Need to "NOT" Know Basis

An approach to sharing confidential information in clinical organizations

In a recent conversation with CareOps about building clinical companies, we discussed the managerial and clinical challenge of information sharing: how to best share information efficiently, without causing distraction, overwhelm or harm? It turns out that regulating the flow of information through a company is an incredibly hard thing to get right, that gets increasingly harder as organizations grow.  Take Conway’s law, that organizations will design their products in such a way that ultimately their mirror communication patterns, as a warning that your communication patterns are not merely an internal problem. Even when you get people talking, you still have to watch out for the SNAFU principle, that communication between levels is inherently dishonest as retaliation is the essence of hierarchy.  

Given these cleverly titled frameworks, consider information sharing as a primary responsibility of senior leadership, because any remaining ambiguity will be resolved by the front line.  As you contemplate your approach to this challenge, consider your philosophical approach before deciding on tactics. Will you follow the historical default, hoarding information in all cases, hobbling your organization’s ability to adapt?  Will you instead follow the reactionary trend toward total transparency, which can quickly cause an organization to devolve into chaos?  Given these two extremes, let’s goldilocks this situation.

Too hard: Need to know basis

The old trope from every government/spy movie.  The general idea here is that information is to be hoarded, protected, only shared when deemed absolutely necessary.  Never mind that most leaders fail to specify which information is to be shared by whom or under what circumstances constitute necessity of its dissemination.  This is the province of bullies and narcissists and the toxic, politicized organizations they lead that feel more like fighting over a pile of loot than working together to solve a problem.  This system can work for a time in profitable organizations, seemingly too big to fail, but that have lost their builders and as such have very few people left who understand how the money was made in the first place.  This pervasive fear of loss results in leaders fighting each other to build empires and remain closer to the pile.  Yuck.  If you find yourself in this type of organization, get ready to fight like hell or just run.  Life is too short and the rewards too low for that kind of stress. 

If you are even considering implementing this approach, consider this conundrum: How could you possibly know enough about what everyone else does or needs to know to do their job, without being able to fully do their job AND knowing everything they know?  The sheer hubris of this approach should warrant it irrelevant if your goal is to make, build and/or improve.  Nevertheless, this closed approach seems to persist, so there is something stable about it. 

Too soft: Total transparency

Having grown up in “need-to-know” organizations, some disillusioned leaders go the opposite extreme, and resolve to “share everything!” While I applaud the sentiment, the transparency approach is fraught with peril.  First, sharing any information comes with decisions on timing, depth of detail, and investment in communication.  Do you put a short sentence in the bottom of an email newsletter or set up an entire company learning campaign?  How much detail is enough? When is the message lost in the details? You will open yourself up to accusations of breaking your communication promise despite your best efforts.  And this goes for both good or neutral news. 

How about the first time you have bad news such as losing a customer, firing an executive, layoffs, missed investment, behavioral misconduct, etc.  Leaders need time to process information so they can support their teams.  Some information should (or must, by law) be kept private for the dignity of those involved.  Your well intentioned promise, even fear of reprisal for breaking that promise, will hamper your ability to lead by properly contextualizing the information.

The pressure to keep the transparency promise can lead to a deluge of unprioritized, hasty, voluminous communication, inculcating anxiety and destroying focus.   As probably not Samuel Johnson said, “What is written without effort is in general read without pleasure.” Think social media levels of distraction. In summary, you’ve denied yourself planning, and constantly distracted your organization, plus you’ve made a promise you cannot possibly keep, because people will start criticizing you almost immediately.  Still want to be transparent?  

Now let’s turn this challenge to caring for patients. In the course of ordinary clinical work, we must rule out scary, low probability diagnoses. Sharing your differential diagnosis without context generates unnecessary anxiety, and possible harm in your patients. If you insist upon immediate, unlimited sharing of all medical information with no controls to your patients, prepare for an onslaught of resistance from your care teams.  Despite the challenges, I remain an incredibly strong advocate of sharing as much information as possible, as fast as possible, with patients.  So, how do we thread the needle in both corporate and patient communication?

Just right: Need to not know basis

Simply put, the transparency folks are correct in spirit, if not in practice.  Most information should be shared most of the time, with the style, detail and timing optimized for the audience.  Every now and again, at the well-reasoned discretion of leaders, information should be withheld so that it can be communicated appropriately–sometimes people need to NOT know things for their benefit.  In a healthy, well-run organization, leaders who abide by this rule will enthusiastically share good news and bad.  Their thoughtful approach to communication, unfettered by fear of breaking an unkeepable promise and tempered by experience, leads to trust in the organization.  

When implementing “need to not know,” the burden falls on those wishing to keep information secret, which is much less work than constantly justifying why information should be shared.  Sharing information is the organizational default, but not the only option for leaders and clinicians. Simply ask yourself prior to communications, “is there anyone who needs to NOT know this information?”  Generally the answer to that question results in disciplined communications planning, a tremendous strength, rather than outright secret keeping.  These decisions can be built right into management processes and software.  For example, all clinical notes could be shared with patients by default, with an option to hide clinical notes on a case-by-case basis.

Given the temptation to revert to information hoarding, the organization must hold leaders accountable, with cross-leadership accountability as crucial for remaining trustworthy.  When the specter of harm is raised in justification for secrecy, those concerns should be validated where possible and examined retrospectively.  The organization builds trust because promises are kept in line with expectations around sharing (mostly, but not all the time).  Irrelevant distractions can be minimized because there is no compulsion to share everything to uphold an impossible standard.  It isn’t perfect, but sharing by default with the expectation that secrets will be kept from time to time is the best worst solution to keep information flowing, while retaining oversight and empathy for your audience.