Dr. Brent James, chief quality officer at Intermountain Healthcare, discusses his groundbreaking approach to clinical quality improvement.

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Margaret, a picture perfect Memorial Day weekend. We had a
great turnout at the Memorial Day parade. You know we love parades at the
Community Health Center and we are very proud that our float won the veterans
award this year.

Margaret Flinter: Well, I guess we are entitled to brag for just a second but it was
a great and wonderful traditional event. And the long weekend, a much needed
rest for everybody. But the hard work of implementing health reform that’s back
in full swing this week. In California, the legislature is looking at trying to pass as
many as 20 different bills related to health reform before they adjourn for the
session. Those provisions keeping adult children on their parents’ policies till age
26, eliminating preexisting conditions for adults, and that all important creation of
the state health insurance exchange. Federally funded but state run all of those
on the agenda.

Mark Masselli: California is certainly a model state for implementation because
of its large size, not to mention its significant population of uninsured. There are
around eight million uninsured residents in California, about the size of State of
New Jersey.

Margaret Flinter: And there is some level on which people are saying they will
hopefully pass reform because the republicans they are calling the legislative
activity premature. There are upcoming elections that could potentially put
republicans back in power and that potentially could result in the repeal of the
reforms. Going back to the surprise republican senate seat victory in
Massachusetts earlier this year, I think Mark it's safe to say the democrats have
learned to take nothing for granted.

Mark Masselli: And when there is a lot of potentials, there is a lot of anxious
people and certainly the poll show Americans are still divided over the new law
but a new NBC News/Wall Street Journal Survey found that the public is more
likely to vote for candidates who would work to improve the bill versus repeal it.

Margaret Flinter: And that’s exactly what people predicted back in March would
happen and that’s good news. Let’s turn out to today’s guest who has been an
innovator in the practice and the science of health care delivery for over 20 years
now. Dr. Brent James is a surgeon. He is also the Chief Quality Officer for
Intermountain, a large health care system based in Utah. He has developed a
very disciplined approach to measuring outcomes and from that creating
standardized clinical treatment plans that have been successfully shown to

improve quality, improve safety, reduce cost and most importantly save lives. We
are so happy to have Dr. James here with us today.

Mark Masselli: We are and there was a great New York Times magazine article
about Dr. James. The author David Leonhardt puts Dr. James in a league with
Don Berwick, Mark McClellan and Dr. John Wennberg of Dartmouth as he puts it
for the past decade or so a loose group of performers who has been trying to
figure out how to improve health care and also holding down the growth in cost.
Dr. James is a real health care reformer.

Margaret Flinter: And that’s quite a group of illustrious visionaries that he has
been keeping company with. No matter what the story, you can hear all of our
shows on our website Chcradio.com. You can subscribe to iTunes to get our
show downloaded or if you would like to hang onto our every word and read a
transcript of one of our shows, come visit us at Chcradio.com.

Mark Masselli: And as always, if you have feedback, email us at Chcradio.com,
we would love to hear from you. Before we speak with Dr. Brent James, let’s
check in with our producer Loren Bonner with the Headline News.

Loren Bonner: I am Loren Bonner with this week’s Headline News. In a very
tangible demonstration of the impact of the passage of the Health Reform Bill,
the Federal Government sent out brochures last week to more than 40 million
Medicare recipients to tell them about their benefits under the new law. The first
benefit will put $250 in the pocket of 80,000 seniors who fall in the Medicare Part
D’s current coverage gap. The government will continue to mail checks every 30
days. The gap known as the Donut Hole will disappear eventually under the new
legislation. Secretary of Health and Human Services, Kathleen Sebelius says
this will be a huge relief to seniors.

Kathleen Sebelius: One of the biggest ways the new law is going to help seniors
is by gradually phasing out the Medicare prescription drug Donut Hole that’s
made it hard for seniors to afford their medications. About eight million a year
reach that Donut Hole gap and coverage.

