Baselinemag.com has an excellent detailed case dissection of the information management problems that beset Kaiser Permanente’s kidney transplant program. Below is the table of contents, with the leading paragraph(s) from each section.
It should be noted that although Halvorson admitted that Kaiser screwed up, they have behaved just as despicably in the handling of the investigation and lawsuits as they always do. The fact that the only people who were fired from the program were those who tried to advocate for the patients, reveals the huge discrepancy between what Kaiser says and what they do. Kaiser continues to officially deny any wrongdoing, and has appealed a ruling that Bernard Burks’ case should go before a jury. The “win no matter how dirty you have to play” philosophy is alive and well and ‘Thrive’-ing at Kaiser Permanente. Too bad many of the kidney patients can’t say the same.
Story Guide:
- Patients Wait?and Wait?for a Kidney
- Kaiser’s First Missteps
- Bad Handoff No. 1: Botched Transfer of Records
- Bad Handoff No. 2: A Blizzard of Wait-Time Forms
- Patients vs. Kaiser: Get a Transplant Before It’s Too Late
- No Complaint System
- Finger-Pointing Instead of Action
- Technology, Finally
After the third time in a year he thought he was scheduled for surgery to replace his failing kidneys, only to see the date pass by, Bernard Burks had enough. On that day in February 2006, he jumped into a car with friends, he says, and drove 90 miles from his home in Sacramento to the Kaiser Permanente hospital in San Francisco, without an appointment, determined to find a person to talk to him.
Kaiser stopped outsourcing kidney transplants in Northern California and brought them in-house in 2004. Because Kaiser already provided both pre- and post-transplant care for its insurance patients, doing the surgeries in between would “provide greater integration of care and convenience for transplant patients,” says Schiffgens, the Kaiser spokesman.
What Kaiser attempted to seed a new kidney transplant program by moving 1,500 patients from other hospitals during the course of several months had not been tried before, according to UNOS officials. Usually, new centers grow gradually after opening.
At UNOS, meanwhile, wait-time transfer forms rained down. Keck remembers hearing the whir of the fax machine for weeks on end. “It’s right outside my door,” he says.
He and his 98 technology staffers were among the first people outside Kaiser alarmed by mounting data problems.
Bernard Burks’ luck ran out in 2004. His kidneys, which had been temporarily knocked out in 2001 by treatments for the hepatitis he’d acquired as a young man, failed again. He was back on dialysis.
By the time Burks made his unannounced visit to Kaiser’s transplant center in 2006, to sit, unbudging, in front of the receptionist, he says he had been battling Kaiser almost from the first day he was sent there from UC-Davis in January 2005. The year had been full of frustrations, according to his lawsuit filed last June in state Superior Court in Sacramento. Kaiser denies Burks’ charges. But the experiences he relates in the suit and in interviews mirror many of the problems state and federal regulators would later find.
Burks never did meet David Merlin, the administrator who blew the whistle on Kaiser’s center, even though Merlin started working at Kaiser in December 2005, two months before Burks staged his sit-in. Merlin says he knew when he was hired that the center had a backlog of patients. But he realized the personal impact of that situation a few weeks into the job, when he started taking patients’ complaints.
Nearly all of the organizations involved blame each other for different aspects of the transplant center’s breakdown. Kaiser executives, including Northern California president Mary Ann Thode and national CEO Halvorson, say UNOS shares responsibility for Kaiser’s administrative problems. At the March Commonwealth Club meeting, Halvorson said UNOS was unprepared to handle Kaiser’s demands. “We said, ‘What does it take to transfer people from one list to another?'” he recounted. “They gave us an estimate, we relied on that estimate, and what’s interesting about that is they assumed we were talking about transferring one person. They didn’t think we were going to transfer 2,000 people.”
In the year since Kaiser said it would close the kidney center, the company has worked to move patients back to the UC facilities and put in new technology and procedures to help. By June 30, 2006, Kaiser had transferred 360 patients. By Dec. 31, 2006, 2,163 patients had been moved. Last month, the last patient left Kaiser’s rolls.
Also in This Feature:
- Top Players Inside and Outside the Organization
- How Kaiser Stacks Up Against Other Kidney Transplant Facilities
More:
ITBusinessEdge.com: A Tale of Two Healthcare Systems — This week, a disturbing story from the healthcare industry demonstrates the best and worst examples of how data integration can make all the difference.
I am one of those transplant victims and one of the many lawsuit participants. I’ve been hearing around Sacramento that Kaiser lawyers think this is a “slamdunk”for them. My feeling is these lawyers for us wouldn’t have taken this on if they didn’t think we would win. What do you think my fellow transplant victims
There is no creature lower than a Kaiser Permanente lawyer. They walk around so full of themselves it’s a wonder their heads don’t explode.
It doesn’t seem possible that they could win considering the outcome of the CMS investigation, but in the Kaiser alternate universe where they routinely falsify documentation to back up their cases, I guess anything could happen. JMO
We’re all waiting for karma to kick in, and when it finally does it will be a beautiful thing.
“We’re all waiting for karma to kick in, and when it finally does it will be a beautiful thing.”
You took the words right out of my mouth.
For the past couple of months, I have been working towards trying to help manifest Kaiser’s “karma” (just as they helped manifest mine)–both in terms of documenting many of the methodological weaknesses within Health Connect and also by exploring legal avenues for holding Kaiser accountable
. . . due to “potential” problems (and the “potential” implications of those problems relative to patient safety) within Health Connect and what those “potential” problems may mean to current Kaiser members and, like all things that involve laws and interpretations of laws, this has NOT been a speedy thing to undertake.
The paragraph above (sorry, I have not followed the link to read the article) about finger-pointing instead of action is SOOOOOOOOOOO TRUE!!
I am attaching part of an email I wrote as the cover to a “Lessons Learned” document I submitted to Kaiser leadership last November–this is before finding out that our daughter’s medical records magically re-appeared (without a name, date, or MRN number at which point I stopped really trying to help Kaiser and “gave up” any hopes of things ever working out).
Anyway, for a small taste of what my opinion of Kaiser’s methodological weaknesses may be I am attaching part of the cover letter to my Lessons Learned doc, dated 11/10/2006:
In a nutshell, all the ways in which a software implementation could go wrong I believe went wrong (WAY wrong) with Health Connect.
Saying this out loud is a “bold” thing to do but there is much much more that can (and should) be said.
But, if you believed that someone just stood by and watched your baby die would you maybe, just maybe, have an “agenda”. Well, based on that logic, I have an agenda with Kaiser Permanente. More, hopefully, yet to come . . .
I do not understand how a “lack of communication” could be such a problem with the computer system, since Kaiser can so easily access a California patient’s other visits to ERs, an so easily blacklist that person. People often complain about a deficiency in patient safety due to the ERs not being able to communicate with each other, but it seems to me that they do FAR too much of that by noting derogatory entries on a patient, and then the patient gets treated worse than a dog when they go for care anywhere in Northern California. Can you explain this apparent paradox? Thanks.