"We Really Did Screw Up" - ' No Complaint System'

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.

Gazing out the window of a San Francisco coffee shop a few blocks from his old office at Kaiser, Merlin says he heard every day from people unable to get appointments with their doctors, for example, or even get phone calls returned. Phone messages from patients might be passed between the transplant center and patient relations for months, he says. Sometimes they got lost. "I saw hundreds of patients' messages unanswered," he says, his face reddening. "I was horrified and overwhelmed, and spent all of my time on the phone."

State and federal regulators confirmed that Kaiser, unlike other transplant centers, had no systematic way of handling complaints. New York-Presbyterian Hospital in New York City, for example, surveys transplant patients monthly and tracks their complaints in a database to develop plans for improvement, says senior coordinator Dianne LaPointe Rudow. The Tulane abdominal program documents and monitors all processes, according to O'Rourke. "If your program doesn't look at the patient as the absolute primary focus, then you're on the wrong track," she says.

But at Kaiser, "patient grievances and complaints were not acknowledged, resolved or tracked in accordance with regulatory requirements, nor were they reported or evaluated," said DMHC, which is still investigating Kaiser's complaint system.

Merlin lasted at Kaiser only two months, until mid-February 2006. Kaiser fired him, he says in his suit for wrongful termination, filed last July in San Francisco Superior Court, after he approached senior administrators and doctors about the lost wait times and other problems he saw at the center. Kaiser denied Merlin's charges and in January settled the suit for an undisclosed sum. The people Merlin spoke to at Kaiser told him to keep quiet about the problems and focus on improving the transplant center's administrative systems, he says, but he refused. He saw patients suffering, and he feared he would be held responsible if he didn't report it to regulators. After he left Kaiser, he hired lawyer Brian Taugher, a former California deputy attorney general who represents whistle-blowers, and together they approached several state and federal agencies.

On May 3, 2006, the workings of the Kaiser kidney transplant center were splashed across the pages of the Los Angeles Times and on the nightly news at KPIX-TV, the CBS affiliate in San Francisco.