Over my career ive got answers like the parking here is good or we can do better than that. This is one fits almost of the u. S. Economy and competition just seems to be at the wrong level and patients are frustrated. Another reason i wrote the book is that doctors are getting crushed right now. They have got declining medicare payments. They have got increasing overhead, hospitals have more expenses. Malpractice rates are going up. The burnout rate is 46 and doctors are getting crushed right now and i just felt like we needed a voice out there and its okay to talk to the general public. Host so you make the point that medical mistakes for the third leading cause of death in the United States. That is a shocking figure. Can you talk a little bit about that . Guest it was shocking even for me as someone interested in the skill and quality to put it in that way. Medical mistakes. We kill as many people from medical mistakes as we do from Car Accidents and other three, four and five causes in the u. S. I guess ive never really thought of it that way because we dont really talk as openly and honestly about mistakes as we showed in our profession, to be very blunt. Think about number one heart disease. The number one cause of death in the u. S. We spend a heck of a lot of time and energy on hard prevention and heart disease. Cancer, a lot of money going to cancer. We are just now beginning to recognize that this is number three and some people have told me, after i wrote unaccountable there is not really a medical mistake problem in the u. S. And i think we are starting to to just now accept that this is something we have got to Start Talking honestly about. Host so, we know that there is tremendous care that is received here in the u. S. And certainly at the institution that you trained at but this concept of kind of equality and disparity of quality. You got interested in it during her Doctoral Program at harvard. Can you talk a little bit about how you came into that and what your interest was in really where did the field come from . Guest well, i think it just started to be recognized as a field when i was a student. It was sort of a right time, right place kind of thing. I had this frustrating experience with a patient of mine that i was assigned to follow. Her name was missed his tanks and she is in the opening of the book. She really didnt want anything done for her cancer which had spread all over. The doctors clearly wanted to do something. They essentially bullied her or talked her into it. They overstated the benefits and understated the risks, something we know from Research Happens especially those of us to do procedures. It just didnt seem right to me. It seemed as if the profession wasnt telling the truth. It seemed as if the profession of medicine had long strayed from its original mention vision. Its not why went into medicine and its why i quite frankly quick. I started school and Public Health where i met david gates who host im sorry to interrupt. So you were in medical school and you have decided you had had enough and you went to the school of Public Health . Guest i basically explained what mrs. Bankston wanted. The they torme upside down for explaining this to them, that she didnt want the procedure done and they basically implied, didnt matter what she wants. This is what she needs and this was to me a sign of a culture that i had observed from the outside but didnt want to be apart of and i quit medical school. Then i started graduate school for Public Health because i heard of a track three could focus on quality and there were people now interested in medical mistakes. The first time they were describing studies were they were looking at handwriting resulting in patient harm and it was a radical concept at the time. David bates put a big study out and he describes the head of one of the largest doctors organizations in the United States calling him and basically saying, what are you doing this for . This is not a problem. I realize that realized that we have had these explosions of knowledge in medicine but we have not coordinated care and all the services that we have end up having so many cracks that the cracks are as harmful as the diseases that we are treating and you have got to step back and ask, you know, are we hurting people overall on a global level . What are we doing sometimes and of course now we have got this reports saying, 30 of everything we do may not be Necessary Health care. When we step back, 30 of all the medications we prescribed and the tests we order and the procedures. This is something i think which is, for the first time, really being called out as a problem. People out there in the general public have been saying for a long time, we dont like the closeddoor culture of medicine. We find medicine even sometimes to be an arrogant industry. We feel like we dont connect. I remember in medical school being told that a nosebleed is at at the status. I citizen than a nosebleed . What else could at the stacks as the . Its like a whole different vocabulary. And that disconnect has a think created an issue with our trust in the public and this issue of overtreatment now has further strained the public trust that medicine has. Its a great job and its a great profession. You are in Health Health healthe and everyday you see folks have tremendous results, the byproduct of phenomenal advances in technology and the art of medicine with compassion. It is a great profession that when we have got the institute of medicine saying 30 of the time we miss the mark, we have got to study this. We have got to make it a discipline of science and say how can we look at this like we look at cancer . Where are the cracks . Where the mistakes . That was the main reason i decided to go down this path. Host that statistic of 30 in quality, waste and variability is a stunning statistic. Why do you think that, and you mentioned culture a little while ago. What is it about the culture of health care, where those types of activities have been allowed to go on