THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: February 21, 2002 09:14 AM Thursday;
Quality control for health care through doctor patient partnership.
......................The Kaiser Papers
2...Proactive steps patients can take to help Kaiser avoid mistakes are
3...Communications Biggest Risk in Health Care, Government, Business
4...Quality Health Care Doctor Patient Partnership Intelligence Support
5...Failure Inevitable Causes Doctors to Give Up Worry Only about Money
6...Slippery Slope Cynicism Caused by Constant Failure Medical Practice
7...Medical Practice High Pressure Constant Failure Invites Slippery Slope
8...Knowledge Management Dilemma Malthusian Challenge Medical Practice
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Medical, Kaiser Exam 990910 Knee Treatments
Kaiser Papers Medical Mistakes, Vickie Travis, 020221
Kaiser Dissapointed About Medical Treatment Request for Help
Medical Mistakes Kaiser Papers Case Management Request SDS Records E
3306 - ..
3307 - Summary/Objective
330801 - Follow up ref SDS 82 0000, ref SDS 81 0000.
330803 - Vickie Travis requests support for efforts to improve Kaiser's medical
330804 - care. She relates tragic loss of her father, age 70, under
330805 - circumstances that indicate Kaiser may have failed to provide adequate
330806 - care, causing the patient to suffer prior to death. Ms Travis wants
330807 - to list on her web site the record seeking treatment by Kaiser for a
330808 - knee problem, which disclosed similar kinds of issues she encountered
330809 - seeking treatment for her father. She provides good advice on how to
330810 - help doctors and care givers do a better job, but her conclusion that
330811 - patients should boycott Kaiser seems ill designed to accomplish the
330812 - goal of improving performance by Kaiser, since bad management due to
330813 - limited time, lack of funds, and the indifference of bureaucracy are
330814 - pervasive in government, industry, education, health and science. We
330815 - all share responsibility and a common interest to improve, and
330816 - Vickie's web site is an inspiration for everyone.
330818 - ..
330819 - Submitted ref DIT 1 0001 linked to this record.
330824 - ..
3311 - Progress
331201 - Received ref DRT 1 0001 from Vickie Travis asking if the SDS record on
331202 - 990925 concerning medical treatment at Kaiser to evaluate knee
331203 - problems, ref SDS 82 0001, can be posted to Vickie's web site....
331205 - [On 050422 Kaiser cancer patient reports good care by Kaiser, and
331206 - Millie relates good care in her case. ref SDS A8 LX6M
331208 - ..
331209 - [On 060809 Millie letter to advice nurse explains Kaiser
331210 - provided adequate care. ref SDS B0 1L5X
331212 - ..
331213 - [On 060809 patient history shows challenges treating complex
331214 - medical conditions that arise with cancer. ref SDS B0 LX5H
331217 - ..
331218 - The Kaiser Papers
331221 - ...which is described as a public service page...
331223 - http://home.earthlink.net/~tomnvic/kaiserpapers.html
331225 - ..
331226 - Kaiser Papers has a compilation of Internet links that chronicle poor
331227 - management attributed to Kaiser. It seems motivated in part to help
331228 - other people avoid problems in treatment that may have led to the
331229 - death of Ms Travis' father, age 70, who was under the care of Kaiser,
331230 - initially for fainting....
331232 - ..
331233 - http://home.earthlink.net/~tomnvic/mydad.html
331235 - ..
331236 - The Kaiser Papers say in part....
331238 - On September 11, 2000 he was euthanized by Kaiser Permanente Staff
331239 - against his and his family's wishes.... because his health
331240 - maintenance had become too expensive for this HMO to honor the
331241 - contract they had with him. His death was painful as he had blood
331242 - poisoning. Kaiser denied him any and all medical care, either
331243 - regular or emergency treatment. Under Kaiser's care he was denied
331244 - any antibiotics and was needlessly prescribed a lethal dose of
331245 - postassium chloride.
331247 - ..
331248 - A more detailed account by Ms Travis is at....
331250 - http://www.hospicepatients.org/euth-acct-two.html
331252 - This underlying record is quite long. Spot review conveys the
331253 - general impression that the patient died due to "....two different
331254 - types of bacterial infection, common in cases of septic infection,
331255 - possibly due to inadequate hospice care by nurses who failed to
331256 - change a urinary catheter. There is also concern that the patient
331257 - was prescribed potassium pills which induced heart failure. There
331258 - is a lot of description about Kaiser failing to timely respond to
331259 - notice of requests for care, i.e., the bureaucracy ignored pleas
331260 - for help, then covered up failure to perform by citing Parkinson's
331261 - disease on the death certificate. Independent review indicated
331262 - this was not true. Travis claims to have demanded changes in
331263 - Kaiser procedures, and the family was offered $219K by Kaiser to
331264 - end the matter, but refused to accept this offer. The matter is
331265 - said to have been investigated by the State Board of Managed
331266 - Health. A report has not been released to the family.
