CONTACTS 
0201 - Philidelphia Daily News
020101 - Ms. Andrea Gerlin; Reporter

SUBJECTS
Medical Practice Requires Records
Privacy, Security - Discovery
Risk Communication Main Factor of Management Success
Rework Cycle Due to Miscommunication
Risk Management Communication Main Task of Managers, Largest Risk
Telephone Game Shows Meaning Drift, Need to Maintain Shared
Communication Biggest Risk Most Time of Managers
90% Managers Time Communication
Crisis Management, Action, Feels Better than Proactive Discovery
Meaning Drift Verbal Communication Error Prone
Competence Challenged by Com Metrics
Denial Managers Making Mistakes Reject Savings

2514 -
2514 -    ..
2515 - Summary/Objective
2516 -
251601 - Follow up ref SDS 55 0000, ref SDS 45 0000.
251602 -
251603 - Author of articles reviewed on 990912 explaining mistakes in medicine
251604 - might consider citing information overload that causes meaning drift,
251605 - as evidenced by the telephone game; and, further, balancing coverage
251606 - by reporting that there are more mistakes in law, construction,
251607 - manufacture, journalism, technology and so on, ref SDS 55 4680,
251608 - because executives in all fields like to work by conversation, and
251609 - communication is the highest risk factor in human endeavors, as
251610 - reviewed on 951212. ref SDS 9 4433
251612 -  ..
251613 - Submitted ref DIT 1 0001 to Andrea, citing...
251614 -
251615 -          [On 990930 received letter from Andrea. ref SDS 58 0001]
251616 -
251617 -          [On 991007 notified Intel single biggest cause of mistakes is
251618 -          communication, meaning drift. ref SDS 62 0001]
251620 -           ..
251621 -          [On 991008 sent letter to reporter on NASA space craft
251622 -          crashing on Mars. ref SDS 63 0001]
251624 -           ..
251625 -          [On 991008 sent follow up to Andrea. ref SDS 64 0001]
251627 -           ..
251628 -          [On 991206 added to publications on Welch Home page.
251629 -          ref SDS 71 1542]
251631 -           ..
251632 -          [On 991207 President Clinton announces national initiative to
251633 -          reduce medical mistakes. ref SDS 72 0889]
251635 -           ..
251636 -          [On 041125 AHRQ publication confirms high cost of medical
251637 -          mistakes caused by communication errors offers 20 tips to
251638 -          reduce. ref SDS 92 SD6N
251640 -       ..
251641 -      Aristotle in 400 BC explained the cause of big mistakes are
251642 -      little deviations that go unnoticed, ref DIT 1 1680, cited in NWO
251643 -      paper, ref OF 7 0520, and are caused by...
251644 -
251645 -                          meaning drift
251646 -
251647 -      ...commonly illustrated by the "telephone game," see below.
251648 -      ref SDS 0 3955
251650 -           ..
251651 -          [On 991001 space craft crashed due to little mistake in the
251652 -          beginning that went unnoticed. ref SDS 60 3192]
251654 -       ..
251655 -      Communication is biggest risk in enterprise, ref DIT 1 1680,
251656 -      because the genetic drive to take immediate action using talking
251657 -      and listening, explained in POIMS, ref OF 5 5106, cause continual
251658 -      bumbling, explained in NWO... ref OF 7 9449  Email is less
251659 -      accurate than conversation, shown by analysis below. ref SDS 0
251660 -      0715 Reflects communication is 90% of the work, and managers
251661 -      waste 70% of the day in unproductive meetings, reported on
251662 -      960205. ref SDS 10 5902
251663 -
251664 -          [On 000207 doctors need help on medical management.
251665 -          ref SDS 79 5568]
251667 -           ..
251668 -          [On 000420 engineers who created tools to connect information
251669 -          don't use it because fast and easy to use email is seductive.
251670 -          ref SDS 81 4911
251672 -           ..
251673 -          [On 080911 article reports many medical mistakes occur from
251674 -          mental errors by doctors involving communication.
251675 -          ref SDS 94 PD7F
251677 -       ..
251678 -      Communication is predicate to action, transfers and defers impact
251679 -      of information not aligned with requirements, reported on 970524
251680 -      in case study linking thousands of communications over 10 years
251681 -      that showed Columbia Space shuttle disaster in 1986 was caused by
251682 -      small problems that grew due to "telephone game." ref SDS 15 7298
251684 -       ..
251685 -      Same point was made by Wayne Wetzel on 940820 that communication
251686 -      defers and transfers responsibility for mistakes to others.
251687 -      ref SDS 5 5588
251689 -       ..
