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Interview with Dr. Bill Nugent

Hedrick Smith: We're talking to Dr. Bill Nugent, the chief of cardiothoracic surgery at Dartmouth-Hitchcock Medical Center. Why is this interdisciplinary meeting so important?

NugnetDr. Bill Nugent: Because this is a team. Taking care of open-heart surgery patients, or angioplasty, requires a team effort. I don't have the skills nurses have in helping patients get well after they’re sick. They don't have some of the skills that I've learned [in] becoming a physician. And I clearly don't understand the implications of anesthesia to care. And when you bring all of that wealth of knowledge to a single room, to a team, so much more is accomplished in overall improvement and [in] the ultimate outcome.

Hedrick Smith: You know, if you'd [have] asked me 10 or 15 years ago what went on in open-heart surgery, if I'd thought about it, I'd’ve said, "Everybody's working as a team." Hasn't that been going on all along?

Dr. Bill Nugent: No. fascinating to me that you use 10 or 15 years as your reference point. Ten or 15 years ago, things were very different. I was introduced to the critical nature of multidisciplinary team interactions, oh, in the late eighties, maybe as late as 1990, when it became evident through the work of the Northern New England Collaborative that there was a variation in the mortality rates of patients undergoing coronary bypass surgery. Interestingly, it's typical for clinicians to explain that variation based on differences in the patients that they see. Namely, older, sicker patients have worse outcomes. If my outcomes are less good [than] someone else's, it's because I have older, sicker patients.

When we, in fact, examined that question, we found that the patients were pretty homogeneous across the region; but the mortality rates differed from institution to institution.

Hedrick Smith: There wasn't teamwork?

Dr. Bill Nugent: There was an implicit teamwork, but there was no explicit teamwork. I had no idea what physical therapy's role was in a recovering open-heart surgical patient. There was no standard time to remove chest tubes, take telemetry wires off patients. And, basically, it was left to the individual surgeon, or individual nurse, or individual clinician to sort of make it up as he went -- even though we thought we had a plan. We thought we were working in the same institution and, therefore, doing it the same way. When we actually sat down in a room together -- it was one of the most powerful experiences I've had in my professional career -- and learned what each of our roles were, and then defined those roles and talked about where the differences were, and actually wrote down the critical pathway. I think it was one of the turning points in care at this institution and in my clinical career.

Hedrick Smith: Why?

Dr. Bill Nugent: Because I began to realize where people fit in this complex pattern of care. I began to recognize how everyone is important in a successful program such as this and how important communicating your needs and your roles is within the greater context of the program itself. Basically, we now understand each other's relative roles. We now work well together. And a streamlined health care has provided some autonomy to caregivers and has revolutionized in many respects the recovery of patients after procedures.

Hedrick Smith: I suspect, in talking about this, that you've used some words you would've used 10 or 16 years ago, but there's something that's different. What's the heart of what's different?

Dr. Bill Nugent: We gave it lip service before, but there was never the opportunity to sit down at an organized meeting to actually create something as a result of that meeting and then manifest and actually see the results of what we've created in improved outcomes downstream.

Hedrick Smith: What was it like before?

Dr. Bill Nugent: It used to be surgeons talked to surgeons, and nurses talked to nurses, and the two never talked together. 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 each acknowledges the relative role that each of us plays in facilitating somebody's recovery.

Dr. Bill Nugent: When the realization came that there were potential differences or variations in mortality rates between institutions, it was a helpless feeling, because you had no clue what to change. You were already doing as well as you could do. So, my initial response was terror, and I think that initial response was echoed throughout the cardiac surgical community.

Hedrick Smith: But what were you terrified of?

Dr. Bill Nugent: I was terrified of 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.

Hedrick Smith: Afraid you'd lose patients?

Dr. Bill Nugent: Lose patients, lose patient credibility, lose market share -- be exposed.

[But we wanted to] go from understanding variation in utilization of a procedure to seeing if we could understand variation in the outcome of a procedure. And that's where we decided to merge or share sensitive mortality data, the five institutions currently practicing cardiac surgery in the three-state area of northern New England, in order to better understand where variation existed in the outcome of of patients undergoing coronary bypass surgery, so that we could work together to improve the outcome of [those] patients.

Hedrick Smith: You talk about variation being bad. Why is variation bad?

Dr. Bill Nugent: Variation isn't bad; variation is good -- if you understand the variation. If you look back at the paradigm of learning in health care, before 1985, there was rampant variation, but no learning associated with it.

Hedrick Smith: The implication is that somebody's not using the best practice?

NugnetDr. Bill Nugent: The unfortunate thing is you can't harness the knowledge of understanding that variation to change people's practices. What we're doing is acknowledging where variation exists, but learning from the variation, so that we cannot just reduce unnecessary variation, but we can find best practices and improve outcomes. So, we're now moving from variation without learning, to understanding variation and coupling [that] with learning. We found that, in fact, there was variation in the mortality rates of patients undergoing open-heart surgery in northern New England by institution, and that that variation was significant, and that it wasn't explained by patient criteria. It was probably more explained by institutional differences.

Hedrick Smith: And what were the implications of [those differences]?

Dr. Bill Nugent: The implications were that practices varied. Oftentimes, the surgeon or the institution is the surrogate for the practice that goes on at that institution, and that variation was likely leading to the variation of the mortality rates downstream, since we couldn't directly blame the patient. So, our next chore was to understand that variation in practice. And that was accomplished by simply introducing ourselves to one another in a formal way.

