CONTACTS 
0201 - Kaiser Permanente - Shadelands
020101 - Walnut Creek
020102 - Ms. Jeanne Bradley; Coordinator
020104 - Administration Department
0202 - Kaiser Permanente - Shadelands
020201 - Walnut Creek, CA
020202 - Mr. Mark Mangrai; 925 906 2209
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 -
1812 -    ..
1813 - Summary/Objective
1814 -
181401 - Follow up ref SDS 25 0000, ref SDS 20 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.
181411 -  ..
181412 - Sent ref DIT 2 0001 to Mark linked to review of letter from Bob Pearl,
181413 - per below. ref SDS 0 1176
181414 -
181415 -     [On 991103 follow up letter to Jeanne. ref SDS 35 5933]
181416 -
181417 -     [On 991109 received letter from Mark. ref SDS 38 0001]
181419 -      ..
181420 -     [On 991130 Jeanne provides feedback. ref SDS 40 0001]
181421 -
181422 -
181424 -  ..
1815 -
1816 -
1817 - Progress
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 19 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 20
181812 - 0001
181814 -  ..
181815 - Cite problem of "meaning drift", ref DIT 1 2548, which is explained in
181816 - the Sep 24 letter, as main target of opportunity to reduce medical
181817 - mistakes, also called the "telephone game" and management by guess
181818 - and gossip.
181820 -  ..
181821 - Key question for Jeanne...
181822 -
181823 -       How do we find people at Kaiser who can grasp both the problem
181824 -       and the opportunity to improve things? ref DIT 1 1640
181826 -  ..
181827 - We need a champion, an ambassador of change, like Jeanne has been with
181828 - SDS records, to look for people at Kaiser who are looking for this
181829 - solution.
181831 -  ..
181832 - After sending the letter to Jeanne, called and talked to Jeanne in the
181833 - afternoon.
181834 -
181835 -      [On 991123 Jeanne suggests talking to Tom Driscoll. ref SDS 39
181836 -      0001]
181837 -
181838 -      [On 991130 Jeanne sent follow up to Tom. ref SDS 40 0005]
181839 -
181841 -  ..
181842 - Mark Effective Advocate of Team Care Improvement with CEOs Office
181843 -
181844 - Jeanne was aware of my call to Mark this morning, and that he is
181845 - trying to set up a meeting on Team Care through Bob Pearl's office.
181846 - per below. ref SDS 0 0966
181847 -
181848 - She visited with Mark this morning after my call, and feels he is
181849 - anxious to make progress. because he is very organized and he sees the
181850 - value of Com Metrics to accomplish his vision of good management.
181852 -  ..
181853 - Jeanne said Mark has worked with the CEOs office on prior matters,
181854 - and so may be able to get support.  She does not have any contacts in
181855 - Pearl's office.
181857 -  ..
181858 - She will talk to Mark again on scheduling a meeting on Team Care,
181859 - based on contacting the Office of the CEO.
181860 -
181861 -    [On 991108 Jeanne plans to talk to Mark. ref SDS 36 0966]
181862 -
181864 -  ..
181865 - Meaning Drift -- Limited Span of Attention, Information Overload
181866 -
181867 - Jeanne has not had time to read the letter on medical mistakes
181868 - carefully.  When she scanned it a few weeks ago, her impression was
181869 - that the letter presents important ideas that are difficult to follow
181870 - because they are not discussed in daily work.
181872 -  ..
181873 - She asked to discuss a few key points for orientation to guide a
181874 - second read of the letter on medical mistakes. ref DIP 2 1680
181876 -  ..
181877 - Jeanne asked for an explanation of "meaning drift."
181878 -
181879 -      Meaning Drift is explained in the letter on medical mistakes as
181880 -      remembering incorrectly from paraphrasing to understand
181881 -      communication in our own terms, but succeeding iterations
181882 -      significantly change the original expression, illustrated by the
181883 -      "telephone game", ref DIP 2 4524  Meaning drift is explained in
181884 -      the New World Order... paper. ref OF 6 9449, reflecting the
181885 -      "fragility of knowledge" defined on 950204, ref SDS 5 0550, and
181886 -      initially came into the record on 960518, reviewing Landauer's
181887 -      paper on cognitive science, Plato's Problem. ref SDS 7 3734
181888 -
181889 -      "Ambiguity of mental maps" is a phrase Andy Grove uses in his
181890 -      book on his time as CEO of Intel, reviewed on 980307. ref SDS 12
181891 -      7571
181893 -         ..