251690 -      Telephone game from the record on 971229, ref SDS 22 1526, is a
251691 -      humorous example of "meaning drift," presented in first para.
251692 -      ref DIT 1 6048  Humorous example is Haley's Comet on 990624.
251693 -      ref SDS 16 7006  On 990303 George Miller's seminal work in
251694 -      cognitive science explains scientific basis of meaning drift
251695 -      occurs from human re-coding information to aid memory.
251696 -      ref SDS 30 2838
251697 -
251698 -          [On 991007 letter to Dave Vannier at Intel cites "meaning
251699 -          drift" as major cause of mistakes and failure in business,
251700 -          leading to the paradigm shift of the millennium. ref SDS 62
251701 -          7920]
251703 -           ..
251704 -          [On 991101 explain "meaning drift." ref SDS 68 0857]
251706 -           ..
251707 -          [On 991207 notified Morris at Intel. ref SDS 73 0001]
251709 -           ..
251710 -          [On 991221 study shows doctors do not communicate adequately
251711 -          with patients 90% of the time. ref SDS 75 0001]
251713 -           ..
251714 -          [On 000211 comedy of errors in medical practice. ref SDS 80
251715 -          3600]
251717 -           ..
251718 -          [On 000724 Professor Randsell suggests using telephone game
251719 -          to illustrate problem of deviations from truth set out in
251720 -          NWO... ref SDS 83 1974
251722 -       ..
251723 -      Execution of good management fails, ref DIT 1 2028, per Fortune
251724 -      article reviewed on 990625. ref SDS 36 7344
251726 -       ..
251727 -      Competence:  fear of being criticized, not promoted, losing
251728 -      credibility, reputation, standing, losing a job, all impact
251729 -      personal livilhood, and so prevent executives, doctors, engineers
251730 -      and other professionals from admitting they need help.
251731 -      ref DIT 1 6048 and ref DIT 1 3933  Report on 990912 that doctors
251732 -      cover up mistakes due to fear about competency. ref SDS 55 3416
251733 -      Another example is USACE on 971017. ref SDS 21 4814  Reflects
251734 -      analysis on 960828, ref SDS 12 KP4N, later on 980405, ref SDS 25
251735 -      5065, and more recenlty the review of Christensen's book
251736 -      "Innovator's Dilemma" on 990527, see...
251737 -
251738 -            On 960924 strong leadership calls for pilot testing that
251739 -            enables people to overcome ignorance, fear and denial,
251740 -            making it possible to discover organizational memory is a
251741 -            benefit that does not threaten competence. ref SDS 13 9A9O
251743 -             ..
251744 -            Attitude and common sense prevent pilot testing, on 990527.
251745 -            ref SDS 33 9711
251747 -             ..
251748 -            Organizational culture inhibits pilot testing on 990527,
251749 -            ref SDS 33 0703, and strong cultural forces prevent
251750 -            improving management. ref SDS 33 1233
251752 -           ..
251753 -          [On 991216 fears about competence cause charges of arrogance
251754 -          to combat trying Com Metrics. ref SDS 74 0902]
251756 -           ..
251757 -          [On 000106 similar point made about arrogance. ref SDS 78
251758 -          8712 and also ref SDS 78 0877]
251760 -           ..
251761 -          [On 010321 added fear about competence to POIMS. ref SDS 84
251762 -          RM4H
251764 -           ..
251765 -          [On 010608 DCMA supports continual learning to strengthen
251766 -          competence. ref SDS 88 IB7I
251768 -       ..
251769 -      Information overload, CBS news on 980412. ref SDS 26 0001
251771 -       ..
251772 -      Nobody has time to think, on 970910. ref SDS 19 3479
251774 -       ..
251775 -      Speech is genetically driven, ref DIT 1 4524, per POIMS.
251776 -      ref OF 5 5106 -- see also below on "attitude" and "culture" to
251777 -      rely on conversation, talk is fast and easy. ref SDS 0 3966
251779 -       ..
251780 -      Alphabet technology, ref DIT 1 5162, shows method developed to
251781 -      avoid mistakes.
251783 -       ..
251784 -      On 931130 Drucker advocates need for analysis. ref SDS 3 7911
251785 -
251786 -         [On 991010 Gutenberg credited with expanding power of alphabet
251787 -         technology. ref SDS 65 3056]
251788 -
251789 -         [On 991025 Drucker's article calls for analysis. ref SDS 66
251790 -         5888]
251792 -          ..
251793 -         [On 991108 history of writing shows it evolved to improve oral
251794 -         communication by adding analysis. ref SDS 70 7048]
251796 -          ..
