Congratulations for excellent
articles reporting that medical mistakes cause
injury and death three times the rate
of automobile and airplane accidents. [On December 7, 1999 a
was launched by the U.S. government to reduce medical mistakes.]
Sadly the cost of mistakes is even higher in
government and business, but it is hard to address due to ignorance, fear
and denial cited in your articles.
A few points stand out for follow up...
Your finding that big mistakes begin as small deviations was
Aristotle in 400 BC. Since communication typically precedes
action, the damage of small deviations in understanding is often
deferred, [see for example NASA's
loss of $125M space craft,], and transferred to others in
constant meetings, calls and email. The result...
Communication is the biggest risk in enterprise.. Executive training teaches talking and listening for the fast and
easy way to get things done, to expedite and avoid paperwork.
Solicitations for new hires seek "strong communication skills," and the
movies show problems are solved by talking things out? These powerful
cultural forces cause constant mistakes (bumbling), loss and conflict
in the new environment of constant communication on the Information
Highway, commonly called "noise" because human intelligence cannot
covert constant information into knowledge accurately. Limited time
and span of attention cause differences of meaning that lead to
.. Interpersonal tensions at home and in
the office are small mistakes we recognize at the moment. The
telephone game is a friendly way to expose small mistakes
resulting from limitations in human cognition that cause meaning
to drift away from original intent. Unlike the telephone game,
and office conflicts that reveal
meaning drift, the impact of most communication mistakes
that constantly occur in meetings, calls and email, but are overlooked
due to limited span of attention, is deferred because there is no
feedback metric that shows lack of alignment until affected action
occurs days, weeks, months later. By then, time has transferred to
others, and thereby hidden and compounded, initially harmless
communication into costly mistakes under Aristotle's rule. Little
progress has occurred over the ensuing 2000 years, because, when costs
and pain are deferred, and borne by others -- customers, stockholders,
taxpayers, insurance -- remedies are rejected. Accepting a remedy
requires admitting mistakes. Such admission impacts self-worth,
competence and accountability. These big personal issues cause denial.
cost of mistakes helps penetrate the shield of denial, which is
essential to make progress.
.. Your articles do not cite
as a prime cause of
mistakes in the modern era, possibly because it has been so
.. An angle that has not received sufficient attention is that constant
exposure to information causes the mind to confuse meaning due to
limited span of attention: medication for the patient in room B2 is
sent to room B12; information from a meeting at 11am is cited in a
phone call at 4pm, in place of information from a meeting at 8am;
"title" information at 9am is reported as "tidal" revisions the next
day, and so on.
.. Why is the
.. Humans are genetically driven to work
spontaneously by speech,
i.e., Let's talk things out; Go do thus and so; No! I didn't say that,
I said just do this...
which is inherently error prone due to limited span of attention that
assigns meaning according to momentary context.
Therefore, since context is constantly changing,
is in constant flux in the human mind. Absent a proactive
external gauge, or "metric," to maintain alignment,
is no longer a mere annoyance, but is rapidly becoming a chronic
cause of continual mistakes, because information overload increases
the frequency and degree of error. Lack
of alignment is a "mistake" waiting to happen, and it is entirely
beyond conscious awareness. It is a secret to the afflicted mind.
Henry Kissinger warns in his book Diplomacy "...people have
strong views, but they don't know why!" Such "time bombs" increase
exponentially when information flows constantly, which is now the
dominate aspect of our culture. Curiously, the proliferation of
mistakes and the corollary of cover-up, i.e., bumbling, give
the impression that big government, big business, big medicine, the
proverbial "they," are conspiring
against "us." Since conspiracy requires maintaining
alignment, which is nearly impossible, the real problem we all
face together is continual bumbling on the Information Highway.
.. Alphabet technology emerged about 5,000 years ago to provide an
external rendering of complex internal thoughts. It is a window on the
mind that exposes lack of alignment in communication and the conduct of
human affairs, relative to objectives. Properly applied, the process of
assembling little pictures, called "letters," reveals gaps in patterns
of human thought, which if left unattended result in costly mistakes.
in about 400 BC is credited with beginning the method of
adding analysis to the mere recording of events. The added
ingredient of analysis produces history that forecasts future
impacts based on trends, leading to the common
past is prologue
Writers of history carefully track the chronology of cause and effect
over time. Painstaking analysis, advocated, for example, by
Peter Drucker as essential to effective management,
shows that small differences in
alignment, often of mundane meaning, grow into huge conflicts. Humans
in pre-literate times developed poetry as the repository of human
wisdom. Prior to the alphabet,
wise men were those blessed with a good memory, and
aided by poetry, to remember critical correlations and hard won lessons
of people solely dependent upon oral communication.