181894 -        [On 991108 Jeanne noted an example of meaning drift.
181895 -        ref SDS 36 3968]
181897 -         ..
181898 -        [On 991108 poetry is an ancient technology to maintain
181899 -        alignment in a pre-literate culture. ref SDS 37 3596]
181901 -         ..
181902 -        [On 991130 meaning drift and cultural forces make communication
181903 -        the biggest risk in enterprise. ref SDS 40 4664]
181904 -         ..
181905 -      Being "confused" reflects meaning drift.
181907 -       ..
181908 -      Confusion generally means we feel uncertain from sensing the
181909 -      possibility of having commingled unrelated information.  We
181910 -      recognize the need for time and help to verify facts and
181911 -      associations in order to avoid a mistake, explained on 920808.
181912 -      ref SDS 2 0877
181914 -       ..
181915 -      An example is being in a meeting and saying something like...
181916 -
181917 -          Bill in accounting says the cost figures for the last quarter
181918 -          will be released next week, and they will show improvement.
181920 -       ..
181921 -      Someone else says...
181922 -          ..
181923 -          We got a memo two days ago saying the cost figures for
181924 -          the last quarter have been released and show no improvement.
181925 -          It said a new cost system will be online next week that is
181926 -          expected to show improvement so that future reports are not
181927 -          delayed.
181928 -      ..
181929 -      You then say...
181930 -
181931 -          Yes, that's right but I distinctly remember Bill saying
181932 -          something about improved figures for the quarter.
181933 -
181934 -          I guess I am confused.  We need to check with accounting
181935 -          again and review the memo.
181936 -      ..
181937 -      Someone else says...
181938 -
181939 -          Look!  I have the memo!
181940 -
181941 -          It says cost figures for last quarter cannot be produced due
181942 -          to a system failure, but the new cost system has been
181943 -          implemented that forecasts improved figures for next quarter.
181945 -       ..
181946 -      So each person remembered most of the same words, but they are
181947 -      arranged differently, which results in different meanings. Future
181948 -      recall will result in different word arrangements, as in the
181949 -      "telephone game" cited in the letter on medical mistakes.
181950 -      ref DIP 2 1680
181951 -
181952 -      "Confusion" arises from remembering words in slightly rearranged
181953 -      patterns that have nearly the same original meaning, but differ
181954 -      in some degree. Sometimes we feel unsure and say to ourselves and
181955 -      others that we are "confused."
181956 -      ..
181957 -      We feel confused because we recognize our "story" is not
181958 -      coherent and there may be conflicts.  The mind is wired to tell
181959 -      us to stop when our "story" seems inconsistent.  Confusion, then,
181960 -      is an innate Communication Metric we have to avoid mistakes.
181962 -       ..
181963 -      People in a meeting can help over come confusion based on their
181964 -      recall.  Often this devolves into heated exchange, that wanders
181965 -      off subject. When the original memo is not available to align
181966 -      communication, people argue about what it said and what other
181967 -      people say it said, going back weeks and months (see for example
181968 -      meeting at PG&E on 941209, ref SDS 4 7777; "confrontation" at
181969 -      Intel meetings reported on 970123, ref SDS 8 1111)  Everyone
181970 -      promises to check the contract, the memo and their notes, but
181971 -      often everybody has to go to another meeting, and so nothing is
181972 -      checked until a mistake occurs, as happened when the space probe
181973 -      crashed into Mars, rather than going into orbit around it and
181974 -      costing a loss of $125M, reported on 991025. ref SDS 26 0304
181975 -      ..
181976 -      People are driven by genetics to rely on speech in relating
181977 -      what they heard, rather than check the record, as explained in
181978 -      POIMS. ref OF 5 1265, and the NWO..., ref OF 6 5653  Inherent
181979 -      inaccuracy of speech causes the story to drift farther and
181980 -      farther from what is in the memo, in the contract, in the invoice
181981 -      and so on, explained on 991108 researching the history of
181982 -      transitioning from orality to literacy. ref SDS 37 7426
181984 -       ..
181985 -      Sometimes meaning drift is harmless because not every mistake
181986 -      impacts performance and earnings.
181988 -       ..
181989 -      A humorous example of meaning drift is...
181990 -
181992 -  ..
