CONTACTS 
0201 - Kaiser Permanente - Shadelands       925 906 2200
020101 - Walnut Creek
020102 - Ms. Jeanne Bradley; Coordinator =925 906 2209
020103 - Jeanne.Bradley@ncal.kaiperm.org
020104 - Administration Department
0202 - Kaiser Permanente - Shadelands       925 906 2200
020201 - Walnut Creek, CA
020202 - Mr. Mark Mangrai; 925 906 2209
020203 - mark.Mangrai@tao.ncal.kp.org
020204 - Patient Assistance

SUBJECTS
Medical Practice Requires Records
Risk Communication Main Factor of Management Success
Risk Management Communication Main Task of Managers, Largest Risk
Telephone Game Shows Meaning Drift, Need to Maintain Shared
Common Administration
Team Care in Medical Practice
Kaiser Medical Group
Ambassadors for Change
Writing "everything" down Not Needed to Understand
Meaning Drift Verbal Communication Error Prone

1812 -    ..
1813 - Summary/Objective
1814 -
181401 - Follow up ref SDS 24 0000, ref SDS 19 0000.
181402 -
181403 - Mark has been unable to get response from the doctors assigned to meet
181404 - on team care practices.  He will contact the CEOs office to look for a
181405 - way to follow up on this. ref SDS 0 0966   Jeanne Bradley will support
181406 - Mark's efforts.  She asked for an explanation of meaning drift and the
181407 - solution of alignment.  She will reread the letter on medical
181408 - mistakes, and look for someone within Kaiser to submit the letter who
181409 - can consider Communication Metrics solution.
181410 -
181411 - Sent ref DIT 2 0001 to Mark linked to review of letter from Bob Pearl,
181412 - per below. ref SDS 0 1176
181413 -
181414 -     [On 991103 follow up letter to Jeanne. ref SDS 34 5933]
181415 -
181416 -     [On 991109 received letter from Mark. ref SDS 37 0001]
181417 -
181418 -     [On 991130 Jeanne provides feedback. ref SDS 39 0001]
181419 -
181420 -
181421 -
181422 -  ..
1815 -
1816 -
1817 - Progress
1818 -
181801 -  ..
181802 - Ambassador of Change to Champion Review of Com Metrics
181803 - Develop Channel at Kaiser for Com Metrics to Solve Meaning Drift
181804 -
181805 - This afternoon OA 1430, sent ref DIT 2 0001 to Jeanne transmitting the
181806 - letter to Mark, ref DIT 1 0001, prepared below, ref SDS 0 1176
181807 -
181808 - Cite Jeanne's offer to help in her letter, ref DRP 5 0001, on 990915,
181809 - ref SDS 18 0001, as basis to follow up getting review of Com Metrics
181810 - for solving medical mistakes, ref DIT 1 0002, as set out in the letter
181811 - on Medical Mistakes, ref DIP 2 0001, developed on 990924. ref SDS 19
181812 - 0001
181813 -
181814 - Cite problem of "meaning drift", ref DIT 1 2548, which is explained in
181815 - the Sep 24 letter, as main target of opportunity to reduce medical
181816 - mistakes, also called the "telephone game" and management by guess
181817 - and gossip.
181818 - ..
181819 - Key question for Jeanne...
181820 -
181821 -       How do we find people at Kaiser who can grasp both the problem
181822 -       and the opportunity to improve things? ref DIT 1 1640
181823 -
181824 - We need a champion, an ambassador of change, like Jeanne has been with
181825 - SDS records, to look for people at Kaiser who are looking for this
181826 - solution.
181827 -
181828 - After sending the letter to Jeanne, called and talked to Jeanne in the
181829 - afternoon.
181830 -
181831 -      [On 991123 Jeanne suggests talking to Tom Driscoll. ref SDS 38
181832 -      0001]
181833 -
181834 -      [On 991130 Jeanne sent follow up to Tom. ref SDS 39 0005]
181835 -
181836 -
181837 -  ..
