria for the collection of outcome data for all cardiac surgery programs. Four years later, Massachusetts issued its first public report on cardiac surgery outcomes.

By that time, I had moved on to become general counsel of UMass Memorial Health Care in Worcester. I had lost track of the issue. Not for long.

In 2005, I received an urgent call from Walter Ettinger, president of our medical center. In the second annual report on cardiac surgery outcomes, UMass Memorial would be identified as an outlier - in the wrong way. Our adjusted mortality rate of 4 percent was the highest in the state. While about average for the nation, it was approximately double the state average of 2 percent.

We could have done what others did in similar situations: question the data, lawyer up, and hunker down. Fortunately, John O'Brien, the chief executive of the hospital system, and Ettinger decided instead to be transparent.

They immediately suspended the program until we could understand the problem. They told our staff and our community what we were doing about it and why. They engaged outside experts to evaluate the program. We made the experts' report publicly available. All told, the program was suspended for six weeks, and the financial loss was about $25 million, a devastating blow.

Fast forward to last month.

The federal government released data on outcomes at thousands of hospitals across the country. On cardiac care, the data list hospital survival rates for patients who had a heart attack. Only nine hospitals out of 4,300 surveyed have survival rates that are significantly better than all the rest. UMass Memorial is one of the nine.

So how - in less than three years - did we cause such a dramatic turnaround?

To start, we completely revamped the program, hired new leaders, and transformed the way care was delivered. These innovative leaders grouped all cardiac patients together so staff could develop expertise with their particular needs. They created a complete team approach to care, where everyone's voice is encouraged and welcomed. The program now serves as a model for all other departments and hospitals in our system (and, I suspect, the country).

What have I learned?

First, public reporting works. It created a strong incentive to improving our quality. Second, responding to the crisis transparently, while more risky, was the right thing to do. At times, even lawyers must lean into the discomfort of transparency. It was the best course for our patients, our staff, and our community. Finally, humility saves lives. There is nothing more humbling than having to suspend a program. But it taught us to never accept the status quo, to know we can always get better, and to highly value a culture of learning and continuous improvement.

Douglas S. Brown is senior vice president and general counsel of UMass Memorial Healthcare Inc.