181993 -
181994 -                      "Operation Haley's Comet"
181995 -
181996 -
181997 -      ...from the military, reported on 970624. ref SDS 9 7006
181998 -
181999 -      The telephone game illustrates meaning drift in a benign setting,
182000 -      reviewed on 971229. ref SDS 11 1526
182001 -
182003 -       ..
182004 -      Communication is Biggest Risk in Enterprise
182005 -
182006 -      Follow up ref SDS 33 0001.
182007 -
182008 -      "Meaning drift," however, is more dynamic and harmful than either
182009 -      confusion or the "telephone game," because it happens on
182010 -      automatic pilot, as interplay between the conscious and
182011 -      subconscious mind outside our attention span.  In addition to
182012 -      rearranging words, meaning drift commingles by drawing on similar
182013 -      word patterns from different events, because they fit a momentary
182014 -      mental map the conscious span of attention assembles to tell a
182015 -      "story,"  As long as the mind assembles a coherent story that
182016 -      does not conflict with the context of the moment, for example,
182017 -      when there is no feedback that challenges the story, the mind is
182018 -      convinced of accuracy.  The mind has belief.  It does not feel
182019 -      confused and in need of help.  It feels secure!
182020 -      ..
182021 -      This false sense of security is called "false knowledge."
182022 -
182023 -          [On 991025 commingled two trips to Yosemite climbing Half
182024 -          Dome, as though they were a single trip. ref SDS 30 4260]
182026 -       ..
182027 -      Since we do not feel confused, we have no restraint on acting and
182028 -      urging others to act on what we strongly believe is true.
182030 -       ..
182031 -      Those who hear a convincing story and have no opposing context,
182032 -      acquire "false knowledge."
182033 -
182034 -      "False knowledge" is spread in meetings and calls and gets into
182035 -      documentation. gaining strength as the official view of reality
182036 -      until it encounters reality in the form of a mistake, a problem,
182037 -      a crisis, causing stress, loss and conflict, explained in the New
182038 -      World Order... paper as Murphy's Law. ref OF 6 9449
182039 -      ..
182040 -      Gaps in "meaning drift" widen as time passes, particularly
182041 -      when information flows increase, because there is much greater
182042 -      opportunity to assemble information incorrectly through
182043 -      commingling when there is a richer body of information from which
182044 -      to assemble incorrect stories that seem coherent, and when there
182045 -      is less time for the mind to sort out conflicts that alert people
182046 -      to feel confused and investigate.
182048 -       ..
182049 -      Information overload, therefore, increases meaning drift, and
182050 -      results in management by guess and gossip, because there is not
182051 -      enough time for anyone to check the original memo, as occurred in
182052 -      our example. ref SDS 0 9020
182054 -       ..
182055 -      These factors mean....
182056 -
182057 -
182058 -              communication is the biggest risk in enterprise
182059 -
182060 -
182062 -  ..
182063 - Alignment, Audit Trail, Solve Meaning Drift
182064 -
182065 - Jeanne asked for a solution to "meaning drift" defined above.
182066 - ref SDS 0 2800
182067 -
182068 - We reviewed...
182069 -
182071 -                           ..
182072 -                          alignment
182073 -
182074 -
182075 - ...is the simple explanation in the letter to Morris at Intel,
182076 - ref DIP 4 2346, sent on 991028. ref SDS 33 0001
182077 - ..
182078 - The larger explanation is using the SDS program that applies a
182079 - range of tools and practices to create and maintain alignment,
182080 - explained in the analysis of Drucker's new article, on 991025.
182081 - ref SDS 31 2846
182083 -  ..
182084 - Jeanne is familiar with the term...
182085 -
182086 -
182087 -                          audit trail
182088 -
182089 -
182090 - ...mostly used in accounting, but everyone knows it refers to keeping
182091 - track of root cause analyses, i.e., critical details about why things
182092 - happen.
182093 - ..
182094 - Alignment and audit trail embody a fancier phrase used in
182095 - management texts and standards...
182096 -
182097 -
182098 -                traceability to original sources
182099 -
182100 -
182101 - ...as for example in ISO 1006 reviewed on 950721. ref SDS 6 1740
182102 -
182104 -  ..
182105 - Com Manager Writes Important Things Down, Makes Connections of Context
182106 - Intelligence Goes a Long Way to Maintain Alignment for Team
182107 -
182108 - Jeanne asked if keeping communication aligned requires that everyone
182109 - has to write everything down every day?
182111 -  ..