181838 - Mark Effective Advocate of Team Care Improvement with CEOs Office
181839 -
181840 - Jeanne was aware of my call to Mark this morning, and that he is
181841 - trying to set up a meeting on Team Care through Bob Pearl's office.
181842 - per below. ref SDS 0 0966
181843 -
181844 - She visited with Mark this morning after my call, and feels he is
181845 - anxious to make progress. because he is very organized and he sees the
181846 - value of Com Metrics to accomplish his vision of good management.
181847 -
181848 - Jeanne said Mark has worked with the CEOs office on prior matters,
181849 - and so may be able to get support.  She does not have any contacts in
181850 - Pearl's office.
181851 - ..
181852 - She will talk to Mark again on scheduling a meeting on Team
181853 - Care, based on contacting the Office of the CEO.
181854 -
181855 -    [On 991108 Jeanne plans to talk to Mark. ref SDS 35 0966]
181856 -
181857 -
181858 -  ..
181859 - Meaning Drift -- Limited Span of Attention, Information Overload
181860 -
181861 - Jeanne has not had time to read the letter on medical mistakes
181862 - carefully.  When she scanned it a few weeks ago, her impression was
181863 - that the letter presents important ideas that are difficult to follow
181864 - because they are not discussed in daily work.
181865 -
181866 - She asked to discuss a few key points for orientation to guide a
181867 - second read of the letter on medical mistakes. ref DIP 2 1680
181868 - ..
181869 - Jeanne asked for an explanation of "meaning drift."
181870 -
181871 -      Meaning Drift is explained in the letter on medical mistakes as
181872 -      remembering incorrectly illustrated by the "telephone game",
181873 -      ref DIP 2 4524  It is explained in the New World Order... paper.
181874 -      ref OF 6 9449, reflecting the "fragility of knowledge" defined on
181875 -      950204. ref SDS 5 0550
181876 -
181877 -      "Ambiguity of mental maps" is a phrase Andy Grove uses in his
181878 -      book on his time as CEO of Intel, reviewed on 980307. ref SDS 11
181879 -      7571
181880 -
181881 -        [On 991108 Jeanne noted an example of meaning drift.
181882 -        ref SDS 35 3968]
181883 -
181884 -        [On 991108 poetry is an ancient technology to maintain
181885 -        alignment in a pre-literate culture. ref SDS 36 3596]
181886 -
181887 -        [On 991130 meaning drift and cultural forces make communication
181888 -        the biggest risk in enterprise. ref SDS 39 4664]
181889 -         ..
181890 -      Being "confused" reflects meaning drift.
181891 -
181892 -      Confusion generally means we feel uncertain as a result of
181893 -      sensing the possibility of having commingled unrelated
181894 -      information.  We recognize the need for time and help to verify
181895 -      facts and associations in order to avoid a mistake, explained on
181896 -      920808. ref SDS 2 0877
181897 -
181898 -      An example is being in a meeting and saying something like...
181899 -
181900 -          Bill in accounting says the cost figures for the last quarter
181901 -          will be released next week, and they will show improvement.
181902 -
181903 -      Someone else says...
181904 -          ..
181905 -          We got a memo two days ago saying the cost figures for
181906 -          the last quarter have been released and show no improvement.
181907 -          It said a new cost system will be online next week that is
181908 -          expected to show improvement so that future reports are not
181909 -          delayed.
181910 -      ..
181911 -      You then say...
181912 -
181913 -          Yes, that's right but I distinctly remember Bill saying
181914 -          something about improved figures for the quarter.
181915 -
181916 -          I guess I am confused.  We need to check with accounting
181917 -          again and review the memo.
181918 -      ..
181919 -      Someone else says...
181920 -
181921 -          Look!  I have the memo!
181922 -
181923 -          It says cost figures for last quarter cannot be produced due
181924 -          to a system failure, but the new cost system has been
181925 -          implemented that forecasts improved figures for next quarter.