Loren Bonner: But other Medicare news is making the headline. Congress did
st
not act in time to avert a June 1 21% pay cut to physicians who care for
Medicare enrollees. The proposed doc fix, a last minute infusion of funds to
stave off a looming cut has been continuously postponed. The uncertainty is
making some doctors take a hard look at their participation in the program.
Democrats have talked about a five-year fix then three years, now it looks like
leaders are proposing postponement of the cut through the end of 2011.

Today on Conversations on Health Care we are exploring the broad area of
transforming health care quality. Saving more lives, reducing costs and
expanding the science of medicine to include the science of measuring health

care outcomes. Cost effectiveness research is an element of transforming
quality. It quantifies how much better one treatment is over the next. How much
reduction in mortality? How much increase in life expectancy? How much
improvement in quality of life, does treatment A give a patient compared to
treatment B. It also takes this comparison one step further and relates that
quantified measure of incremental benefit to cost. How much does it cost to get
a particular level of improvement in health outcomes? Almost every western
country has adopted CER into their health care system in one way or another.
CER encourages change that can improve both the efficiency and the quality of
care. In the US however there is still a widespread fear that CER will prevent
patients from receiving affective or life saving care. Milton Weinstein the Henry J.
Kaiser Professor of Health Policy and Management in the Harvard School of
Public Health refutes such a claim. Expensive life saving treatments and drugs
are not ruled out under CER he says.

Milton Weinstein: Even very expensive drugs such as Imatinib which is used for
leukemia among other forms of cancer, despite its high sticker price is an
extraordinary value in terms of the cost per life-year saved for patients who
previously didn’t have any attractive treatment options.

Loren Bonner: There is also fear from the medical community that CER will do
more harm than good in part by threatening individual physician’s autonomy and
professionalism. Weinstein agrees that this can be difficult but remedied.

Milton Weinstein: Getting physicians and healthcare institutions to change
behavior require some tangible incentives. Many people talk about something
called value-based insurance design whereby physicians and health care
providers might be paid different amounts depending on the cost effectiveness of
what it is they are being paid for so that holding everything else equals, such as
the cost of delivering the service they might get paid a higher percentage of cost
for procedures that are more cost affective.

Loren Bonner: The health reform legislation specifically prohibits the use of CER
information and making coverage decisions. The bill will however fund a private
organization called the Patient-Centered Outcomes Research Institute which will
identify which patient-centered research will help providers and payers make
informed decisions about how to treat patients effectively without wasteful over
spending. The bill also sets up pilot projects that will examine new physician
payment systems, penalize hospitals that have high readmission rates and
establish an independent commission that will determine which treatments
Medicare should cover. Let's turn now to our interview with Dr. Brent James,
Surgeon, Scientist and Chief Quality Officer of Intermountain Healthcare, a Utah
based health care system that has earned a national recognition for its work and
achieving better than average patient outcomes at less than average cost, using
principles that the rest of the country will need to consider and adopt.

Mark Masselli: This is Conversations on Health Care. Today we are speaking
with Dr. Brent James, Chief Quality Office at Intermountain Healthcare. Welcome
Dr. James. Your institution Intermountain Healthcare has been frequently sited in
health reform discussions throughout the past year. Your Public Relations
Department must be very happy but it's not about vapor , as Chief Quality Officer
you had a strong influence in getting physicians and nurses to move toward the
disciplined measurement of outcomes, and use of treatment guidelines based on
data generated by that measurement. Could you start out by telling us how a
cancer surgeon like yourself, a former physicist, started down this path?