331268 - ..
331269 - None of the facts in the report are supported by sources, and no
331270 - official findings are cited. A lengthy report by a medical doctor
331271 - supports Travis' account and attributes failed treatment to bad
331272 - faith by Kaiser. It is a general and vitriolic attack against
331273 - HMOs, yet says in part the following....
331275 - ..
331276 - ....[the HMO] system burdens such care givers with too many
331277 - patients to do good care. Then, cutting corners falls to the
331278 - care giver to simply get through the day's tasks and try to get
331279 - home to the family. The choice given is take care of the
331280 - patient correctly or see your family. This is how they morally
331281 - break almost everyone in the organization. But morally broken
331282 - leads to financially restored.
331284 - This aligns with the record on 990625 where Doctor Connoly
331285 - reported that there is not enough time to perform Kaiser's
331286 - procedures for doctor and patient communication that is
331287 - essential for effective treatment. ref SDS 46 1978
331289 - ..
331290 - Bonuses are given for productivity by withholding care, and are
331291 - protected when there is silence about error characterized as
331292 - "collegiality." All of this is done without any paper trail.
331294 - ..
331295 - The doctor is not identified nor is the report signed. The only
331296 - remedy that seems to be promoted by the doctor is to eliminate the
331297 - requirement to settle medical claims in arbitration and to support
331298 - legislation for a patient's bill of rights which includes the
331299 - right to sue for damages. No specifics are identified showing
331300 - what rights would have saved the patient in this case. There is
331301 - an impression that filing law suits is proposed to encourage
331302 - better performance by HMOs, and this is true, but does not improve
331303 - capability to deal with the underlying problem of information
331304 - overload which causes continual bumbling.
331306 - ..
331307 - There is no record shown at this Internet address representing
331308 - Kaiser's version of events.
331310 - ..
331311 - The Kaiser Papers website presents many reports of medical mistakes,
331312 - which are attributed to Kaiser's motive for earning income, as seen by
331313 - the following....
331315 - Kaiser Permanente is a business entity that makes and tries to
331316 - keep it's money. Kaiser is an insurance company, a form of
331317 - business. Insurance is a form of legalized gambling. Kaiser
331318 - claims not for profit status yet Kaiser has numerous sub entities
331319 - that are purely for profit. This is the plain truth about Kaiser
331320 - Permanente. -
331322 - ..
331323 - How could Kaiser Permanente have overpaid $30,000,000 (30 million
331324 - dollars) to Enron and not know about it? with a link to....
331326 - http://www.miami.com/mld/miamiherald/2681920.htm
331328 - ...which is an article on 020217 by Knight Ridder Newspapers that
331329 - relates investigations showing Kaiser was over-billed $30M by
331330 - Enron due to mis-management, shown in another record today.
331331 - ref SDS A4 0001
331333 - ..
331334 - Bad management at Enron was reported on 020204. ref SDS A3 EX5O
331336 - ..
331337 - The Kaiser Papers home page has a link to another location....
331339 - http://home.earthlink.net/~tomnvic/horror.html
331341 - ...which is described as....
331343 - Kaiser Patient Horror Stories ... actual Kaiser Permanente
331344 - Patients that have been abused, maimed and killed.
331346 - ..
331347 - This page lists people who the authors believe died as a result of
331348 - improper treatment or neglect by Kaiser. Did not take time to review
331349 - these accounts for details and sources substantiating allegations, but
331350 - it is evident that people have suffered great loss, and feel that
331351 - Kaiser is at fault.
331353 - ..
331354 - Other stories describe failed and troubled treatment.
331357 - ..
331358 - Proactive steps patients can take to help Kaiser avoid mistakes are
331359 - listed on Vickie's website under the title....
331362 - What you as a Kaiser patient can do to survive the Kaiser
331363 - Permanente experience.
331366 - ..
331367 - http://home.earthlink.net/~tomnvic/survive.html
331371 - ..
331372 - Communications Biggest Risk in Health Care, Government, Business
331374 - Kaiser Papers lists steps to reduce the high cost of medical mistakes
331375 - reported on 990912, primarily caused by failed communications.