181926 -
181927 -      So each person remembered most of the same words, but they are
181928 -      arranged differently, which results in different meanings. Future
181929 -      recall will result in different word arrangements, as in the
181930 -      "telephone game" cited in the letter on medical mistakes.
181931 -      ref DIP 2 1680
181932 -
181933 -      "Confusion" arises from remembering words in slightly rearranged
181934 -      patterns that have nearly the same original meaning, but differ
181935 -      in some degree. Sometimes we feel unsure and say to ourselves and
181936 -      others that we are "confused."
181937 -      ..
181938 -      We feel confused because we recognize our "story" is not
181939 -      coherent and there may be conflicts.  The mind is wired to tell
181940 -      us to stop when our "story" seems inconsistent.  Confusion, then,
181941 -      is an innate Communication Metric we have to avoid mistakes.
181942 -
181943 -      People in a meeting can help over come confusion based on their
181944 -      recall.  Often this devolves into heated exchange, that wanders
181945 -      off subject. When the original memo is not available to align
181946 -      communication, people argue about what it said and what other
181947 -      people say it said, going back weeks and months (see for example
181948 -      meeting at PG&E on 941209, ref SDS 4 7777; "confrontation" at
181949 -      Intel meetings reported on 970123, ref SDS 7 1111)  Everyone
181950 -      promises to check the contract, the memo and their notes, but
181951 -      often everybody has to go to another meeting, and so nothing is
181952 -      checked until a mistake occurs, as happened when the space probe
181953 -      crashed into Mars, rather than going into orbit around it and
181954 -      costing a loss of $125M, reported on 991025. ref SDS 25 0304
181955 -      ..
181956 -      People are driven by genetics to rely on speech in relating
181957 -      what they heard, rather than check the record, as explained in
181958 -      POIMS. ref OF 5 1265, and the NWO..., ref OF 6 5653  Inherent
181959 -      inaccuracy of speech causes the story to drift farther and
181960 -      farther from what is in the memo, in the contract, in the invoice
181961 -      and so on, explained on 991108 researching the history of
181962 -      transitioning from orality to literacy. ref SDS 36 7426
181963 -
181964 -      Sometimes meaning drift is harmless because not every mistake
181965 -      impacts performance and earnings.
181966 -
181967 -      A humorous example of meaning drift is...
181968 -
181969 -
181970 -  ..
181971 -
181972 -                      "Operation Haley's Comet"
181973 -
181974 -
181975 -      ...from the military, reported on 970624. ref SDS 8 7006
181976 -
181977 -      The telephone game illustrates meaning drift in a benign setting,
181978 -      reviewed on 971229. ref SDS 10 1526
181979 -
181980 -
181981 -       ..
181982 -      Communication is Biggest Risk in Enterprise
181983 -
181984 -      Follow up ref SDS 32 0001.
181985 -
181986 -      "Meaning drift," however, is more dynamic and harmful than either
181987 -      confusion or the "telephone game," because it happens on
181988 -      automatic pilot, as interplay between the conscious and
181989 -      subconscious mind outside our attention span.  In addition to
181990 -      rearranging words, meaning drift commingles by drawing on similar
181991 -      word patterns from different events, because they fit a momentary
181992 -      mental map the conscious span of attention assembles to tell a
181993 -      "story,"  As long as the mind assembles a coherent story that
181994 -      does not conflict with the context of the moment, for example,
181995 -      when there is no feedback that challenges the story, the mind is
181996 -      convinced of accuracy.  The mind has belief.  It does not feel
181997 -      confused and in need of help.  It feels secure!
181998 -      ..
181999 -      This false sense of security is called "false knowledge."
182000 -
182001 -          [On 991025 commingled two trips to Yosemite climbing Half
182002 -          Dome, as though they were a single trip. ref SDS 29 4260]
182003 -
182004 -      Since we do not feel confused, we have no restraint on acting and
182005 -      urging others to act on what we strongly believe is true.
182006 -
182007 -      Those who hear a convincing story and have no opposing context,
182008 -      acquire "false knowledge."