Literacy over the past 2,000 years has proven to be a stronger
memory method, i.e., it fixed serious cognitive
flaws in verbal communication that cause mistakes,
and, as a result, has enabled civilization to flourish, particularly
since the time of
in 1455, who greatly leveraged the power of
alphabet technology by expanding its reach with the printing press.
Thus, civilization has developed a highly effective technology
to fix the deadly
but in the modern era
we need a faster, more flexible, way to manage writing
day-to-day in order to maintain alignment that otherwise drifts away in
spontaneous speech and constant information that overwhelms limited
span of attention on the Information Highway of today.
.. Analysis, history, knowledge, wisdom and vision need a boost.
.. So, the first point is that reducing mistakes in medicine, and
requires helping human cognition with tools, processes and
roles that shore up an inherent weakness of
which is now
compounded by success in reaching the goal of getting more information.
We need to fix the
telephone game. The only solution is to improve alphabet
remembering the connections of cause and effect that convert
information into useful knowledge.
.. We are not going to solve meaning drift by working harder,
trying to get along, better verbal skills, listening, email, being
understanding, shouting at each other, hiring psychologists, firing
people, or any other of the many
serious methods people have tried
the past 50 years, and from the beginning of time. We have to use
technology in a new, more powerful way, to improve human cognition.
.. This takes tools and processes for
intelligence to help people understand and remember,
as defined in POIMS...
summary linked to detail
.. We need to work smarter, not harder, to fix the
Mistakes are common to every industry,
possibly less so in medicine
because there is greater scrutiny due to occurrence of pain, which is a
"feedback" metric that leads to published articles calling for
This communication "metric" is missing at Intel, GE, United Airlines,
and so on. Industry can buy off mistakes because competitors are
bumbling at similar rates, since nobody uses effective
metrics for aligning communication. Every industry and every
organization is infected by the virus of meaning drift because strong
cultural pressures that force
reliance on oral communcation, and to ignore literacy,
.. Large scale operations, like manufacturing and farming, have a grace
factor. Despite bumbling, products eventually get designed, the
factory eventually gets built, months or years late, but it works, and
often with significant improvements, due to competition. Even at 2 - 4
times the cost of what it should be, due to bumbling, selling millions
of cars or computer chips, amortizes the cost of bad management. Once
the assembly line is rolling the influence of management is minimized.
Not so in service industries, like law, journalism, medicine or car
repair. In those industries bad management directly impacts every
project, every patient. Since the impact of mistakes cannot be
amortized in service industries, it is greater than in manufacturing.
But, the frequency and
degree of mistakes is actually lower in service industries, because
there is greater visibility of impact.
.. Even the notion of "management" is quite different in large scale
operations. The focus is on vision and business model, which is
marketing, and work process design, not management, per se. The
goal is to find something that enough people will buy to pay for bad
management. Warren Buffett explains the successful investor seeks a
company protected by a "moat" of fortuitous market conditions
that shield accountability for management mistakes. Drucker
points out that eventually markets change and management becomes the
controlling factor. By then smart people have cashed in, and are
looking for the next business model with a large enough "moat" to
protect against bumbling from constant communication mistakes.
.. So, why worry? Because adding "intelligence" to management
raises the quality
of life and reduces conflict for everyone, indeed lifts civilization to
a new plateau.
Every industry, including, perhaps especially,
medical practice, has well thought out procedures, policies and
guidelines for effective communication
that reduce mistakes, based on centuries of hard won experience.
.. The problem is not lack of knowledge about how to avoid mistakes.
.. The problem is
lack of execution. Execution fails because...
Limited time and span of attention
Information overload from constant meetings, calls, documents,
media exposure on television, radio, print and email, means there
is not enough time to review the record and develop analysis, which
discloses mistakes in understanding.
rely on conversation ,
and its modern cousin, email, to save time, but
this causes mistakes that increase cost and delay, due to
in alignment from requirements, policies and objectives
that go unnoticed until the
multiplying effect of time causes a major crisis.