251797 -         [On 991108 cultural forces ignore literacy and insist on
251798 -         reliance on oral communication. ref SDS 70 7520]
251800 -       ..
251801 -      Nobody has time to follow procedures. ref SDS 35 4620
251803 -       ..
251804 -      Cognition must be helped to fix telephone game of meaning drift.
251805 -      ref DIT 1 4160
251807 -       ..
251808 -      Downsizing leads to larger case loads, limited time causes more
251809 -      mistakes, like battlefield conditions. ref DIT 1 1445 Report on
251810 -      990625 shows doctors do not have time to follow good practice.
251811 -      ref SDS 35 2652
251812 -
251813 -         [On 991028 Robert Pearl, CEO of Kaiser, says doctors have
251814 -         "freedom" to practice medicine as it should be practiced,
251815 -         which conflicts with large case loads. ref SDS 67 2555]
251817 -       ..
251818 -      Fortune article reviewed on 990625 explains that CEOs refuse to
251819 -      execute good management because of personal "preference," driven
251820 -      by "psyche." ref SDS 36 4914
251822 -       ..
251823 -      Crisis management permits people who do not want to be
251824 -      responsible for analysis, organization and alignment to work by
251825 -      conversation, ref DIT 1 2904, since there isn't time for good
251826 -      management practices.  Indulging this preference without a crisis
251827 -      is laziness and hubris, reviewed in Fortune article on 990625.
251828 -      ref SDS 36 7848
251830 -       ..
251831 -      Emergency medical treatment is the classic example of continual
251832 -      crisis management dominated entirely by doing things without
251833 -      investing time for thinking and planning. ref DIT 1 5923
251834 -
251835 -
251836 -
2519 -

SUBJECTS
Medical Management Needs SDS Tools Patient Assistant New Professiona

4303 -
430401 -  ..
430402 - Patient Assistant Improves Communication Doctors Patients
430403 - Communication Doctor Patient Fails Causes Case Management Failure
430404 - Treatment Fails When Patients Don't Understand Scope of Care
430405 -
430406 -
430407 -      Medical practice needs a Patient Assistant role with tools to
430408 -      help doctors and patients capture an accurate, comprehensive
430409 -      record of medical history (reported on 990625, ref SDS 35 0899),
430410 -      and follow up to ensure actions align with objecties,
430411 -      requirements, and commitments.  Tools and roles leverage skills
430412 -      and optimize time to provide quality care at less cost.  The new
430413 -      world order of mind numbing complexity occurs from compressing
430414 -      time and distance (see NWO, ref OF 6 1675).  More patients,
430415 -      regulations, procedures, technologies, stakeholders, and layers
430416 -      of organization, i.e., bureaucracy. impact patient care, because
430417 -      people get mixed up in constant meetings, calls, and documents.
430418 -      Little details slip through the cracks, causing delays, errors,
430419 -      and omissions.  Successful medical practice that extends life
430420 -      increases complexity of patient history.  Advancing complexity of
430421 -      modern health care requires a new player with tools that make
430422 -      sense of complexity by "connecting the dots" in time to be
430423 -      effective. ref DIT 1 2955
430424 -
430425 -            [On 041125 HHS article published by AHRQ agency for quality
430426 -            medical management cites emerging challenge that complexity
430427 -            rising in modern health care causes errors and omissions in
430428 -            medical practice. ref SDS 92 JF5V
430430 -             ..
430431 -            [On 080911 article reports many medical mistakes occur from
430432 -            mental errors by doctors involving communication.
430433 -            ref SDS 94 PD7F
430435 -       ..
430436 -      We are gridlocked in a loop of fear and denial that resists
430437 -      improvement. ref DIT 1 1Y96
430439 -       ..
430440 -      A new player with new tools is the only way to transcend gridlock
430441 -      by adding "metrics" to daily communication.  Otherwise, mistakes
430442 -      will proliferate due to rising information density that
430443 -      overwhelms span of attention with complexity.  In chaos theory,
430444 -      when order is maintained complexity creates positive synergy
430445 -      among multiple contributors that significantly leverages
430446 -      productivity.  Without order (i.e., rising entropy), complexity
430447 -      drives negative synergy (see NWO, ref OF 8 RO6G) that degrades
430448 -      productivity toward zero under the second law of thermal
430449 -      dynamics. ref DIT 1 P553
430451 -          ..
430452 -         [On 030123 any big project that starts behind schedule
430453 -         presents a crisis mentality to take short cuts on good
430454 -         management that increases problems creating perpetual crisis
430455 -         management which escalates delay, extra cost and harm to
430456 -         people. ref SDS 90 Y55G
430458 -       ..