182009 -
182010 -      "False knowledge" is spread in meetings and calls and gets into
182011 -      documentation. gaining strength as the official view of reality
182012 -      until it encounters reality in the form of a mistake, a problem,
182013 -      a crisis, causing stress, loss and conflict, explained in the New
182014 -      World Order... paper as Murphy's Law. ref OF 6 9449
182015 -      ..
182016 -      Gaps in "meaning drift" widen as time passes, particularly
182017 -      when information flows increase, because there is much greater
182018 -      opportunity to assemble information incorrectly through
182019 -      commingling when there is a richer body of information from which
182020 -      to assemble incorrect stories that seem coherent, and when there
182021 -      is less time for the mind to sort out conflicts that alert people
182022 -      to feel confused and investigate.
182023 -
182024 -      Information overload, therefore, increases meaning drift, and
182025 -      results in management by guess and gossip, because there is not
182026 -      enough time for anyone to check the original memo, as occurred in
182027 -      our example. ref SDS 0 9020
182028 -
182029 -      These factors mean....
182030 -
182031 -
182032 -              communication is the biggest risk in enterprise
182033 -
182034 -
182035 -
182036 -  ..
182037 - Alignment, Audit Trail, Solve Meaning Drift
182038 -
182039 - Jeanne asked for a solution to "meaning drift" defined above.
182040 - ref SDS 0 2800
182041 -
182042 - We reviewed...
182043 -
182044 -
182045 -                          alignment
182046 -
182047 -
182048 - ...is the simple explanation in the letter to Morris at Intel,
182049 - ref DIP 4 2346, sent on 991028. ref SDS 32 0001
182050 - ..
182051 - The larger explanation is using the SDS program that applies a
182052 - range of tools and practices to create and maintain alignment,
182053 - explained in the analysis of Drucker's new article, on 991025.
182054 - ref SDS 30 2846
182055 -
182056 - Jeanne is familiar with the term...
182057 -
182058 -
182059 -                          audit trail
182060 -
182061 -
182062 - ...mostly used in accounting, but everyone knows it refers to keeping
182063 - track of root cause analyses, i.e., critical details about why things
182064 - happen.
182065 - ..
182066 - Alignment and audit trail embody a fancier phrase used in
182067 - management texts and standards...
182068 -
182069 -
182070 -                traceability to original sources
182071 -
182072 -
182073 - ...as for example in ISO 1006 reviewed on 950721. ref SDS 6 1740
182074 -
182075 -
182076 -  ..
182077 - Com Manager Writes Important Things Down, Makes Connections of Context
182078 - Intelligence Goes a Long Way to Maintain Alignment for Team
182079 -
182080 - Jeanne asked if keeping communication aligned requires that everyone
182081 - has to write everything down every day?
182082 -
182083 - I explained this is a big concern, as reported, for example, by Ross
182084 - Armstrong at IBM on 910626. ref SDS 1 5822
182085 -
182086 -    The report on medical mistakes says an investment in a new role and
182087 -    new tools provides "intelligence" support for the team. ref DIP 2
182088 -    1403
182089 -
182090 -    Common administration using a Patient Assistant or Advocate is one
182091 -    idea explained in the letter on reducing medical mistakes.
182092 -    ref DIP 2 2955
182093 - ..
182094 - We reviewed the solution at PG&E and U.S. Army Corps of
182095 - Engineers that found a Communication Manager is cost effective in
182096 - providing useful "intelligence," so everyone does not have to write
182097 - everything, yet the organization benefits from having a resource of
182098 - shared knowledge.
182099 -
182100 - The U.S Army Corps of Engineers published a report on 970328, that
182101 - says "intelligence" support for managers is analogous to the role of
182102 - the CIA in analysing and summarizing important events for the
182103 - President of the United States every day. ref DRP 2 2022  Technology
182104 - has increased the past 50 years, making information overload more
182105 - widespread, so more people need "intelligence" support that maintains
182106 - alignment in order to avoid meaning drift.  Since everyone cannot
182107 - afford a big department, a new kind of technology is needed and new
182108 - skills to make it cost effective for more people to use intelligence
182109 - in daily management.