331376 - ref SDS 72 0001
331378 - ..
331379 - This section has suggestions for resisting being identified as having
331380 - a mental problem as a result of complaining about symptoms that the
331381 - medical staff may have difficulty diagnosing...
331383 - ..
331384 - Buddy system -- bring a friend to sit in on all visits with
331385 - Kaiser, is recommended in para 4.
331387 - ..
331388 - Tape record meetings and calls with Kaiser staff is recommended
331389 - in para 5.
331391 - ..
331392 - Medical record review is recommended in para 6.
331395 - ..
331396 - I generally agree with these suggestions because they address the
331397 - common problem that communication is the biggest risk of mistakes, as
331398 - explained in POIMS. ref OF 5 R69H
331400 - ..
331401 - Tape recording puts people off, and fails to improve the work, which
331402 - is the key issue presented by the Kaiser Papers. However, it is a
331403 - step toward providing organizational memory, which is critical to
331404 - avoiding mistakes, but not enough. In addition to providing a record,
331405 - effort is needed to organize and present the record in a way that
331406 - promotes doctor/patient partnership. This takes mutual
331407 - responsibility, as shown in the record on 000207. ref SDS 96 0004
331409 - ..
331410 - Currently, it is difficult to develop effective organizational memory
331411 - on doctor patient communication (or for anything else) for reasons in
331412 - the record on 010924. ref SDS A0 JS6G On 000121 Kaiser reported plans
331413 - to develop better technology by the end of last year, ref SDS 93 7654,
331414 - but there is no record this has succeeded, and the report at SRI on
331415 - 000324 shows that nobody else in health care, government, industry,
331416 - education, etc., has accomplished this goal, because it is hard to do.
331417 - ref SDS 97 4877
331419 - [On 060106 Kaiser began using computer systems for team
331420 - care collaboration on diagnosis, treatment prescriptions,
331421 - capturing a legible record in the medical chart, referrals,
331422 - and doctor/patient communications, which together implement
331423 - Knowledge Management for efficient, comprehensive health
331424 - care, ref SDS A9 FE4I; however, system limitations paralyze
331425 - productivity by inaccurate, cursory, and incomplete
331426 - communication that increases mistakes with the illusion of
331427 - efficiency. ref SDS A9 1O8F
331429 - ..
331430 - The SDS record 991027, which Vickie wants to cite on her web site,
331431 - further illustrates problems of failed medical management. ref SDS 91
331432 - 0001
331434 - ..
331435 - There is no evidence in the Welch record showing anyone at Kaiser has
331436 - deliberately failed to provide effective treatment due to bad faith
331437 - performance of medical management. To the contrary, doctors and staff
331438 - at Kaiser uniformly try to perform complex work with professionalism,
331439 - competence and consideration for the patient. Properly managed,
331440 - Kaiser delivers health care at or above the level of quality available
331441 - anywhere else, e.g., Johns Hopkins, Mayo Clinic, UCLA Medical Center,
331442 - UCSF, Stanford, etc. Resistance to good management is equally
331443 - ubiquitous common to bureaucracy.
331445 - [On 041212 Andy Grove, CEO Intel, and survivor of cancer
331446 - recommends patients be their own project manager for
331447 - effective care through the doctor patient partnership.
331448 - ref SDS A7 F25K
331450 - ..
331451 - Since SDS records are published on the web, Vickie can cite this
331452 - material....
331454 - Communication key to effective treatment....990625, ref SDS 46 4185
331455 - Kaiser publishes good procedures............990625, ref SDS 46 0806
331456 - Staff not enough time to follow procedures..990625, ref SDS 46 1978
331457 - Medical records lost Kaiser ID Error........990910, ref SDS 71 0001
331458 - Staff work hard to avoid/correct mistakes...000118, ref SDS 92 0001
331459 - Patient communication withheld from doctor..000124, ref SDS 94 7600
331460 - Multiple medical charts confuse treatment...000124, ref SDS 94 2065
331461 - Team care requires com support..............000207, ref SDS 96 9O9N
331462 - Kaiser doctors support good communication...000207, ref SDS 96 2783
331464 - ..
331465 - This record supports the anonymous report on Vickie Travis' website
331466 - that says Kaiser staff are too busy to follow good medical management
331467 - that requires communication for effective doctor patient partnership.
331468 - ref SDS 0 L36G It does not, however, support the evident conclusion
331469 - Ms Travis reaches that Kaiser deliberately fails to provide good care.
