CONTACTS 

SUBJECTS
Purpose Meetings Unknown Review Background Communications Complexity

3103 -
3103 -    ..
3104 - Summary/Objective
3105 -
310501 - Follow up ref SDS 13 0000. ref SDS 11 0000.
310502 -
310503 - Purpose of meeting today turned out to be for physical examination.
310504 - ref SDS 0 UX7N  Case study shows challenge of complexity.  Considered
310505 - adding support for clear, concise, complete communication. ref SDS 0
310506 - R74O  Physical examination showed improvement in primary vitals;
310507 - scheduled next examination in 1 year. ref SDS 0 N83H  Cholesterol
310508 - levels were high from a LIPID test a year ago, which, if unchecked,
310509 - present risks of heart attack and stroke.  The doctor ordered an
310510 - update to check for improvement tracking improved vitals. ref SDS 0
310511 - MA6I  The doctor made a referral for dental work based on examination
310512 - showing service related follow up required. ref SDS 0 TR9I  Brief
310513 - visit with doctor in GI Clinic Department C revealed that a report on
310514 - the manometry test will be issued next week, and the procedure to
310515 - treat achalasia will be scheduled at that time. ref SDS 0 FT6M
310516 -
310517 -        [On 060512 meeting at VA for eye examination. ref SDS 20 UF6K
310519 -         ..
310520 -        [On 060529 follow up letter asks about response time on dental
310521 -        referrals, because meeting has not yet been scheduled.
310522 -        ref SDS 21 GM6P
310524 -         ..
310525 -        [On 060614 visited VA; Rubin is out of office until 060616; so,
310526 -        met with Renato who will ask Rubin to follow up on scheduling
310527 -        dental care. ref SDS 23 YR4J
310529 -         ..
310530 -        [On 060614 GI clinic has experienced increased work load, which
310531 -        requires prioritizing; patient advocate, Rubin Soto, will
310532 -        coordinate with the GI Clinic notifying the customer of the
310533 -        schedule based on current priorities. ref SDS 23 J86N
310535 -         ..
310536 -        [On 070220 letter to VA asks about progress getting test
310537 -        results from VA in Sacramento, and scheduling surgery for
310538 -        achalasia. ref SDS 25 5R5R
310539 -
310540 -
310541 -
310542 -
310544 -  ..
3106 -
3107 -
3108 - Progress
3109 -
310901 - Complexity Compounds Challenge of Communications to Save Time Money
310902 - Purpose of Meeting Review Background Communications Saving Time Money
310903 -
310904 - Follow up ref SDS 13 P18O.
310905 -
310906 - Doctor asked about the purpose of meeting today?
310908 -  ..
310909 - We reviewed prior work on determining the purpose of meeting, and that
310910 - it may have been a mistake, but there are several issues that can be
310911 - discussed today. ref SDS 0 R76I
310913 -  ..
310914 - Reviewed background....
310915 -
310916 -    1.  VA submits 2 letters both asking
310917 -        patient to call VA and schedule
310918 -        meetings; purpose for meetings
310919 -        is not presented..................... 060322, ref SDS 15 0001
310921 -         ..
310922 -    2.  Called VA as directed, Patty said
310923 -        there is nothing in the computer
310924 -        that explains purpose of meeting;
310925 -        she said the notices seem to be a
310926 -        mistake, so recommended throwing
310927 -        away and ignoring VA notice because
310928 -        it seems like a duplication of
310929 -        meeting with doctor a week earlier
310930 -        on 060317............................ 060324, ref SDS 16 P18O
310932 -         ..
310933 -    3.  Patty decided to send a request
310934 -        to the doctor's program manager,
310935 -        Connie, asking to confirm meetings
310936 -        and enter the purpose in the VA
310937 -        computer, or confirm there was a
310938 -        mistake and there are no
310939 -        meetings scheduled at this
310940 -        time................................. 060324, ref SDS 16 N158
310942 -         ..
310943 -    4.  VA computer did not have enough
310944 -        space in email system to notify
310945 -        Connie about context of problem;
310946 -        Patty had many other patients
310947 -        waiting on hold for assistance so
310948 -        there wasn't enough time for VA to
310949 -        confirm purpose of meetings, schedule
310950 -        the meetings, or to confirm that
310951 -        patient should ignore notices;
310952 -        Patty transferred call to
310953 -        Connie............................... 060324, ref SDS 16 OY7H
310955 -         ..
310956 -    5.  Left message for Connie explaining
310957 -        Patty's request for help following
310958 -        up notices from VA to call and
310959 -        schedule two (2) meetings............ 060324, ref SDS 16 N15K
310961 -         ..
310962 -    6.  Received another letter showing
310963 -        another meeting scheduled with
310964 -        primary care physician on