182112 - I explained this is a big concern, as reported, for example, by Ross
182113 - on 910626. ref SDS 1 5822
182114 -
182115 -    The report on medical mistakes says an investment in a new role and
182116 -    new tools provides "intelligence" support for the team. ref DIP 2
182117 -    1403
182119 -     ..
182120 -    Common administration using a Patient Assistant or Advocate is one
182121 -    idea explained in the letter on reducing medical mistakes.
182122 -    ref DIP 2 2955
182124 -  ..
182125 - We reviewed the solution at PG&E and U.S.  Army Corps of Engineers
182126 - that found a Communication Manager is cost effective in providing
182127 - useful "intelligence," so everyone does not have to write everything,
182128 - yet the organization benefits from having a resource of shared
182129 - knowledge.
182131 -  ..
182132 - The U.S Army Corps of Engineers published a report on 970328, that
182133 - says "intelligence" support for managers is analogous to the role of
182134 - the CIA in analysing and summarizing important events for the
182135 - President of the United States every day. ref DRP 2 2022  Technology
182136 - has increased the past 50 years, making information overload more
182137 - widespread, so more people need "intelligence" support that maintains
182138 - alignment in order to avoid meaning drift.  Since everyone cannot
182139 - afford a big department, a new kind of technology is needed and new
182140 - skills to make it cost effective for more people to use intelligence
182141 - in daily management.
182143 -  ..
182144 - Communication Metrics provides these new tools, skills and roles that
182145 - enable people to use information productively, rather than be
182146 - overwhelmed by information overload.
182148 -  ..
182149 - A meeting with the U.S. Army Corps of Engineers in Washington D.C. on
182150 - 971202 explained a little "intelligence" goes a long way to build and
182151 - maintain shared meaning for everyone that avoids "meaning drift."
182152 - ref SDS 10 0838
182154 -  ..
182155 - Basically, the idea is to spread "intelligence" rather than guess and
182156 - gossip.
182157 -
182158 -
182160 -  ..
182161 - Training Communication for Effective Doctor/Patient Partnership
182162 -
182163 - We discussed the need to transition an organization toward
182164 - Communication Metrics by introducing change gradually.
182165 -
182166 - Jeanne likes the idea of doctor/patient communication training set out
182167 - in the letter on solving medical mistakes, ref DIP 2 2601, which was
182168 - originally posed in the record on 990625, ref SDS 14 5358, and more
182169 - recently on 990913. ref SDS 18 0844
182171 -  ..
182172 - An example of the need for training is the letter from Craig Boulris
182173 - on 991028, which explains scope of training. ref SDS 32 8499
182175 -  ..
182176 - Communication training is item 6 in the list of pending issues for
182177 - review of Kaiser in the record on 991008. ref SDS 27 0899
182178 -
182179 -     [On 991103 submitted letter on this. ref SDS 35 5933]
182180 -
182181 -     [On 991206 discussed with Tom Driscoll. ref SDS 41 2208]
182182 - ..
182183 - Good work habits and practices have to be reviewed regularly,
182184 - because bad habits flourish without regular reinforcement of good
182185 - habits. It's a lot like going to church.  People need reinforcement
182186 - and training to apply good practices for avoding "meaning drift,"
182187 - because it is a prevelant problem that is hidden from our attention,
182188 - and so makes....
182189 -
182191 -  ..
182192 -
182193 -            Communication the biggest risk in enterprise
182194 -
182195 -
182196 - ...explained in a letter to Intel, ref DIP 4 0001, submitted 991028.
182197 - ref SDS 33 0001
182199 -  ..
182200 - Here is the initial idea...
182202 -  ..
182203 - Once or twice a month a different doctor from the local facility can
182204 - lead a training session that has new patients and at least two other
182205 - doctors from the facility.  A facilitator can support the meeting to
182206 - ensure professional presentation.  Existing patients can attend to
182207 - explain communication issues and request assistance.  Patient
182208 - Assistance can attend to ensure follow up.
182209 - ..
182210 - A film can be produced showing typical scenarios to set up
182211 - discussion in the training class.
182213 -  ..
182214 - Having a doctor lead training on communication practices to implement
182215 - the guidelines in Kaiser's Healthwise Handbook, provides reminders and
182216 - reinforcement for the doctor to follow the guidelines, which are
182217 - currently not being used.
182219 -  ..
182220 - Doctors and patients work issues together.
182222 -  ..