182110 - ..
182111 - Communication Metrics provides these new tools, skills and roles
182112 - that enable people to use information productively, rather than be
182113 - overwhelmed by information overload.
182114 -
182115 - A meeting with the U.S. Army Corps of Engineers in Washington D.C. on
182116 - 971202 explained a little "intelligence" goes a long way to build and
182117 - maintain shared meaning for everyone that avoids "meaning drift."
182118 - ref SDS 9 0838
182119 -
182120 - Basically, the idea is to spread "intelligence" rather than guess and
182121 - gossip.
182122 -
182123 -
182124 -
182125 -  ..
182126 - Training Communication for Effective Doctor/Patient Partnership
182127 -
182128 - We discussed the need to transition an organization toward
182129 - Communication Metrics by introducing change gradually.
182130 -
182131 - Jeanne likes the idea of doctor/patient communication training set out
182132 - in the letter on solving medical mistakes, ref DIP 2 2601, which was
182133 - originally posed in the record on 990625, ref SDS 13 5358, and more
182134 - recently on 990913. ref SDS 17 0844
182135 -
182136 - An example of the need for training is the letter from Craig Boulris
182137 - on 991028, which explains scope of training. ref SDS 31 8499
182138 -
182139 - Communication training is item 6 in the list of pending issues for
182140 - review of Kaiser in the record on 991008. ref SDS 26 0899
182141 -
182142 -     [On 991103 submitted letter on this. ref SDS 34 5933]
182143 -
182144 -     [On 991206 discussed with Tom Driscoll. ref SDS 40 2208]
182145 - ..
182146 - Good work habits and practices have to be reviewed regularly,
182147 - because bad habits flourish without regular reinforcement of good
182148 - habits. It's a lot like going to church.  People need reinforcement
182149 - and training to apply good practices for avoding "meaning drift,"
182150 - because it is a prevelant problem that is hidden from our attention,
182151 - and so makes....
182152 -
182153 -
182154 -  ..
182155 -
182156 -            Communication the biggest risk in enterprise
182157 -
182158 -
182159 - ...explained in a letter to Intel, ref DIP 4 0001, submitted 991028.
182160 - ref SDS 32 0001
182161 -
182162 - Here is the initial idea...
182163 -
182164 - Once or twice a month a different doctor from the local facility can
182165 - lead a training session that has new patients and at least two other
182166 - doctors from the facility.  A facilitator can support the meeting to
182167 - ensure professional presentation.  Existing patients can attend to
182168 - explain communication issues and request assistance.  Patient
182169 - Assistance can attend to ensure follow up.
182170 - ..
182171 - A film can be produced showing typical scenarios to set up
182172 - discussion in the training class.
182173 -
182174 - Having a doctor lead training on communication practices to implement
182175 - the guidelines in Kaiser's Healthwise Handbook, provides reminders and
182176 - reinforcement for the doctor to follow the guidelines, which are
182177 - currently not being used.
182178 -
182179 - Doctors and patients work issues together.
182180 -
182181 - In a facility with 15 or so doctors, this training will require
182182 - perhaps 5 - 10 hours per year in the evening, which means twice a year
182183 - conducting a training session, and twice attending as members of the
182184 - class, to contribute in guiding discussion.
182185 -
182186 - ..
182187 - Follow up...
182188 -
182189 - Jeanne will review the letter on medical mistakes again in relation to
182190 - our discussion on meaning drift and alignment. ref SDS 0 2800
182191 -
182192 - She will look for someone to champion Com Metrics at Kaiser.
182193 -
182194 -
182195 -     [On 991103 submitted letter on this. ref SDS 34 5933]
182196 -
182197 -
182198 -
182199 -
182200 -
1823 -
1824 -

SUBJECTS
Patient Assistant
Questions, Suggestions
Medical History, Xrays Not Submitted for Meeting
Medical Chart Missing Information
Policy Procedures on Communication
Team Care, Primary Care Physician
Patient Assistance Delays Action 2 Weeks
Doctors Fail Perform Assignment to Review Medical Mistakes
Medical Mistakes Require Review

3012 - Progress
3013 -
301301 -  ..