310965 -        060505............................... 060331, ref SDS 18 P18O
310967 -         ..
310968 -    7.  Visited VA, explained background
310969 -        getting three (3) letters on
310970 -        scheduling meetings; Rhonda said
310971 -        the letters were a
310972 -        mistake.............................. 060331, ref SDS 18 XL48
310974 -         ..
310975 -    8.  Rhonda decided to schedule meeting
310976 -        with primary care physician
310977 -        on 060505 to follow up examination
310978 -        a few weaks earlier on 060317;
310979 -        purpose of meeting not shown in
310980 -        computer; there is no one to ask
310981 -        about purpose of meeting in order
310982 -        to confirm the patient should
310983 -        meet with the doctor................. 060331, ref SDS 18 6S6F
310985 -         ..
310986 -    9.  Connie called and advised she talked
310987 -        to the doctor; he was not aware of
310988 -        any reason for meeting on 060505, as
310989 -        scheduled by Rhonda on
310990 -        060331............................... 060403, ref SDS 19 IX3M
310992 -         ..
310993 -   10.  Connie said the doctor recalled
310994 -        needing research for grounds to make
310995 -        a referral on dental support, and
310996 -        asked if this has been
310997 -        done................................. 060403, ref SDS 19 YY4J
310999 -         ..
311000 -   11.  Connie suggested sending an email
311001 -        to Kim with research on dental
311002 -        referral which she can forward to
311003 -        primary care physician............... 060403, ref SDS 19 EN57
311005 -         ..
311006 -   12.  Letter sent to Kim in Department C
311007 -        VA in Martinez with link to research
311008 -        on dental referral................... 060403, ref SDS 19 3G8F
311010 -  ..
311011 - Initially, handed to primary care physician a copy of the letter to
311012 - Kim on 060403, ref SDS 19 3G8F, asking about the purpose of the
311013 - meeting today, and providing research and background for dental
311014 - referral for review by primary care physician. ref DIP 1 0001
311016 -  ..
311017 - Research on 960205 reports a study showing that people waste 70% of
311018 - the day in unproductive meetings, ref SDS 2 5222, and one reason is
311019 - because the purpose for meeting is not clear. ref SDS 2 5902  Research
311020 - on 040312 shows complexity of organizations and communication greatly
311021 - leverages human intelligence, ref SDS 6 5P9I, but when complexity
311022 - overwhelms span of attention, productivity falls. ref SDS 6 CA5I
311024 -  ..
311025 - Doctor Sandhu said he had not received anything from Kim.
311027 -  ..
311028 - The doctor checked his computer.
311030 -  ..
311031 - The doctor found that the purpose of meeting today is to perform an
311032 - annual physical examination.  He was glad that Patty did not cancel
311033 - the meeting on 060324, ref SDS 0 WG54, and that Rhonda did not cancel
311034 - the meeting during the visit to the VA on 060331, ref SDS 0 HB40, and
311035 - that Connie did not cancel the meeting when he told her on 060403 that
311036 - a meeting was not needed. ref SDS 0 315N
311038 -  ..
311039 - The doctor explained that VA doctors see so many patients that the
311040 - record of patient history becomes very complex.  This conmplexity from
311041 - information density makes it hard to remember details, like the
311042 - purpose of meetings.  That is why he told Connie on 060403 that there
311043 - was no reason for a meeting today. ref SDS 0 315N
311045 -  ..
311046 - The doctor further explained that he was able to discover the purpose
311047 - of the meeting today to perform an annual physical examination because
311048 - of an entry he made in his computer showing patient history.  The
311049 - entry does not expressly say "physcial examination," but he alone is
311050 - able to interpret this purpose from the context.  That is why Patty,
311051 - Rhonda, and Connie could not make the same determination, and so
311052 - proposed cancelling the meeting as a computer mistake.
311054 -  ..
311055 - There was discussion that investing time for clear, concise, complete
311056 - communications, called out in NWO. ref OF 1 EH7I  Entering in the
311057 - computer case that the purpose of meeting today is for an annual
311058 - physical examination, would have saved time, and reduced the burden of
311059 - cognitive overhead on the customer, on Patty, Rhonda, Connie, and on
311060 - Kim, per patient history. ref SDS 0 P18O  Good management frees up
311061 - time for helping other customers.
311063 -  ..
311064 - The doctor said there is no reason for the customer and VA staff to
311065 - know the purpose of meetings, so long as the doctor can figure it out,
311066 - once the meeting gets underway, as occurred today. ref SDS 0 UX7N
311067 -
311068 -
311069 -
3111 -