.. Pressure to reduce costs by increasing doctor patient case
loads has the same effect that downsizing has
in law, engineering and other fields.
Fewer people are chasing more information, so nobody has
time to think.
Lack of thinking that otherwise maintains alignment of
communication with requirements, causes mistakes to increase.
Reengineering to downsize "flattens" organizations,
which makes communication complex under long settled
span of control standards. Gurus and vendors sold the
idea in the mid-90s that modern technology, which boils
down to mean "email," can expand span of control, so that a lot of
managers could be eliminated.
Precisely the opposite is the case.
.. Conventional email, like
oral communication in meetings and
calls, is a stream-of-conscience rendering that lacks alignment
with objectives, requirements and history. Email is worse than
dialog for conducting daily business accurately and on time,
because the process is one-sided and cursory. Email omits
information and abreviates words that assume common understanding
that are often recognized in a verbal exchange through gestures,
expression, and various support props, like pointing to a diagram,
or jointly looking at a setting while talking. All of this is
missing from email, because there is no immediate feedback to
clarify context, as occurs in ordinary speech. Lack of context
increases complexity exponentially, which overwhelms span of
attention, causing errors in understanding, i.e., continual
bumbling, which cause delay, extra cost and conflict.
Additionally, email practice routinely leaves words out, conveying
the opposite meaning of intended communications. Even proof
reading, which is rarely part of email practice, because people
regard email as chatting, where cordiality and speed seem more
important than accuracy, reads past words omitted from email text,
becasue the eyes see what a hurried mind intended, rather than what
is actually written. Omitting words kills collaboration and
coordination with people going in opposite directions,
complementary action, as explained in NWO.
This makes email a killer application that destroys
productivity, when there is no energy added to convert information
into the power of knowledge.
.. Cost per patient for medical care
on the battlefield is pretty low. Thousands
of patients are treated by very few doctors. Mistakes escalate due
to limited span of attention and fatigue, but these are forgiven
because some people are saved under harsh conditions. Absent a
technology to expand span of attention, continued pressure to
reduce medical cost off the battlefield,
means quality moves closer to battlefield conditions
of low cost, and exigent care. As in other industries,
everything becomes an emergency, a crisis.
Attitude and Culture of Feel Good Management
People Like Crisis... Spontaneous Action, No Accountability.
.. Fortune published
an article on June 21, explaining CEOs fail because
they don't execute good communication practices, and this causes
mistakes that reduce earnings. Fortune said CEOs refuse to use
good management because of personal preference, called
psyche. They prefer to avoid understanding and
influencing complex details that impact earnings, because it is
difficult and takes time. Fortune found that CEOs are fast thinkers
and talkers, who get bored by mundane tasks, like preparing for
meetings, and analysing the record. This causes mistakes and
eventual crisis, which then require snap judgements and fast
talking that lead to future crises, hence: Crisis Management.
.. "Psyche" is a polite way of saying they don't feel like using
good management, because it's not fun, it's boring...
.. At the low end it is laziness and hubris. For others it
reflects emotional limits, as with a fidgety or high strung child.
Andy Grove, CEO of Intel, writes in his book
Only the Paranoid Survive, that he takes copious notes to
remove ambiguity of mental maps. This requires diligence and a lot
of time to track critical details,
especially, if you don't have the right tools. Grove
admits it's not fun, and it's not easy, but it is necessary in
order to succeed. Fidgety, emotional,
short-sighted people cannot do this work. They cannot deal with
the psychological shock of discovering
that communication is not aligned, and
requires diligence to restore and maintain alignment
in order to avoid future mistakes that otherwise cause
delay and extra cost.
Grove's method takes a lot of emotional capital that not
everyone possesses. In fact, very few have the attitude to
overcome the allure of Feel Good management, essential for
.. Fortune says most CEOs, like the rest of us, prefer to
work by conversation. They don't like to track critical
details. They want subordinates to
write up the record and review understandings in order to be
prepared for performing the work. But everyone has to go to
another meeting, so ambiguity is never removed, and some of it
shows up the next day, or next week as a small issue. In a few
weeks it's bigger, but ignored. Then it grows into a "problem,"
and becomes an agenda item at meetings.