Hedrick Smith: Okay. So, your first study gets done. And what's your instinct after you've done this northern New England collaborative study?

Dr. Bill Nugent: [It was] clearly a watershed event for both the group and for me personally. I was terrified about publishing these data and, in fact, argued strongly that our obligation was not just to describe the variation in mortality rate, but improve it and reduce that variation before we published it. You know, "We've found the variation. Let's now work to reduce it, understand it; and then let's publish that paper."

Hedrick Smith: And variation becomes a substitute for the word "problem." "We've found a variation." --- "We've identified a problem."

Dr. Bill Nugent: Different mortality rates by institution after accounting for variables in patient severity. So, yeah, it's variation in mortality rate, meaning one institution with a higher mortality rate than another.

Hedrick Smith: And that's a big problem.

Dr. Bill Nugent: Yeah. It's a big problem when you don't know what to do about it. And it's less of a problem if you understand what to do or have some handle on what you can do about it. It's a bigger problem when you're completely out to sea in terms of acknowledging from the beginning that you're already doing the best job you can. And our own personal response here was to organize ourselves, and this has led to the critical path development, protocol development, multidisciplinary teamwork, a quick identity with our cardiology referring partners to say, "We are now going to mold ourselves into a Cardiac Services Division that will work together to improve our outcomes," so that we'll work together to understand our interventions.

Hedrick Smith: People are competitive. Hospitals are competitive for patients. Doctors must be competitive for patients.

Dr. Bill Nugent: Our primary purpose and our reason for existence is to take better care of our patients. We are allowed to share information. Society would allow clinicians to share information if the end result is a better outcome for their patients. We're not Kodak versus Fuji in protecting our proprietary interests. And this is where I think we can rise above the economic venue of health care and concentrate on improving patient care, and use the combined wisdom.

Hedrick Smith: But even if you don't have economically competitive instincts at work, you have psychologically competitive instincts at work. I mean is there a certain defensiveness at being held accountable?

Dr. Bill Nugent: I lectured at physician groups trying to organize regional collaborative[s] similar to [our] Northern New England group, and they're already either responding defensively to a statewide initiative to profile their institutions against one another or they're responding defensively against advertising campaigns on one institution against another, using outcomes data from one source or another. And that's perfectly legitimate, and a perfectly reasonable response to that kind of pressure.

We work on ways to understand our outcomes, put them in a context, put them in a context or put them in some kind of a statistical context so you know what's significant and what isn't. We try to break down the fear that's associated with the ranking process that is sort of a natural, human instinct.

Changes can occur within your practices from what you've learned from the data itself.

Hedrick Smith: It sounds to me as though what you're describing is a cultural sea-change within the medical profession in terms of people's mind-sets, how they approach their common problem. Am I right?

Dr. Bill Nugent: You're absolutely right. It's a cultural change. Clinicians need to begin to embrace accountability. We need to accept some level of profiling. We need to be proactive about the accountability movement and allow a certain amount of profiling to occur. And at the same time, we have to learn from this information. We have to take some control of this whole process and, I think, work together to use this process to document the improved outcomes that can occur from the information that you learn from it.

Hedrick Smith: How does the mind-set change? What do people have to accept they didn't accept before?

Dr. Bill Nugent: Well, unfortunately, I think you were right on. I think it is a cultural change, and I think clinicians have to accept a level of accountability for our practice. They have to acknowledge that if we're to be trusted as stewards of our practice, then we need to be accountable for it. I think, physicians need to be proactive, not reactive, and I think they need to work together, not compete with one another. I think they need to acknowledge that they're mutually responsible for a set population of patients, [to] work together to improve the outcomes of those patients and account for that improvement -- no -- document that improvement.

Hedrick Smith: So, would you do that here in Northern New England? Would you publish the statistics? Not blind. You publish them now blind and by institution. Would you publish them openly and by surgeon?

Dr. Bill Nugent: That's come up. We've been asked whether we would do that by outside people. We've never had to do it. I don't think we are as afraid of doing it now. I wouldn't oppose it anymore, like I did before. I think public accountability, or the public awareness of profiling, has worked. It's reduced mortality rates, and that's been shown in New England. That's been shown in New York State. And even without the public accountability, it's reduced mortality rates comparably in New England. Both concepts work. If you're going to use this data for improvement, then you need to drive as much fear out of it as possible. It needs to be shared, and it is sensitive data. I think it's been harder for the profiled states to organize themselves, for physicians to be proactive in the context of public accountability.

Hedrick Smith: Because they're afraid.

NugnetDr. Bill Nugent: Right. I think it's been harder for them to take that giant step forward and take control of this. And it's been hard, and it's been difficult overcoming the fear and paranoia in places like New York State and Pennsylvania for those clinicians. At the same time, I’ve been encouraged by…New York State physicians looking for opportunities to collaborate regionally, looking for opportunities to be proactive rather than reactive. So, there're organizational efforts now in New York State to put regional groups together. There're organizational efforts in New Jersey that are currently under way. There're organizational efforts in many states -- Alabama, Michigan, Iowa, Colorado, Virginia -- all now proactively formed by clinicians to share information and document the improvement that can be seen with that collaborative spirit.

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