SUBJECTS
Meeting Primary Care Physician Annual Physical Examination Follow Up

3603 -
360401 -  ..
360402 - Agenda Meeting Report New Issues and Progress on Medical Treatments
360403 -
360404 - After determining the purpose of the meeting, ref SDS 0 P18O, we
360405 - discussed the following agenda....
360406 -
360407 -    1.  Physical examination annual............... ref SDS 0 OY6M
360408 -    2.  Dental.................................... ref SDS 0 YR4J
360409 -    3.  Manometry Test............................ ref SDS 0 FT6M
360410 -
360412 -  ..
360413 - Vitals Show Continued Improvement...
360414 -
360415 -                        Blood
360416 -                        Pressure   Pulse  Temperature  Weight
360417 -
360418 -     060505...........  127 77      68       96.3       195
360419 -     060333...........   97 63      79       96.8       194
360420 -     050629...........  117 75      87       97.1       204
360421 -
360422 -
360423 -
360424 -
360425 -
360426 -
3605 -

SUBJECTS
Physical Examination Annual Meeting Primary Care Physician VA Martin

3903 -
390401 -  ..
390402 - Physical Examination Finds No Problems Requiring Treatment
390403 -
390404 - Follow up ref SDS 7 HS5G.
390405 -
390406 - The doctor performed a standard clincial physical examination,
390407 - including rectal cancer test, following up prior work on 050629.
390408 - ref SDS 7 I597
390410 -  ..
390411 - Vitals were taken earlier, ref SDS 0 L45N, showing improvement in
390412 - weight, pulse, and blood pressure. ref SDS 7 388I
390414 -  ..
390415 - The doctor noted loss of 10 pounds, and recommended losing about 30
390416 - more pounds.
390418 -  ..
390419 - Stethoscope tested heart and lung function.
390421 -  ..
390422 - Ear examination found scar tissue, but no current problems.  The
390423 - doctor asked if there was any history of damage to the right ear?
390424 - There is no patient history on this.
390426 -  ..
390427 - Doctor wants follow up physicial 070407.
390428 -
390429 -
390430 -
390431 -
390432 -
3905 -

SUBJECTS
Cholesterol LIPID Test August 2005 Very High Order Follow Test by Pr

4203 -
420401 -  ..
420402 - Cholosteral High from Test 050801 Prescribe Exercise Diet Drugs
420403 -
420404 - Follow up ref SDS 7 UY6M, ref SDS 5 7933.
420405 -
420406 - The doctor looked through patient records on his computer for
420407 - background on the physical examination, discussed above. ref SDS 0
420408 - N83H  He cited a report of high cholesterol and low good cholesterol,
420409 - from an LIPID blood test performed last year in August.  He feels the
420410 - ratio should be improved with diet, exercise and medication.
420412 -  ..
420413 - There were actually 2 blood tests in August 2005, and a third test in
420414 - September.  The meeting with the doctor on 050816 shows lab results of
420415 - high WBC were discussed, however, nothing was mentioned about LIPID
420416 - and high cholesterol at that time. ref SDS 8 G540  A follow up lab 2
420417 - days later verified high WBC, and shows medication was prescribed, but
420418 - also does not mention discussion of cholesterol, reported on 050818
420419 - 1452. ref SDS 9 DG8G  Another follow up labe was done a month later on
420420 - 050906, but no results are reported on 050906 1204. ref SDS 10 DG8G
420422 -  ..
420423 - It was unclear from the meeting today which of the three (3) labs last
420424 - year in 2005 identified high cholesterol, or whether this was reported
420425 - in all 3 labs.
420427 -  ..
420428 - Today, the doctor reviewed risks of high cholosteral with high weight
420429 - that can cause high blood pressure, and high pulse.  These conditions
420430 - can cause heart failure, and stroke.  This aligns with background on
420431 - high cholesterol and side effects reported on 990719. ref SDS 4 8585
420433 -  ..
420434 - The doctor ordered a follow up LIPID test for cholosteral to update
420435 - the record from a year ago.  Received document with instructions...
420436 -
420437 -    1.  Lab test ordered 060605.
420438 -
420439 -    2.  Fasting - nothing but water 12 - 14 hours prior to blood draw.
420441 -  ..
420442 - Improved blood pressure, and pulse, with lower weight in vitals taken
420443 - today, and compared with a year ago, ref SDS 0 L45N, suggest
420444 - improvement.
420445 -
420446 -            [On 060623 0840 Teri reports results of lab show continued
420447 -            high cholesterol; doctor prescribes treatment with
420448 -            Lovastatin to reduce cholesterol. ref SDS 24 UO5N
420450 -             ..
420451 -            [On 090812 1030 Doctor orders another lab to test
420452 -            cholesterol and other factors that may explain sudden
420453 -            weight loss, besides improve fitness. ref SDS 26 NF4G
420454 -
420455 -
420456 -
420457 -
4205 -