Most management time is devoted to
problem handling,, also, called expediting and
Some problems escalate into
crisis. CEOs, doctors, all of us, like to work on crises.
permit, indeed require, spontaneous decisions and management
through conversation, i.e., 30 second sound bite. It, also,
avoids responsibility for exercising diligence to prevent
mental mistakes. Avoiding accountability for indulging the
preferance to avoid diligence is
.. We just show up, talk and listen, demand the "bottom
line," insist on a summary of critical details,
complain that people are not telling the
truth, dash off a cursory email devoid of alignment,
then go to the next meeting, next patient, next email and say,
write or do whatever pops into the mind at the moment. We don't
have to exercise diligence to align the work
with requirements and background, because in a crisis,
everyone knows there isn't enough time.
When a crisis is solved, we are a
hero; that feels good. When crisis ends in disaster, well honed
talking skills kick in to
We say everyone tried hard, but there was not enough time to check
the record; and so we
replaced the left hip instead of the right hip, replaced tires
instead of the fan belt, specified 2000# concrete instead of 3000#
concrete, launched space ships with the
wrong O rings, and the
wrong course, all due to
administrative snafus by overworked staff.
.. We feel bad about mistakes, but we feel good for having tried
hard and talked things out at the next meeting.
Solutions to reduce mistakes require technology that makes
it easier to maintain alignment of
communication with requirements, objectives, commitments, policies and
guidelines. This removes ambiguity of mental maps so
that little deviations are caught before they grow into
crisis. Technology that
makes good management easier reduces the level of diligence
needed to do good work. So, we need technology that leverages mental
acuity in processing information, i.e., we need
.. Some experts call for increasing accountability. That is easy to do,
but conflicts with feel good management. We need a solution
that makes people feel good by reducing
mistakes, so they get credit for better work and higher earnings.
Medical practice needs a
Patient Assistant role with tools to
help doctors and patients capture an accurate, comprehensive
record of medical history, and follow up to ensure actions align
with objecties, requirements, and commitments. Tools and roles
leverage skills and optimize time to provide quality care at less cost.
New World Order of mind numbing
complexity occurs from compressing time and distance (see NWO).
More patients, regulations, procedures,
technologies, stakeholders, and layers of organization, i.e.,
bureaucracy. impact patient care, because people get mixed up in
constant meetings, calls, and documents. Little details slip
through the cracks, causing delays, errors, and omissions.
Successful medical practice that extends life increases
complexity of patient history. Advancing complexity of modern
health care requires a new player with tools that make sense of
complexity by "connecting the dots" in time to be effective.
.. Medicine is well suited to conduct
for doctors, staff
and patients on effective
which is largely communication.
Forcing doctors to regularly explain good communication practices to
increases the chance of implementation by the doctor and the patient.
New patients can learn medical management that
aids the doctor, and existing patients
can report new issues that need attention procedurally, under
continual learning precepts called out by ISO criteria.
.. The Patient Assistant performs routine analysis for
to align communication, similar to an accountant, who
aligns finances. Unlike the dreaded "bean counter" constantly berated
for maintaining alignment with budgets, a Patient Assistant or
Communication Analyst aligns information from meetings, calls,
and documents with objectives, requirements, and commitments from the
evolving record of work history, e.g., the medical chart. Continual
alignment avoids future mistakes so that budgets are not exceeded.
It takes enormous faith to begin adding "intelligence" that
converts information into the
power of knowledge. People feel they
are intelligent enough, and are good communicators, who don't make
mistakes. When mistakes occur, we are all more afraid of being
discovered than of consequences to others for not making corrections.
We are gridlocked in a loop of fear and denial that resists
A new player with new tools is the only way to transcend gridlock by
adding "metrics" to daily communication. Otherwise, mistakes will
proliferate due to rising information density that overwhelms span of
attention with complexity. In chaos theory, when order is maintained
complexity creates positive synergy among multiple contributors that
significantly leverages productivity. Without order (i.e., rising
entropy), complexity drives
that degrades productivity
toward zero under the second law of thermal dynamics.
For most of modern history, say from 1800, people might get one or two
letters a month. More recently, a businessman might get 2 or 3 letters
a week. Ten years ago this began to increase on the Information
Highway, as people began to receive and send 2 or 3 faxes a day. Five
years ago this escalated to 10, or so in a day. Two years ago it was
up to 70 documents a day, and now for some it is in the range of 200.