430459 -      Adding roles and tools for intelligence support significantly
430460 -      strengthens the doctor/patient partnership that improves care
430461 -      with less time and expense, because "connecting the dots" of
430462 -      cause and effect converts information into the power of knowledge
430463 -      (see NWO, ref OF 8 I38N) that controls the future.  This avoids
430464 -      meaning drift to reduce mistakes and costs.  To some
430465 -      "intelligence" sounds funny and alien; to others new roles and
430466 -      tools seem like unnecessary overkill.  Only strong leadership can
430467 -      pioneer a path to a better future. ref DIT 1 6G85
430468 -
430469 -            [On 080911 article reports many medical mistakes occur from
430470 -            mental errors by doctors involving communication.
430471 -            ref SDS 94 PD7F
430473 -       ..
430474 -      Grove's book on writing copious notes. ref SDS 24 3668
430476 -       ..
430477 -      Meaning is in constant flux in human mind. ref SDS 11 4488
430479 -       ..
430480 -      Bumbling is continual, on 990127. ref SDS 29 7399
430482 -       ..
430483 -      Guidelines for effective communication, 990625. ref SDS 35 4620
430484 -
430485 -
430486 -
4305 -

SUBJECTS
Email Accuracy Less than Conversation Killer Application Communicati

4403 -
440401 -  ..
440402 - Email Leaves Words Out Conveying Opposite Meaning Kills Collaboration
440403 - Email Weak Business System Less Accurate Conversation
440404 - Killer Application Continual Bumbling Email Kills Productivity
440405 -
440406 - Email is a popular killer application because it seems to be free and
440407 - provides a fast easy way to send documents with broad distribution.
440408 - On 960927 Dave Vannier said that email was one of the best business
440409 - systems at Intel; though listed as #3, rather than the top system.
440411 -  ..
440412 - POIMS lists weaknesses of email. ref OF 5 CZ6K
440414 -  ..
440415 - Email stream-of-conscious rendering lacks alignment so is less
440416 - accurate than speech through conversation and dialog in meetings and
440417 - calls. ref DIT 1 1045
440419 -  ..
440420 - Email practice routinely leaves words out, which conveys the opposite
440421 - of intended communication.  This kills collaboration and coordination.
440422 - People go in opposite directions rather than take complementary
440423 - action, explained in NWO. ref OF 7 IH7L  This makes email a killer
440424 - application which kills productivity. ref DIT 1 X57L  Even if someone
440425 - proofreads a letter before transmission, the mind's ability to read
440426 - past mistakes to "read" what was intended, rather than what was
440427 - written, makes the risk of error very high.
440428 -
440429 -          [On 010408 Gary's letter reviewed weaknesses of email.
440430 -          ref SDS 85 9H8H
440432 -           ..
440433 -          [On 030415 further explains problem that words are omitted
440434 -          using email, and even proofreading does not solve the
440435 -          problem, reported today, that is addressed by new SDS
440436 -          software feature that strengthens proofreading. ref SDS 91
440437 -          PY4W
440439 -  ..
440440 - This makes communication the biggest risk in enterprise, cited above.
440441 - ref SDS 0 5576
440443 -           ..
440444 -          [On 991001 email caused Nasa probe to crash on Mars.
440445 -          ref SDS 60 3077
440447 -           ..
440448 -          [On 991108 accuracy factual expression not primary objective
440449 -          of speech; conversation and dialog require continuity for
440450 -          stream-of-conscious presentation attract attention, persuade
440451 -          for leadership toward normative views through entertainment,
440452 -          comity, and exaggeration. ref SDS 70 4505
440454 -           ..
440455 -          [On 991227 example in medical management. ref SDS 76 9844]
440457 -           ..
440458 -          [On 991230 example from author. ref SDS 77 7840]
440460 -           ..
440461 -          [On 000505 email proposed as core of KM. ref SDS 82 4392
440463 -           ..
440464 -          [On 010411 history of email causing poor productivity.
440465 -          ref SDS 86 936T
440467 -           ..
440468 -          [On 010426 Pat Lincoln explains email for software
440469 -          engineering has structure and metrics that reduce meaning
440470 -          drift. ref SDS 87 QY5G
440472 -           ..
440473 -          [On 030415 developed SDS feature to render SDS records in
440474 -          HTML for proofreading with a different appearance that helps
440475 -          the mind avoid overlooking omitted words. ref SDS 91 0001
440477 -           ..
440478 -          [On 070302 example doctor writes 4 times daily, but intended
440479 -          3 times, because there is no feedback loop in the
440480 -          communication process. ref SDS 93 FN5M
440482 -       ..
