Rod Welch
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700

January 13, 2000

03 00050 61 00011301

Dr. Thomas E. Connolly, MD
Physician Leader
Permanente Medical Group, Inc.
Park Shadelands
320 Lennon Lane
Walnut Creek, CA 94598

Subject:   Welch; Patient 05519189
Knee Examination on Sep 10, 1999
Patient Assistance Report October 6, 1999
Team Care Process; Doctor Patient Partnership
Correcting Medical Mistakes

Dear Doctor Connolly,

Thanks for your letter dated January 9, 2000, received today, and congratulations on your new assignment as Physician Leader at Park Shadelands.

Jeanne and Mark have done an outstanding job the past 4 months seeking good faith review to correct medical mistakes. The worry in your letter that they have been diverted from assigned duties is incorrect. Extra effort occurred because the medical staff refused and failed to address medical mistakes, and ignored Kaiser procedures on doctor, patient partnership. Inquiry was made on November 9, 1999 for off-site people to accomplish timely, first order review, only after local doctors failed to conduct a review directed by Doctor Ross Armstrong, Chief of Internal Medicine, on October 21, 1999.

Fixing medical mistakes is a continual process of review and adjustment that requires involvement of all hands. Medical mistakes occur along a continuum from administration to direct, hands on care and treatment, that impacts patient health. Continual improvement is not extra work and does not detract from regular duties; it is the duty of everyone to improve quality, as set out by Kaiser's CEO, Robert Pearl, MD, in his letter on October 15, 1999. Doctors, who fail to review process and procedure, fail their patients and the profession.

When Mrs. Connolly assigned a primary care physician on June 25, 1999, you were the first choice, because your examination room had a big message to leave an email address to facilitate communication. I did that; but Sylvia said you were too busy to assign another patient. She suggested Doctor Naqvi instead. We did that, and Doctor Naqvi has done a great job, as previously reported to Kaiser.

Later, Sylvia did a great job overcoming resistance to get a meeting with a specialist to examine my knees. She was frustrated by lack of response from the orthopedic team, but through persistence succeeded. What followed resulted in a series of errors that have cascaded, and led to your letter, as shown in the record on October 8, 1999.

This record invites the question of why, if everyone is doing a great job, did all these mistakes occur? What leads good people to make continual mistakes that cost dearly in treasure and tragedy? Clearly doctors and patients have a common mission to join with President Clinton, who announced on December 7, 1999 a national agenda to overcome the culture of denial that prevents review and correction of mistakes, as occurred in this case.

Kaiser's policy on doctor patient partnership for accomplishing quality health care necessarily implies that patients support review and correction of medical mistakes in order to make both quality and partnership effective.

Your letter received today is a strong first step. The next step is to review the mistakes, and then decide on a course of action where needed.

Please call or submit a letter on how you plan to proceed.



Rod Welch

Copy to:

  1. Jeanne Bradley
  2. Mark Mangrai