SUBJECTS
Dental Referral Was Made on 060406 for Treatment of Service Related

4803 -
480401 -  ..
480402 - Dental Referral for Service Related Follow Up
480403 -
480404 - Follow up ref SDS 13 YR4J.
480405 -
480406 - We reviewed the examination on 060317 when the doctor found failed
480407 - dental work orginally performed by the US Army. ref SDS 13 YR4J
480409 -  ..
480410 - Today, the doctor said he cannot make a referral for dental work
480411 - unless the problem is service related.  He did not recall getting the
480412 - letter on 060403 that provided support for referral, ref SDS 19 3G8F,
480413 - submitting research requested by the doctor on 060317. ref SDS 13 M56G
480414 - The doctor further noted that issues of elegibility for referral
480415 - should be presented by the patient to Rubin Soto in the VA Elegibility
480416 - Department.  The doctor was adament that the primary care physician
480417 - role should not coordinate health care support for the patient.
480418 -
480419 -     [On 060601 Kim forwarded a letter asking about timing of dental
480420 -     referrals to Rubin for advocacy expediting patient care.
480421 -     ref SDS 22 T68I
480423 -      ..
480424 -     [On 060614 visited VA; Rubin is out of office until 060616;
480425 -     so, met with Renato who will ask Rubin to follow up on
480426 -     scheduling dental care. ref SDS 23 YR4J
480428 -  ..
480429 - While checking his computer on the cholesterol problem, per above,
480430 - ref SDS 0 MA6I, the doctor found the letter dated 060403 which Kim had
480431 - forwarded to support dental referral for service related follow up, as
480432 - requested by the doctor on 060317, ref SDS 13 YR4J, and discussed with
480433 - Connie on 060403. ref SDS 19 YY4J
480435 -  ..
480436 - Looking further in his computer, the doctor found that on 060406 he
480437 - made a referral for dental work, based on research which he received
480438 - from Kim on 060403. ref SDS 19 3G8F  The doctor said that the dental
480439 - departent is very busy.  He expects that scheduling a meeting could
480440 - take 6 to 8 weeks.  This aligns with research o 060317 showing that
480441 - the VA has the busiest dental practice in the country. ref SDS 13 SU6H
480442 -
480443 -     [On 060529 follow up letter asks about response time on dental
480444 -     referrals, because meeting has not yet been scheduled. ref SDS 21
480445 -     GM6P
480447 -      ..
480448 -     [On 060601 Kim forwarded letter asking about timing of dental
480449 -     referrals to Rubin for advocacy expediting patient care.
480450 -     ref SDS 22 T68I
480452 -      ..
480453 -     [On 060614 visited VA; Rubin is out of office until 060616;
480454 -     so, met with Renato who will ask Rubin to follow up on
480455 -     scheduling dental care. ref SDS 23 YR4J
480457 -  ..
480458 - This completes medical management for this matter, as planned on
480459 - 060317. ref SDS 13 M46N
480461 -  ..
480462 - There was consideration about feedback to let Kim know her letter was
480463 - received and action was taken.
480469 -  ..
480470 - Resistance to follow up and feedback aligns with cultural objections
480471 - to good management set out in NWO, ref OF 1 2670, and discussed on
480472 - 990527. ref SDS 3 1233
480473 -
480474 -
480475 -
480476 -
480477 -
4805 -