Dr. Brent James: It was as usual a complete accident. I was at Dana-Farber
Cancer Institute, a member of the faculty of Harvard School of Public Health
studying new therapies for cancer patients. Mostly a personal circumstance I
needed to move back home close to the family and had a job offer from
Intermountain. Frankly that was a strange experiment. They were starting to
reach out to physicians back in 1986, physicians who were interested in research
and they wanted to start some sort of research program, got here and we had an
interesting and we had an interest in measuring variation in care, a obscure
branch of medical science but surprisingly well founded. Everybody till that point
had looked at variation in hospitalization rates, we looked at what happened to
people after they were hospitalized. What we showed was an extension of the
existing knowledge. It turns out that where you live is more important than
whether you have insurance and determining the care you actually received. We
showed that one step further who treated you within the hospital was more
important than any other factor in determining the actual care. And the problem
was that the variation was so large, it was pretty much physically impossible that
all patients even with full access to care were getting good care. Well the next
step it’s one of those happy accidents so I shared some of this data in the
national meeting, met a fellow for the first time who became a very good friend,
Dr. Paul Batalden then the Vice President for Quality at HCA back before they
became part of the Columbia System, now at Dartmouth University. Paul looked
at our variation analysis and sort of reminded him of the work of a statistician in
industry. A fellow named W Edwards Deming, yeah and he introduced me to Dr.
Deming and that was a match made in heaven. Well I came back home and
tried some of Deming’s ideas in trials, treatment, experiments so we had to go at
Intermountain. Dr. John Burke was leading the team up at LDS Hospital, he was
doing this research, we were all trained health services researchers. We know
how to measure very precisely but we focused our attention pretty much
exclusively on clinical outcomes. And Deming’s idea was toss money in there,
toss and cost is just one more outcome. He came back to Dr. Burke and said
hey John have you ever thought about tracking cost? We thought it was a really
cool idea and the question was how he measured the cost? Well, again pure
serendipity. It turns out that Intermountain was one of the first systems in the
world to build a system that could measure cost actually. The fellow who had
done that was a guy named Steve Busboom, the Vice President for finance and I
met him here. So I said to Dr. Burke, I said John, Busboom, he can help us. We

will get this done. Well we threw that cost metric in, we showed our infection
rates off of 1.8% to 0.4% as part of the trial. But because we didn’t have to pay
to treat the infections the cost of operations at LDS Hospital fell by almost $2
million a year.

Margaret Flinter: Dr. James, I think Dr. Deming hasn’t got quite as much credit
as he should in these health care reform discussions we have been having. So
thank you so much for sharing that history with us. And you know, I have read
some of your comments and I think you have spoken so eloquently about the role
that intuition and experience in caring for patients, you clearly have a deep
appreciation for the sixth sense health care providers develop about patients and
treatment decisions. But you have made this point, usually when healthcare
providers are talking about my experience they are really talking about the last
few patients they treated and you were quoted in a New York Times article as
saying, “My goal is for doctors and nurses not to say in my experience but rather
to say in my measured experience”, that’s a culture change and I know that you
are very involved in training the next generation of health care providers to
embrace that change and you are doing it outside the academic institutions
largely. Can you tell us a little bit about your work in that area?

Dr. James: We run a big training program called the Advanced Training Program
in Clinical Practice Improvement. It started in 1992. It was an attempt to change
the culture of Intermountain. Dr. Deming told me that if I wanted to change kind
of the attitudes and beliefs and the approach that physicians showed, he said
you don’t need to get everybody but he said if you have got n individuals you
need about square root of that. So we started the ATP the Advanced Training
Program to do that. Trouble was as I wanted to bring in some very prominent
faculty and that costs money, we couldn’t afford it. So I opened it up to people
from around the country. We run it at break-even that about I don’t know 20% of
the attendees are from Intermountain or the other care-delivery groups here in
Utah. The other 80% come in literally from around the world. Since then we
have trained about 3500 people in the principles of clinical quality improvement
that’s just playing the fun. I mean you get health experts from all around the
world. People, who are doing that hands-on experience, get them together in a
room it means when you bring up any issue you are going to see it from eight
different directions including a British direction or an Israeli direction or a North
American direction, you see.

Mark Masselli: Dr. James, speaking of other institutions, Mayo Clinic and
Geisinger Clinic are also praised for their quality, outcomes and ability to avoid
over-treatment and testing but one key difference between Intermountain and
those systems is that the other systems are a staff model institution in which the
physicians are employees. The model would seem to allow for greater control
over physician practices and consequently incomes that are not based on
volume of visits and procedures. Tell us about the challenges you face in trying

to drive change in improvement in a system like Intermountain where you don’t
have that level of control.