331470 - While undoubtedly there are incompetent, ineffective, obstructionist
331471 - staff in a large organization like Kaiser, the record in the Welch
331472 - case shows there are outstanding people at Kaiser trying their best,
331473 - as set out in the letter, ref DIP 5 PZ3G, to Kaiser on 000206,
331474 - ref SDS 95 0004, and shown by the record on 020118. ref SDS 92 0001
331476 - [On 041212 Andy Grove, CEO Intel, and survivor of cancer
331477 - recommends patients be their own project manager for
331478 - effective care through the doctor patient partnership.
331479 - ref SDS A7 F25K
Failure Inevitable Causes Doctors to Give Up Worry Only about Money
Bad Management Overwhelming Tendency Cheaper than Good Management in
Slippery Slope Cover-up Ignore Small Problems Not Enough Time Ignored
Good Management Ineffective Slippery Slope Overwhelming Tendency of B
Givine Up Difficult Slow Progress Ambitious Define Management Science
Overwhelming Tendency Bad Management Give Up Quit Trying to Improve G
Medical Practice Doomed to Fail Good Management Ineffective Slippery
Failure Medicine Inevitable Every Patient Dies Slippery Slope Cynaci
451101 - ..
451102 - Quality Health Care Doctor Patient Partnership Intelligence Support
451103 - Failure Inevitable Causes Doctors to Give Up Worry Only about Money
451104 - Slippery Slope Cynicism Caused by Constant Failure Medical Practice
451105 - Medical Practice High Pressure Constant Failure Invites Slippery Slope
451107 - Medical treatment is ultimately a losing proposition. No matter how
451108 - much money is spent, nor how hard and competently doctors work, every
451109 - patient eventually dies. The challenge in medical treatment is
451110 - fostering effective patient partnership to help doctors and care
451111 - givers avoid the slippery slope toward sloth and indifference under
451112 - pressures of limited time, expanding treatment options that foster
451113 - giving up and cynacism because failure is inevitable, as related on
451114 - 990625. ref SDS 46 B38M
451117 - ..
451118 - Knowledge Management Dilemma Malthusian Challenge Medical Practice
451120 - Successful health care that prolongs life presents a Malthusian
451121 - Knowledge Management dilemma. Better technology, and greater
451122 - diligence and skill prolongs lives. Living longer obviously increases
451123 - medical costs expended over a longer period. Living longer also
451124 - exposes ailments at lower levels of biology than were previously
451125 - known, because so few people lived long enough to recognize the
451126 - problem. Demographics of longevity increase demand to discover and
451127 - deploy treatments for endlessly expanding infirmities. An aging
451128 - population overwhelms ability to treat everything for everybody. It's
451129 - a dilemma.
451131 - [On 070328 demographics of aging population increases cancer
451132 - cases overwhelming health care system. ref SDS B1 TG6O
451134 - ..
451135 - How can expanding treatment options cause pressure on doctors, rather
451136 - than relieve pressure by helping to heal ailments and preserve life?
451138 - ..
451139 - More options mean more things to evaluate, investigate and decide. A
451140 - longer list of subjects to think about inevitably increases stress due
451141 - to limited span of attention. This dynamic compounds the rate of
451142 - mistakes, under research reported on 990303. ref SDS 37 6120 A few
451143 - months later on 990912, articles reported that mistakes by doctors
451144 - kill 300% more patients than people who die from automobile, train,
451145 - and airplane accidents combined. ref SDS 72 0001
451147 - ..
451148 - These conditions present a good opportunity for patients to increase
451149 - their chances by filling the gap between what is needed for case
451150 - management, and what doctor's can reasonably get done in days work.
451152 - ..
451153 - [On 020726 example of Doctor's under pressure to treat failing
451154 - patients while giving attention to patients who have not yet
451155 - failed. ref SDS A5 YT6L
451157 - ..
451158 - [On 040517 case history on challenge of "connecting the dots" in
451159 - time to be effective treating cancer. ref SDS A6 S66O
451161 - ..
451162 - [On 070328 promising biomarker technology 100,000 - 1,000,000
451163 - proteins to identify cancer, 1261 currently identified, and only
451164 - 9 have been approved for treatment, suggesting overwhelming task
451165 - of medical care for aging population. ref SDS B1 3O6O
451167 - ..
451168 - How can patients optimize case management to relieve stress and reduce
451169 - medical mistakes?
451171 - ..
