THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700




September 24, 1999

03 00050 61 99092401




Ms. Andrea Gerlin
Reporter
Philidelphia Daily News
Street address
Philedelphia, PA Zip
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Subject:   Solving High Cost of Medical Mistakes
Deadly Telephone Game Biggest Risk in Management

Dear Andrea,

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 national initiative 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.
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A few points stand out for follow up...
  1. Your finding that big mistakes begin as small deviations was noticed by 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...
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    Communication is the biggest risk in enterprise
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    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 mistakes.
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    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. Publishing the high cost of mistakes helps penetrate the shield of denial, which is essential to make progress.
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    Your articles do not cite information overload as a prime cause of mistakes in the modern era, possibly because it has been so widely covered.
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    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.
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    Why is the
    telephone game
    so deadly?
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    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, meaning is in constant flux in the human mind. Absent a proactive external gauge, or "metric," to maintain alignment, meaning drift 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.
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    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. Thucydides 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 rule:
    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 Gutenberg 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 telephone game, 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.
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    Analysis, history, knowledge, wisdom and vision need a boost.
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    So, the first point is that reducing mistakes in medicine, and everywhere, requires helping human cognition with tools, processes and roles that shore up an inherent weakness of
    meaning drift, 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 technology for remembering the connections of cause and effect that convert information into useful knowledge.
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    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.
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    This takes tools and processes for intelligence to help people understand and remember, as defined in POIMS...

    organization
    alignment
    analysis
    summary linked to detail
    feedback
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    We need to work smarter, not harder, to fix the
    telephone game.
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  2. 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 improvement. 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, are overwhelming.
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    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.
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    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.
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    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.
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  3. 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.
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    The problem is not lack of knowledge about how to avoid mistakes.
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    The problem is lack of execution. Execution fails because...
    1. 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.
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      People rely on conversation , and its modern cousin, email, to save time, but this causes mistakes that increase cost and delay, due to small deviations in alignment from requirements, policies and objectives that go unnoticed until the multiplying effect of time causes a major crisis.
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      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.
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      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.
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      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, rather taking 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.
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      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.
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    2. Attitude and Culture of Feel Good Management

      People Like Crisis... Spontaneous Action, No Accountability.
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      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.
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      "Psyche" is a polite way of saying they don't feel like using good management, because it's not fun, it's boring...
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      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 succesful leadership.
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      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 rework. Some problems escalate into crisis. CEOs, doctors, all of us, like to work on crises.
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      The
      Emergency Room , the War Room , 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 Feel Good management.
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      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 avoid accountability. 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.
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      We feel bad about mistakes, but we feel good for having tried hard and talked things out at the next meeting.

  4. 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 intelligence support.
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    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.
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    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. The 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.
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    Medicine is well suited to conduct common education for doctors, staff and patients on effective partnering, which is largely communication. Forcing doctors to regularly explain good communication practices to patients, 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.
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    The Patient Assistant performs routine analysis for Common Administration 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.
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    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.
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    We are gridlocked in a loop of fear and denial that resists improvement.
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    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 negative synergy that degrades productivity toward zero under the second law of thermal dynamics.
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    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.
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    Leadership is the missing ingredient.
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    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.
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    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."
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    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 calamity.
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    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
    intelligence 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 provides an intelligence support role that is needed more broadly today 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 organization.
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    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.
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    Executives, managers, including doctors, love to change the factory floor, revise procedures for subordinates, and scream that others did not tell the truth, or did not work hard enough; but, they loathe changing their own work practice, according to Grove.
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    Tools without leadership 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.
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    We have to leverage cognitive strength. This takes intelligence.
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 meaning drift is fun in the telephone game, 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 CEO, 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, begins with commitment 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.
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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
meaning drift 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 rising complexity.
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Please continue to sound the alert about the high cost of current practice.

Sincerely,

THE WELCH COMPANY




Rod Welch