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."

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Keck at UNOS agrees that he and his staff "were completely unaware" that Kaiser would be sending data on so many patients, but that Kaiser should have been clearer. If the launch of the center "had been treated as a major project, with all the players meeting and scheduling their pieces and putting processes in place to accomplish things, it wouldn't have been like it was," he says.

He adds that regulators should have audited Kaiser sooner, based on its transplant surgery record performing operations at a slower rate than other centers in the region, and twice as many wait-listed people dying as getting kidneys. "You have to wonder, how does a health care system evolve to that kind of situation?" he asks. "What are the quality-management processes going on there? Where are the accrediting bodies?"

Deborah Romero, Medicare's survey and certification manager for San Francisco, says her agency acts on patients' complaints, and they didn't have any before the stories about Kaiser broke in the media last May. "Our initial survey was triggered by the Los Angeles Times," she says. Patients, she adds, didn't seem to know where to go to complain. DMHC declined to comment. Karel, the Forrester analyst, says regulators define data and process rules, and hospitals must comply, with all parties creating "an information ecosystem." It happens in most industries. In this case, he says, "Kaiser is the care provider and in the end, they're responsible."