182223 - In a facility with 15 or so doctors, this training will require
182224 - perhaps 5 - 10 hours per year in the evening, which means twice a year
182225 - conducting a training session, and twice attending as members of the
182226 - class, to contribute in guiding discussion.
182227 -
182228 - ..
182229 - Follow up...
182231 -  ..
182232 - Jeanne will review the letter on medical mistakes again in relation to
182233 - our discussion on meaning drift and alignment. ref SDS 0 2800
182235 -  ..
182236 - She will look for someone to champion Com Metrics at Kaiser.
182237 -
182238 -
182239 -     [On 991103 submitted letter on this. ref SDS 35 5933]
182240 -
182241 -
182242 -
182243 -
182244 -
182245 -
1823 -

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

3011 -
3012 - Progress
301301 -  ..
301302 - Contact Bob Pearl's Office about Meeting on Quality Team Care
301303 -
301304 - Follow up ref SDS 29 0001, ref SDS 28 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 28 0001, per
301309 - agenda on 991008. ref SDS 27 9055
301311 -  ..
301312 - Mark has still not heard from either doctor.
301313 -
301314 -     [On 991109 received letter from Mark. ref SDS 38 0001]
301316 -  ..
301317 - He next plans to send them the letters I have submitted that explain
301318 - issues to be reviewed, shown in the record on 991008. ref SDS 27 9055
301319 - ..
301320 - We considered the prospect that an effective meeting on team
301321 - care needs attention by people expressly assigned to formulate and
301322 - support the program.  Doctors with a patient load, must of necessity
301323 - give first priority to patients.  Like engineers who just want to work
301324 - on technology, reported on 990525, ref SDS 13 0966, doctors just want
301325 - to work on patients.  Recent articles on medical mistakes published
301326 - beginning on 990912 point out that busy doctors do not have time to
301327 - think about work process, ref SDS 16 0001, and often are unable to
301328 - admit problems because of concerns about personal competency.
301329 - ref SDS 16 3416
301331 -  ..
301332 - On 990625 Doctor Connolly advised doctors do not have to follow Kaiser
301333 - Guidelines on communication. ref SDS 14 1978 so it is understandable
301334 - that there isn't time for looking at policy issues at the practitioner
301335 - level.
301336 - ..
301337 - We discussed the letter from Bob Pearl, CEO of Kaiser,
301338 - ref DRP 6 0001, received on 991028, that points out doctors have
301339 - freedom to practice medicine the way it should be practiced.
301340 - ref SDS 32 2555  This freedom to focus on medicine is correct, but
301341 - means there is less time for doctors to look at management process
301342 - aimed at ensuring quality care.
301344 -  ..
301345 - Mark considered contacting the Kaiser IT department about meeting on
301346 - issues in the letter on 991008. ref DIP 6 0001
301348 -  ..
301349 - We reviewed the advantage of involving folks who formulate Kaiser's
301350 - Quality Team Care program, rather than IT people, for the first
301351 - meeting.
301353 -  ..
301354 - Mark requested a copy of the letter from Bob Pearl. ref DRP 6 0001
301355 - ..
301356 - He plans to call Bob's office and ask who can meet on issues of
301357 - quality team care.
301358 -
301359 - ..
301360 - Submitted ref DIT 2 0001 linked to the record on 991028 citing
301361 - Pearl's letter. ref SDS 32 0800   Sent a copy to Jeanne Bradley, per
301362 - above. ref SDS 0 1927
301364 -  ..
301365 - Cited my letter, ref DIP 6 0001, to Kaiser on 991008 setting the
301366 - agenda for a meeting on team care. ref SDS 27 9055
301368 -  ..
301369 - Explain Mark's efforts the past few months, including his report this
301370 - morning, ref SDS 0 0966, show that due a heavy patient load, doctors
301371 - do not have time to think about team care work process. ref SDS 0 2562
301372 - It also reflects freedom doctors have reported by Pearl in his letter
301373 - on 991028. ref SDS 32 2555
301374 -
301375 -     Above, Jeanne Bradley discussed this with Mark this morning and
301376 -     plans to follow up. ref SDS 0 0297
301378 -      ..
301379 -     [On 991109 Jeanne plans to follow up with Mark. ref SDS 36 0966]
301381 -      ..
301382 -     [On 991109 received letter from Mark. ref SDS 38 0001]
301383 -
301384 -
301385 -
3014 -