for such a length of time. If you look at any other industry, 30 waste or 30 error rate really would be unacceptable. How does that occur within health care . You know its a great wondered why people tolerate 30 waste and health care but they wouldnt tolerated in any other industry. I saw a statistic recently in a report, the average income of an american in the United States gone up about 30 over the last decade. The increase in Health Care Costs that they are paying have gone up about 68 over the same time period. Essentially we have offset the increases in income with increased Health Care Costs so you wonder why is it that we tolerate this . I have talked to Business Leaders who say you know, every contractor we pay we have some metric of how well they perform except for one, Health Health c. We keep throwing money added and patients say the same thing with their premiums and their new high deductibles. We keep throwing money at it. What more are we getting for our money . There has been this culture of medicine that has respected the art of individual autonomy, but at the great risk that some best practices never get standardized. In my own field, pancreas auto transplant where we take a pancreas out of somebody, treat the cells and give the cells back to the patient. We need a laboratory to treat the cells. Medicare at one point paid a bonus of 20,000dollar payment to hospitals for doing this on top of what they were already charging. It became a very profitable business. We have a laboratory at Johns Hopkins in the operating room and we have the patient asleep under anesthesia, take a pancreas have intrigued the cells and give the cells back right then and there, same operation. Hospitals across the country started doing this operation, taking the pancreas out but because they dont have a laboratory, put it into a cooler and send it by jet to another city, have it treated at another facility in another city or state, have it flown back and then cut the patient open up again for second operation. Why would anyone have that done . They just dont know about the other option. Im not talking about hospitals. Im talking about to the top 10 hospitals in the country do this. We have got smart people, good people working in a bad system where the financial incentives lure people to do things that just arent right. I think if hospitals are accountable for their results the results and the Patient Satisfaction is scored in the Patient Outcomes and the complication rate, the volumes in the readmission rates, all the basic metrics in Health Care Performance that doctors are endorsing as valid, they were available to the public, people could choose where to go based on who performs the best like any other free market works and like any other uses to reduce waste in their field. Host so the issue of Patient Choice about where they seek care and what has been out there and certainly the health care literature and discussions amongst leaders for a number of years, where many people advocate that if indeed the patient had the opportunity to see the quality and see the individual physician, hospital infection rates etc. They would naturally gravitate to those institutions. Theres another school of thought that says, you put all the information out there but that wont really happen and patients will naturally gravitate to it. You reference in referenced in your book where patients seek their care. I go there because my mother was born there or because its two miles from my house. Talk to me a little bit about the balance there and how if indeed all of the quality is a factor, how do we get patients informed as to how they can seek this information and will it make a difference and where they seek their care . Guest well you know i have got some patience you tell me. , whatever you want to do you just tell me and i will do it and they have total blind trust to the doctor in the system. Baby for that, thats okay but more more patients now want to know the options and they want to know something can be done minimally evasive. If they really need to take the medication a medication or affairs a holistic or naturalistic or preventive means, maybe they can do physical therapy to avoid something. They want to know now. We have an informed public and increasingly we are seeing that. One critic of the book told me you know, if you put stuff out there people will never use it and it wont reduce health care ways. Four weeks after the book came out, a study in the journal of the American Medical Association showed that when there was public reporting of heart procedures we are talking about stenson angiograms, the overall number of procedures went down by 14 and there was no difference in Patient Outcomes. A big study, jama, four weeks after the book came out showing the public reporting reduces waste and has no impact. The patient did just as well. I think increasingly we are learning about the impact of public reporting and look, all of us know. Theres this should not be practicing. One National Conference i was at, they asked the audience how many of you know that doctor that shouldnt be practicing in every single hand went up. I think its because we all recognize there is going to be some bad apples that are going to respond to financial incentives and there is little accountability in general and health care. The hospital seven miles down the street from my house had a doctor put in at least 500 unnecessary hearts fans. Now, if those procedures would have been recorded and given to the patient on a thumb drive as they advocate in the book in general, that doctor wouldnt have gotten away with putting in stems and arteries that were never even blocked. There would would have been some oversight like when we had speed traps with cameras at an intersection. Everybody follows the law. In the compliance rate we are trying to get everyone to follow the speed limit and forget raids its been horrific. Since we have had automobiles would have been trying to do education. Education doesnt work to get