That is a lot of information to align. Inevitably a larger share is
overlooked and used incorrectly, as reported in the articles on
rising medical mistakes published on September 12, 1999, because
no one has enough time to maintain alignment, absent tools and people
to process information faster and accurately.
Leadership is the missing ingredient.
.. People don't like to work on small problems. Its no fun; it takes
diligence. You don't get noticed for solving miscommunication.
There is no TV coverage.
People like to rely on conversation because it is personable,
fast and easy, like in the movies where all of the problems are
solved by talking things out. Talking provides deniability and
wriggle room. When problems are small, people disagree about scope
and remedy; see Korea and Vietnam. That's not fun. Big problems are
much easier to manage
because everyone falls in line to work on the solution, with
less controversy, see WWII. Even where there is a lot of pain, people
accept it to accomplish a larger good endorsed by the culture at large.
Everyone left standing feels good, they worked hard, and feel justified
in forgetting that crisis could have been avoided by greater diligence
to resolve problems when they were smaller. Besides, nobody likes
Monday Morning Quarterbacking, and the dreaded "second guess."
Leadership is essential to help people adopt tools and processes that
make it easier to use good work practices consistently,
cited in Fortune and by
Grove at Intel. This adds
intelligence to information from constant meetings,
calls, and documents, and so reduces
mistakes. Intelligence reduces "second guessing," because the first
guess is more accurate and supported by the record. Enlightened
leadership encourages diligence to correct small problems, when
they are easy to fix, so they don't grow into conflict, crisis, and
.. One solution is to assign someone using specialized tools
to capture the record
and make the connections of cause and effect that reveal misalignment
of communication with requirements before
mistakes occur. This is
work. In about
1945, following the end of WWII, the President of the United States was
overwhelmed by information, and so instituted a new role to perform
daily analysis, and provide a summary connected to details. The CIA
support role that is needed more broadly
because the Information Highway now overwhelms doctors, executives and
everyone in like manner. Since everyone cannot afford a big agency,
technology must perform this work faster and cheaper so that a single
person can support a large group, and a department can support a large
.. Right now the Communication Department is mostly aimed at cover up and
publicity, selling the party line. Reengineer the Communication
Department to support daily communications so there is less to cover
up and the party line is backed up by performance.
.. Executives, managers, including doctors, love to change the
factory floor, revise procedures for subordinates, and scream
that others did not tell the
or did not work hard enough; but, they
loathe changing their own work practice,
according to Grove.
.. Tools without
are not used; leadership without tools is
baying in the wind. Avoiding communication mistakes requires different
capabilities from traditional technologies that leverage muscle power
to fly, talk, see, lift and carry.
We have to leverage
cognitive strength. This takes
Doctors do a better job than
the rest of us in overcoming the impulse to work
spontaneously by conversation that causes continual mistakes and bumbling.
Exposing the secret flaw of
is fun in the
but resists correction at the
office, due to ignorance, fear and denial. Smart, well-meaning executives,
and all of us, steadfastly hope that working harder and being more
careful, i.e., diligence, can align daily communications in an age of
information overload. At best this is ignorance, but mostly it is denial due
to fear that asking for help with communication is admitting to
lack of competence. This overlooks the fact that the boss
needs help, too! Everyone's boss, all the way up to the
has the same
problem with information overload that prevents execution of sound management
practice, as reported
by Fortune. Therefore, improving medical care, and other enterprise,
to personal improvement by requesting change to help everyone solve a common
problem. The personal characteristic and common problem that needs improvement
is "intelligence" in order to
to keep up with the explosion of details on the Information Highway.
Leadership must overcome ignorance, fear and denial so that
tools, processes and roles to support "intelligence" can be deployed.
Adding roles and tools for
intelligence support significantly
strengthens the doctor/patient
partnership that improves care with less time and expense, because
"connecting the dots" of cause and effect
converts information into the
power of knowledge
that controls the future. Obviously timely, accurate knowledge avoids
to reduce mistakes and
costs. To some "intelligence" sounds
funny and alien; to others new roles and tools seem like
unnecessary overkill. Only strong
leadership can pioneer a path to a better future in the new world order of
Please continue to sound the alert about the high cost of current practice.