451172 - Kaiser has good procedures, shown on 990625, ref SDS 46 4185, and good
451173 - people, shown by the record on 020118. ref SDS 92 G75G To the extent
451174 - that efforts like "The Kaiser Papers" project sponsored by Vicki
451175 - Travis, noted above, ref SDS 0 EG4K, contribute to implementing good
451176 - procedures by holding Kaiser accountable for falling short, and by
451177 - providing an accurate record of case study to improve, then those
451178 - efforts are constructive and applauded. Improved health care serves
451179 - as a proud legacy to Vicki's father under the rule of trial and error
451180 - than advances civilization.
451182 - [On 041212 Andy Grove, CEO Intel, and survivor of cancer
451183 - recommends patients be their own project manager for
451184 - effective care through the doctor patient partnership.
451185 - ref SDS A7 F25K
451187 - ..
451188 - The argument that Kaiser places profit over people, and so withholds
451189 - care to increase income overlooks requirements at Intel, Harvard,
451190 - Pacific Bell, US Steel, the Red Cross, Johns Hopkins, UCSF Medical
451191 - Center, Mayo Clinic, and government sponsored health service in Canada
451192 - and in England. Everywhere, including the family budget, there must
451193 - be a balance between income and expense, and there must be profit to
451194 - invest in capability, expand service, reward taking risks, and pay for
451195 - failure, because if risks are never taken, there will be no advance.
451196 - Therefore, failed performance at Kaiser cannot be excused nor blamed
451197 - on the need for revenue, as some suggest. Since medical treatment
451198 - will ultimately fail, there is inherent tension between how much to
451199 - spend and when to redirect resources in any given case. The only
451200 - issues are whether decisions were made in good faith with adequate
451201 - deliberation by competent people and align with the evidence and
451202 - prevailing context.
451204 - ..
451205 - A collateral issue is whether technology can empower people to improve
451206 - by expanding span of attention that enables comprehensive and reasoned
451207 - deliberation, more commonly called "listening," reviewed on 890809,
451208 - ref SDS 3 CJ9J, and sometimes called....
451210 - working intelligently
451212 - ...explained in POIMS. ref OF 10 1X6G
451214 - ..
451215 - The cause of difficulties at Kaiser mirrors the larger economy where
451216 - too many people are having too many problems, reported on 001207.
451217 - ref SDS 98 V54M Ms Travis' work with the Kaiser Papers argues that
451218 - Kaiser, despite good procedures and good people, is being misled by
451219 - bad management that occurred at Enron, reported on 020204. ref SDS A3
451220 - 0001 Her only solution is to avoid Kaiser. Henry Kissinger on the
451221 - other hand argues management in all fields has become an "Alice in
451222 - Wonderland" of bumbling, reported on 940609. ref SDS 12 4238 Ideas
451223 - for a solution were set out in a letter, ref DIP 2 0001, dated 990924.
451224 - ref SDS 80 0001
451226 - ..
451227 - The difficulty with singling out Kaiser is that the problem of bad
451228 - management under new realities of expanding information density that
451229 - overwhelms span of attention threatens the entire economy.....
451231 - Too many people too many problems...... 001207, ref SDS 98 0001
451232 - Productivity paralyzed by quagmire of
451233 - information overload................... 011003, ref SDS A1 EC5N
451234 - Improvement hopeless at Aerospace
451235 - company................................ 011006, ref SDS A2 MO6F
451236 - Fixing the car comedy of errors........ 990507, ref SDS 41 0001
451237 - Flying to Mars......................... 991001, ref SDS 86 0001
451238 - Other examples......................... 950327, ref SDS 18 0200
451240 - ..
451241 - Suppose folks stop going to Kaiser.
451243 - ..
451244 - On 990912 a series of reports on the high cost of medical mistakes
451245 - shows bumbling is pandemic in health care, as it is in government,
451246 - business, education, etc. ref SDS 72 0001 Going to the government for
451247 - help is jumping from the frying pan into the fire. Since it is a
451248 - common problem we have to work together toward a common solution.
451249 - After all, people at Kaiser go the doctor, like everyone else, so they
451250 - share a common objective to work toward effective care.
451252 - ..
451253 - This record calls for a solution to the problem of bad management, as
451254 - set out in POIMS, ref OF 5 0001, and for Kaiser to take corrective
451255 - measures, as Ms Travis seems to be advocating.
451257 - [On 041212 Andy Grove, CEO Intel, and survivor of cancer
451258 - recommends patients be their own project manager for
451259 - effective care through the doctor patient partnership.
451260 - ref SDS A7 F25K