Dr. James Brent: Well the first thing that is a basic misunderstanding and that
people think you can control a physician through employment, you can't.
Physicians are mostly driven by professional goals. So what we did here, where
most were physicians are community based we built our measures around
shared professional goals. And what I can tell you from experience it pretty much
always trumps some money. If you can show them what's really happening to
their patients they all believe they are doing good. They all get up every morning
and say how can I help people and in a very real sense the money they receive
is just the _______ their force to bear for the good they are doing in our
community, right, to make a little bit of a joke out of it. When we started to make
care truly transparent so they could see the short and long term results their
patients were experiencing it overwhelmed the money.

Margaret Flinter: Let's talk about the patients for a second Dr. James. We
recognize that just because the treatment has been proven to be safe and
effective doesn’t mean we necessarily have the data and the science to know
when it's effective and in which groups of patients it is most effective. And it
makes sense to give patients a role in that you at Intermountain have developed
a sheer decision model I understand, that’s the responsibility patients may or
may not be ready to accept. Can you give us your thoughts on that and do you
have any data on the benefits of a sheer decision making model with patients?

Dr. James Brent: Well in truth we didn’t develop it here so much as we brought
up from Dr. Albert Mulley at Massachusetts General Hospital and the work he
has done with Dartmouth. He went up to Dartmouth and Jack Wennberg and
that group and now it's a little not-for-profit company called Health Dialog. Dr.
Albert Mulley though did the initial scientific work. He measured the values of
patients as he made decisions and he checked whether the decisions they made,
the treatment decisions they selected match their values. He then would follow
up after the fact kind of a buyer’s remorse approach that I found to be pretty
compelling about how did you feel about it after you had it done. He showed that
if you prepared information for patients in a particular way on all of those metrics
patients were much, much happier with their care experience. And then he
started to develop tools to make that practical. It turns out it’s not just showing
statistics, you have to tell stories. But then he took people who would face the
same choice and he interviewed them and made them into a series of short
vignette. So if you had it he mentioned that you have ischemic heart disease,
you have a potential for heart attack and you have some choices about how you
treat them, lot about surgery. The way you sit down at a computer it tell us about
your choices and the probabilities of each outcome you are interested in. Will I
die? Will I have a major complication? Will I get a stroke or you know bad
depression these sorts of things. The next thing though it will match you as a
person to this library of vignettes and you might get all 8 or 10 little pictures on

your spin and you can click on and hear these people tell their story. It turns out
that really works. Well the next thing they built in were metrics. They measure
your values. Well what Dr. Mulley’s approach did was match up the choices to
the patient’s values along these lines. So we are trying to deploy that.

Mark Masselli: Today we are speaking with Dr. Brent James, Chief Quality
Officer and I guess storyteller at Intermountain Healthcare. Under your
leadership Intermountain has successfully developed and implemented more
than 50 detailed best practice standards and guidelines based on outcome data
from care delivered in your own institutions. In many instances you clearly
demonstrated patients were more likely to live if the doctor and the healthcare
team followed the recommended standards. You didn’t force it on your doctors. I
understand that you have established these as default standards that the
individual physician could overwrite. If you know the outcome will it be better
using the developed standards? Why not require it and is it not enough to rely on
just the persuasiveness of the data?