301302 - Contact Bob Pearl's Office about Meeting on Quality Team Care
301303 -
301304 - Follow up ref SDS 28 0001, ref SDS 27 0001.
301305 -
301306 - Mark sent a follow up letter last Friday, from our work on 991024,
301307 - asking the two doctors to respond that Ross assigned to handle the
301308 - meeting on Team care, as reported on 991021. ref SDS 27 0001, per
301309 - agenda on 991008. ref SDS 26 9055
301310 -
301311 - Mark has still not heard from either doctor.
301312 -
301313 -     [On 991109 received letter from Mark. ref SDS 37 0001]
301314 -
301315 - He next plans to send them the letters I have submitted that explain
301316 - issues to be reviewed, shown in the record on 991008. ref SDS 26 9055
301317 - ..
301318 - We considered the prospect that an effective meeting on team
301319 - care needs attention by people expressly assigned to formulate and
301320 - support the program.  Doctors with a patient load, must of necessity
301321 - give first priority to patients.  Like engineers who just want to work
301322 - on technology, reported on 990525, ref SDS 12 0966, doctors just want
301323 - to work on patients.  Recent articles on medical mistakes published
301324 - beginning on 990912 point out that busy doctors do not have time to
301325 - think about work process, ref SDS 15 0001, and often are unable to
301326 - admit problems because of concerns about personal competency.
301327 - ref SDS 15 3416
301328 -
301329 - On 990625 Doctor Connolly advised doctors do not have to follow Kaiser
301330 - Guidelines on communication. ref SDS 13 1978 so it is understandable
301331 - that there isn't time for looking at policy issues at the practitioner
301332 - level.
301333 - ..
301334 - We discussed the letter from Bob Pearl, CEO of Kaiser,
301335 - ref DRP 6 0001, received on 991028, that points out doctors have
301336 - freedom to practice medicine the way it should be practiced.
301337 - ref SDS 31 2555  This freedom to focus on medicine is correct, but
301338 - means there is less time for doctors to look at management process
301339 - aimed at ensuring quality care.
301340 -
301341 - Mark considered contacting the Kaiser IT department about meeting on
301342 - issues in the letter on 991008. ref DIP 6 0001
301343 -
301344 - We reviewed the advantage of involving folks who formulate Kaiser's
301345 - Quality Team Care program, rather than IT people, for the first
301346 - meeting.
301347 -
301348 - Mark requested a copy of the letter from Bob Pearl. ref DRP 6 0001
301349 - ..
301350 - He plans to call Bob's office and ask who can meet on issues of
301351 - quality team care.
301352 -
301353 - ..
301354 - Submitted ref DIT 2 0001 linked to the record on 991028 citing
301355 - Pearl's letter. ref SDS 31 0800   Sent a copy to Jeanne Bradley, per
301356 - above. ref SDS 0 1927
301357 -
301358 - Cited my letter, ref DIP 6 0001, to Kaiser on 991008 setting the
301359 - agenda for a meeting on team care. ref SDS 26 9055
301360 -
301361 - Explain Mark's efforts the past few months, including his report this
301362 - morning, ref SDS 0 0966, show that due a heavy patient load, doctors
301363 - do not have time to think about team care work process. ref SDS 0 2562
301364 - It also reflects freedom doctors have reported by Pearl in his letter
301365 - on 991028. ref SDS 31 2555
301366 -
301367 -     Above, Jeanne Bradley discussed this with Mark this morning and
301368 -     plans to follow up. ref SDS 0 0297
301369 -
301370 -     [On 991109 Jeanne plans to follow up with Mark. ref SDS 35 0966]
301371 -
301372 -     [On 991109 received letter from Mark. ref SDS 37 0001]
301373 -
301374 -
301375 -
301376 -