440483 -      Feel Good management on 911123. ref SDS 1 1331
440485 -       ..
440486 -      Not telling the truth on 950412. ref SDS 7 3920
440488 -       ..
440489 -      Intelligence in POIMS. ref OF 5 0582
440491 -       ..
440492 -      Patient Advocate concept developed from visiting Kaiser on
440493 -      990625, ref SDS 35 0899, is set out. ref DIT 1 2955
440494 -
440495 -          [On 991006 submitted to Kaiser. ref SDS 61 7280]
440497 -       ..
440498 -      Common Administrator from 990328. ref SDS 31 9641
440500 -       ..
440501 -      Attitude and culture of denial uses feel good management, need
440502 -      leadership, ref DIT 1 2904, per analysis on 990912. ref SDS 55
440503 -      3416
440505 -       ..
440506 -      Loath changing work practice, ref DIT 1 7650, per Grove on
440507 -      980307. ref SDS 24 1657
440509 -       ..
440510 -      CEOs and everyone rely on conversation, ref DIT 1 1596, 990924.
440511 -      ref SDS 57 2479 -- because speech is genetically driven, per
440512 -      above. ref SDS 0 0279
440514 -       ..
440515 -      Conversation is fast and easy, ref DIT 1 4833, on 950426.
440516 -      ref SDS 8 4392
440517 -      ..
440518 -      Email is weakest application of technology for management,
440519 -      since it is very similar to conversation. ref DIT 1 1045  On
440520 -      990909 Bill DeHart explained weaknesses of email at PG&E.
440521 -      ref SDS 53 8112
440522 -
440523 -          [On 991001 email likely caused $125M loss of space probe that
440524 -          crashed on Mars. ref SDS 60 3077]
440526 -           ..
440527 -          [On 000505 email cited as core KM capability. ref SDS 82 4392
440529 -       ..
440530 -      Problem handling, ref DIT 1 1596, cited Ross at IBM on 980808.
440531 -      ref SDS 27 4140,
440532 -      ..
440533 -      Rework cites USACE report on 971007, ref DRP 2 4680, shown
440534 -      at ref DIT 1 1596.
440535 -
440536 -         Cost of rework is reported on 971008. ref SDS 20 2710
440538 -       ..
440539 -      Explain cover up and avoiding accountability from POIMS.
440540 -      ref OF 5 4079
440541 -      ..
440542 -      Training communication medical practice, ref DIT 1 2601,
440543 -      developed on 990625, ref SDS 35 5358, based on unique conditions,
440544 -      of medical practice. ref SDS 35 9772
440546 -       ..
440547 -      Partnering in medicine. ref SDS 35 5358
440549 -       ..
440550 -      Managing the doctor on 990927. ref DIP 2 0001
440551 -
440552 -         [On 991103 submitted proposal to Kaiser. ref SDS 69 5933]
440554 -       ..
440555 -      Leadership on 970703. ref SDS 17 9603
440557 -       ..
440558 -      Explain commitment from discussion with Morris on 990817.
440559 -      ref SDS 52 6829
440560 -
440561 -
440562 - ..
440563 - Contra Costa Times has a web site....
440564 -
440565 -
440566 -                      http://www.hotcoco.com
440567 -
440569 -  ..
440570 - They also have an email address...
440571 -
440572 -
440573 -                      hotcoco@cctimes.com
440575 -  ..
440576 - Called Contra Costa Times Editor, John Armstrong
440577 -
440578 -                        925 943 8377
440579 -
440580 - ...however, reached Sandra Kayes office, who is the managing editor,
440581 - and talked to Beverly, a research person.
440582 - ..
440583 - Asked to contact...
440584 -
440585 -      Andrea Gerlin is a staff writer for Knight Ridder Newspapers.
440587 -  ..
440588 - She does not work for Contra Costa Times.
440590 -  ..
440591 - Beverly will try to get an email address and a phone number for
440592 - Andrea.
440593 -
440595 -  ..
4406 -
4407 -
4408 - 1321
4409 -
440901 - Beverly called back.       925 952 2626
440902 -
440903 - She works in news research.
440904 -
440905 -    [On 990930 submitted letter to Beverly and Gail. ref SDS 59 0001]
440907 -  ..
440908 - Andrea Gerlin is at...
440909 -
440910 -               Philidelphia Daily News
440911 -
440912 -               agerlin@phillynews.com
440913 -
440914 -               215 854 4531
440915 -
440916 -
440917 -
440918 -
440919 -
440920 -
4410 -