| June 11, 2000 | 03 00050 61 00061102 |
Mr. Clarence H. Braddock III, MD, MPH
Assistant Professor
braddock@u.washington.edu
Medicine, Medical History & Ethics, and Health Services
University of Washington
1660 S. Columbian Way;
Box 358280
Seattle, WA 98108
| Subject: | Doctor Patient Partnership, Communication Metrics |
Dear Doctor Braddock,
Thanks for your letter today asking about progress improving medical practice at Kaiser, based on my letter to you six (6) months ago requesting help solving the problem you identified, along with Doctor Barry, in a study showing that 90% of the communication between doctors and patients fail to disclose important information.
This is a complex subject that requires careful consideration.
There is good news.
In January, about six (6) months after being notified of problems in medical management that caused patient care mistakes, and, also, being notified about the cause of mistakes and how to make improvements, Kaiser reported they have created a
Physician Leader role.This role provides a systemic solution to help overworked doctors too busy to perform medical management called out by Kaiser guidelines, reported on June 25, 1999. The first effort to implement this new policy yielded case study guidance for fine tuning procedures.
In my case, Doctor Tom Connolly wrote a thoughtful letter received on January 13, 2000, reporting having reviewed the record of mistakes extending back to July. This solved a prior problem where numerous doctors had been assigned by Kaiser management to take action, but did not have time. Doctor Connolly moves the ball forward, recognizing that communication is a critical issue at Kaiser.
Doctor Connolly's letter did not cite any of the letters he reported having reviewed, nor did he specify a single problem set out in the record.
I suggested in a response that the Physician Leader can be strengthened by listing what is reviewed (e.g., "your letter dated ....") and identifying problems discerned in the record. This provides feedback that builds common understanding, for working together, as called out in Kaiser's requirements for partnership.
A doctor who sees a different patient every 15 minutes may be justified in claiming not to have time to perform this requirement. The Physician Leader should perform the requirements, get help, if needed, or notify management that other procedures are needed to accomplish the aims of quality care. Merely saying communication is a critical issue is not enough to improve the work.
Doctor Connolly, also, reported having asked the Associate Director of Kaiser's regional Clinical Information Systems about who can review Communication Metrics? The Associate Director failed to designate anyone to do this, and instead directed patients to Kaiser's web site...
...for sending a letter to the webmaster. Doctor Connolly was told this will be the most facile method of getting Kaiser's patients...
...using email. On November 6, 1999 Kaiser's web master was contacted for assistance and failed to respond. The weakness of email that increases mistakes is set out in a letter on Septebmer 24, 1999, showing that Kaiser's proposed remedy needs review.
Thus, appointing a Physician Leader is a good start, but there is more to do.
The big issues are how a doctor patient-partnership can improve health care by implementing Kaiser's procedures for communication that reduce mistakes under Kaiser's Team Care model. This requires investigation of case studies provided by the SDS record.
Leaving ethics aside, a medical practice that fails to perform its own requirements, places doctors and patients in jeparody.
A response was submitted encouraging Doctor Connolly to take the lead in helping Kaiser management direct resources toward such an initiative, and requested further review of medical mistakes in my case.
Doctor Connolly disagreed. In his reply, he referred the matter back to a primary care physician, who earlier did not have time to respond, and whose practice was at issue, reflecting a defensive mode rather than a willing partner to discover the cause of mistakes and propose improvements.
This action suggested that the Physician Leader had exhaused authorized remedies, and that Kaiser was unable to perform the commitment to quality care called out by Kaiser's CEO, Doctor Robert Pearl, in a letter to members on October 15, 1999.
Later an administrative aide, Jeanne Bradley, jumped in and reviewed the record, which had been pending for 6 months. In a matter of days, she took the initiative to get rework started on fixing mistakes.
This indicates there is adequate staff at Kaiser; however, as at other organizations, the weak link is communication. Kaiser's procedures address this, but doctors do not have time nor the training to apply the procedures, again, as at other organizations.
On February 6, 2000 I sent a letter to Ms. Bradley commending her work, and on February 7, 2000 we met and noted how easy it was to get thing done when there is a good record, and the team relies on the record, rather than conversation. This is an example of how Kaiser's partnership concept can improve medical care, when implemented in good faith.
Ms. Bradley facilitated getting another primary care physician assigned, and in a meeting the doctor indicated willingness to work with Communication Metrics to reduce mistakes. In the first communication the doctor reported this method was well beyond traditional medical practice.
One issue that arises from this record is the prospect that doctors are not good managers, and may not want to be. Like all of us, they want to show up, look at the work, take action that pops into the mind at the moment, then go home.
Management is a deeper process. People think it is about giving orders. You get to yell at people if you are the boss, and can hire and fire. That's fun.
However, in order to figure out what orders to give, and what to yell, if that is your style, management requires generating and reviewing the record to align a wide range of factors for marshalling resources toward, in the case of medicine, caring for the patient. Thus, the notion of a primary care physician, as a project manager in charge of a Team Care model, needs review. Team care implies coordination, so someone with authority is needed for that role. As things stand, the doctor has that authority, but does not want the responsibility. They want to be responsible for what they learned at school. They got a A on the heart transplant test, and so that is what they want to do.
This record supports suggestions in the letter on September 24, 1999 setting out the cause of medical mistakes, and how to reduce them.
Fortunately, it only requires implementing good practices called out in Kaiser's requirements. While this is difficult to do under current conditions, there is at least an ethical dimension to working on the problem beyond telling the partner, the party most at risk, that communication is important. Kaiser, as with every organization, has a strong cadre of professionals who want to do a good job, but are stymied by the proverbial system. Leadership from responsible quarters is essential for progress. On December 7, 1999 President Clinton called for a national initiative to reduce the high cost of medical mistakes, but more is needed to bring improvements.
Communication Metrics can play a role, and requires pilot testing to discover how to incorporate into medical practice. A letter to a project group at SRI under the leadership of Doug Engelbart, Ph.D., working on next generation knowledge management solutions, proposed starting off with senior citizens to develop Kaiser's partnership ideas.
What can you do to help?
Sincerely,
THE WELCH COMPANY
Rod Welch
rowelch@attglobal.net
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