people to follow the speed limits. What works is when somebody sees a camera or an officer on the side of the road and then everybody is compliant. Lean health care have a lot of room to increase accountability and quite frankly i think itll really restore the trust that has been broken with the general public. Host so lets go back to the culture question again. I was riveted when i was reading the book about your account when you are a net room and everybody raised their hands. In fact as you describe it, you were to raise your hand. There was a senior position next to you who looked at usaid really, you dont know anyone . But what about the culture do you think has led us to this point where we actually said where we no harm is occurring or we have a sense of it that we have gotten to this point where people are afraid to speak up and afraid to criticize their peers or the institution . You make a point a number of times in the book that, and actually in your opening chapter, where you talk about the fact that you know, go to where the people in health care, the nurses and the doctors and administrators at that hospital, where they would be. How is the culture proliferate what you have been talking about, or the public, how did they seek that information out . Guest you know i once told a friend the best way to find out about the quality of a hospital is to ask an er nurse who works there. A nurse knows more about the quality of the hospital than probably anyone else there, and for that matter any industry, frontline worker, providing the services be it creating products probably knows more than any of the administrators of the institution about the culture. The reason is that culture drives everything we do. In economics there is this phrase, no one has ever washed a rented car. They dont own it so why would they . A sense of owning the delivery of care is a critical important element. That is what bothers me about sina statistics now, that 40 of. Org Zinni Nida States are burned out according to mayo clinic. They did a study three weeks ago. When we have 46 of frontline providers in any industry burned out, of course the quality is going to be poor and of course mistakes are going to happen and of course people are going to fall through the cracks. When people dont feel that they own the service code docs tell me when i go to conference is an speak, i often know how to health care make health care a better institution and i know out of care make the care safer for people but i dont feel empowered. That i think is one of the great divides right now in health care and United States. Increasingly, we have some doctors saying in some facilities that there is a chasm between themselves and their unit manager, between themselves in those who are making the policies or those calling the shots on a national level. They dont feel empowered and we are seeing more variability because of that. Host you talk in your book about the administrative crack downs if you will, where you get providers of care and Senior Administrative leaders working a little bit more together or getting the administrators out from their offices if you will. Talk a little bit about that in what and what you see the value of that being as well as its impact if you will on the quality. Guest you know we all want the same thing. Doctors, administrators, Insurance Companies, policymakers. There is an astronaut from outer space who was asked, what does the middle east look like from outer space . The astronaut said you know there are no lines when you look at it. The lines are manmade and that is what is going on in health care. The lines we have made in health care or manmade. We dont want the same good for the public. We have got good people. There it is sometimes working in this artificial system. We tell administrators, make a profit, billiar beds so they make a profit and they fill the beds. We tell doctors to see more patients so they see more patients. Everyone seems like they are doing their job but as don burke said its like the jobs are designed wrong and we have good people. When my dad was a practicing doctor at sizing or hospital, i remember this administrator named ken ackerman who would come down and sit down with a doctor, walked down the hallway, prop himself right in their office and say, hows it going . What do you need to do your job better . He was not a doctor, ken ackerman but the doctors on the staff said that he was the administrator in a white coat. That is how he got the nickname. He was in touch with the frontline providers. You see it in a kind of industries, be at lehman brothers, be it large corp. Delivering a service that is multinational. When the administrators lose touch with the frontline folks, that is when bad things start to happen and that is when the accountability becomes a problem because there is no transparency and that was really the impetus for writing unaccountable. Guest as a hospital president and my struck by the fact that if you want to know where the issues are ugoda the frontline and you go to the operating rooms. But why do you think that we, and many hospitals, perhaps there has been a separate differentiation are defied if you will between administration, doctors, and does it have anything to do with incentives. We talked a little earlier about this so what do you think . Guest i have seen both extremes in the United States and the talk about both extremes in the book. I recently learned an emergency room that was built that was freestanding with no hospital attached to it. Can you imagine if you had a heart attack and you go to the emergency room and they dont have a hospital to put u. N. . They have two ship you across a floating bridge across a lake the lake to go to another hospital because that is their associate hospital that they admit patients in. In in the United States this happens and you see these doctors saying this is an right and even sometimes administrators will say we know its not rational but that is the way we get paid. And you realize when