SUBJECTS
Manometry Test Expedite Report and Schedule Treatment Achalasia Meet

5103 -
510401 -  ..
510402 - Manometry Test Expedite Report and Schedule Treatment for Achalasia
510403 -
510404 - Follow up ref SDS 13 FT6M, ref SDS 12 5K5F.
510405 -
510406 - While waiting to the see the primary care physician at 0830, about
510407 - 0815 Doctor Lee walked through the lobby on his way to work upstairs
510408 - in Department C, GI Clinic.  We walked up stairs together, and then
510409 - had a brief meeting.
510411 -  ..
510412 - We reviewed background.  The doctor said the letter on 060403 received
510413 - through Kim was helpful confirming plans to follow up manometry
510414 - testing. ref SDS 19 UW6J
510416 -  ..
510417 - Doctor Lee recalled today planning on 060330 to submit diagnostic data
510418 - from the manometry test at VA Mather AFB in Sacramento, and to
510419 - schedule a procedure treating achalasia with balloon dilation of the
510420 - esophageal sphincter valve. ref SDS 17 MD4N
510422 -  ..
510423 - The doctor advised that VA Martinez is ready to perform esophageal
510424 - dilation to relieve achalasia, because 2 weeks ago he received the
510425 - pneumatic balloons needed for the procedure.
510427 -  ..
510428 - The doctor advised that follow up has been delayed, because the VA
510429 - Mather AFB Sacramento has not yet submitted the results of manometry
510430 - test.  He called last week, and was told the data would be mailed to
510431 - him at VA Martinez this week.  However, he has still not received the
510432 - data.  He plans to follow up next week, and will submit a letter on
510433 - results of the test on 060330, and further he will schedule a
510434 - procedure to treat achalasia, as planned at that time.
510435 -
510436 -    [On 060529 submitted letter asking about schedule on submitting
510437 -    results of manometry testing on 060330, and scheduling treatment
510438 -    for achalasia. ref SDS 21 FT6M
510440 -     ..
510441 -    [On 060601 Kim forwarded the letter issued on 060529 for expediting
510442 -    submission of a report on results of manometry testing on 060330,
510443 -    and scheduling treatment for achalasia. ref SDS 22 OQ5R
510445 -     ..
510446 -    [On 060614 GI clinic has experienced increased work load,
510447 -    which requires prioritizing; patient advocate, Rubin Soto,
510448 -    will coordinate with the GI Clinic notifying the customer
510449 -    of the schedule based on current priorities. ref SDS 23
510450 -    J86N
510452 -     ..
510453 -    [On 070220 letter to VA asks about progress getting test
510454 -    results from VA in Sacramento, and scheduling surgery
510455 -    for achalasia. ref SDS 25 5R5R
510456 -
510457 -     [On 090812 1030 after suffering severe weight loss of 30 pounds in
510458 -     a few months, primary care physician notified GI clinic to review
510459 -     schedule for performing surgery to relieve achalasia. ref SDS 26
510460 -     P58H
510466 -  ..
510467 - After discussion in the hallway with the doctor in the GI clinic, the
510468 - meeting the primary care physician was called at 0830, and these
510469 - understandings were presented for background coordinating and
510470 - expediting pending issues.
510471 -
510472 -     [On 090812 1030 after suffering severe weight loss of 30 pounds in
510473 -     a few months, primary care physician notified GI clinic to review
510474 -     schedule for performing surgery to relieve achalasia. ref SDS 26
510475 -     P58H
510476 -
510477 -
510478 -
510479 -
510480 -
5105 -

SUBJECTS
Case Management Interferrence Primary Care Physician Collaborate Coo

6003 -
600401 -  ..
600402 - Case Management Referral Team Care Patient Challenge of Leadership
600403 -
600404 - The primary care physician indicated that the scope of this role does
600405 - not perform case management to collaborate and coordinate follow up on
600406 - referrals, in this case the GI Clinic treating achalasia.  Doctors
600407 - resist support to get things done.  Coordination, collaboration,
600408 - management and leadership are viewed as "interference," rather than
600409 - timely reminders to avoid problems by treating the patient.
600411 -  ..
600412 - This report indicates the patient does not have a single point of
600413 - contact for case management, and so must fill the Communication
600414 - Metrics role of understanding and follow up, defined on 950327,
600415 - ref SDS 1 7777, rather than rely on the medical team care process.
600416 -
600417 -     [On 090812 1030 after suffering severe weight loss of 30 pounds in
600418 -     a few months, primary care physician notified GI clinic to review
600419 -     schedule for performing surgery to relieve achalasia. ref SDS 26
600420 -     P58H
600421 -
600422 -
600423 -
600424 -
600425 -
6005 -

SUBJECTS
Eyes and Dental Examination Request Meeting to Review Recent Problem

6303 -
630401 -  ..
630402 - Eyes Very Painful to Light for Extended Periods Cannot Work
630403 -
630404 - Follow up ref SDS 13 OY6M.
630405 -
630406 - On 060320 receive notice of meeting with optometry on 060512,
630407 - ref SDS 14 XV5O, which was ordered by the doctor following examination
630408 - during the meeting on 060317. ref SDS 13 OY6M
630410 -  ..
630411 - There was no reason for discussion on this subject today.
630412 -
630413 -        [On 060512 meeting at VA for eye examination. ref SDS 20 UF6K
630414 -
630415 -
630416 -
630417 -
630418 -
630419 -
630420 -
6305 -