Dr. Brent James: The reason is that we have pretty good evidence that you
cannot write a guideline or a protocol that perfectly fits a new patient except the
very narrow circumstances. The way to think about it the humans who come to
us for help we know that they are genetically different, I train them surgery, I
know that every patient will be slightly different anatomically. It goes a level
deeper they have different circulating enzymes. On top of that the way that we
say on the drug or a medicine in the community you get different exposure to
pathogens, things that cause disease. So you maybe exposed to something I
am not, well different exposure, because of your different genetics you will have a
different expression of the disease, different presentation, you will have a
different response to treatment. Lay on top of that your different personal values,
your resources, your preferences, it's no surprise that you can't really write a
protocol that perfectly fits in a new patient. We used a form of quality three
called Lean. Many people may have heard of this. The subset is mass
customization. So what I say to our physicians, I say look we are going to take
this evidence based on this practice protocol. We are going to build it into the
flow it works so you don’t have to remember it. If you just take the default that’s
what's going to happen, all right. On the other hand I actually say this to with
some regularly guys it's not just that we allow or even that we encourage, we
demand that you adjust that individual patient needs, and it has some real
impact. First of all, you get these massive improvements in patient outcomes.
We count our successes in lives very literally, thousands of lives, people who
didn’t die. The second thing is that it tends to be much more economical. When
I say that it's more than 50% waste in care delivery today this is how you get after
it.

Margaret Flinter: So Dr. James when you look around the country as you do and
the world what do see that really excites you in terms of innovation and who
should our listeners of Conversations be keeping an eye on?

Dr. Brent James: Well you should keep an eye on the American Board of Internal
Medicine. They are the people who do board certification for interns. Chris
Cassel a physician who leads that. Put this theory in the theory of quality the
things we have been talking about as a testing requirement to become an
internal medicine doctor. The following year the American Council Graduate
Medical Education, the ACGME, did the same thing for all residency training
programs across the entire house of medicine. Now you have to understand
these groups are kind of the flame keepers I guess of our professional values,
amazingly conservative organizations as they should be. I will suggest you, that
when that kind of group makes that kind of transition it's a done deal
intellectually. It represented the healing professions choosing a new course.
Now it takes a while to deploy it. When I talked to Dr. Cassel she tells me that
her biggest problem is finding faculty who can teach it. But it very clearly is on
track. That transformation underneath works hand in glove, dovetails with
developments in new electronic medical records. That allows us to give the data
to physicians about what really happens. It opens their eyes I guess, takes off
the dark glasses so you can see its transparency. That combination is
transforming the field.

Mark Masselli: Today we have been speaking with Dr. Brent James, Chief
Quality Officer at Intermountain Healthcare. Thank you so much Dr. James.
Each week Conversations highlights a bright idea about how to make wellness a
part of our communities in everyday lives.

Margaret Flinter: This week’s bright idea comes from the National Complete
Streets Coalition, a group that’s making our streets and town more livable by
taking a critical look at how we design our roadways. The coalition works to help
cities build complete streets i.e. roadways to serve the needs of all users, not
simply personal automobiles. The Complete Streets vision includes all members
of the community from bicyclist to public transportation riders, from wheelchair
users to pedestrians. Complete Streets can include many different components
such as sidewalks, bicycle lanes, wide shoulders, well designed and well placed
crosswalks, reduction in the number of driveways, and even traffic calming
measures like center medians, street trees, and staggered parking. Any and all
of these measures go a long way to increase residents’ safety and therefore
improve their health. Well the National Complete Streets Coalition considers any
individual complete street a victory. Their goal is to help cities and states adopt
comprehensive compete street policies in which every area roadway is designed
according to a set of guidelines. As the benefits of Complete Street policies
become more visible they are being enacted in more and more places across the
country. Successful implementation of Complete Street Policies has already
occurred in 14 states including California, Florida, Kentucky, South Carolina, and
Pennsylvania. Well, attempts at Federal Complete Streets legislation stalled in
the house last year but the advocates aren’t giving up on what they see as
essential protections of public safety and health. Jonathan Patz President of the

International Association for Ecology and Health said Complete Streets may
present the greatest public health opportunity that we have had in the century.
By taking the holistic approach to roadway design, The National Complete
Streets Coalition is helping make our communities safer, healthier, and more
cohesive one street at a time. Now that’s a bright idea. This is Conversations on
Health Care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli. Peace and heath.

Conversations on Health Care broadcast from the campus of Wesleyan
Universtiy at WESU streaming live at WESUFM.org and brought to you by the
Community Health Center.