Veterans Hospitals Systemic Problems
Veterans Administration Healthcare Scandal
Project Report on Hospital Systemic Failures
(A Congressional Report Sponsored by Lara Publications, St. Louis, MO)
The V.A. hospitals problem is not a V.A. problem as much as it is a nationwide endemic problem in hospitals and healthcare facilities due to systemic failures across the nation.
The management of the healthcare system in the U.S. across the nation is badly damaged beyond repair. The obstacle placed by those who want to make money, spilling the blood of innocent patients including Veterans, is one of the critical factors. The problem has been endemic in hospitals and other healthcare facilities across the nation for many decades. What has just been exposed in relation to the V.A. Hospitals patients’ neglect of care is very common in health institutions that are designed to generate an increase in revenue at the expense of killing patients. Studies have indicated that hospitals which make medical errors, are being handsomely compensated while removing the incentives to fix systemic failures and improve the quality of patients' care. Some hospitals are performing unnecessary procedures on patients for the sake of increasing their revenue. Patients are dying in the process.
A USA TODAY study found that tens of thousands of times each year, patients undergo surgery they don't need.
Doctors at Halifax Health accused of performing unnecessary surgeries.
Doctors Perform Thousands of Unnecessary Surgeries: Are You Getting One of Them?
Unfortunately, those endemic management problems and greed have spilled over to into the V.A Hospitals system.
KILLING VETERANS IN V.A. HOSPITALS FROM UNNECESSARY SURGERY AND CANCER PROCEDURES, reported to Senator Bill Nelson recently.
The V.A.'s troubled history.
100,000 veterans face long waits to see V.A. doctors.
With these painful revelations, there is hope that the exposure will motivate both, the judiciary executive and the legislative branch of the government to do something about the staggering number of preventable medical errors killing thousands of patients every year in American hospitals, including veterans. The V.A. hospitals alone are not an exceptions - our inability to change the status quo because the “business man” wants to make money, is the reason for the current state of healthcare facilities. The increase of medical errors across the nation is an indication of continuous systemic failures of hospitals' administration.
Veterans' Malpractice Claims On the Rise: Settlements and court judgements have cost taxpayers $845 million since 2003.
These problems are not fixable no matter how much money we throw at them until we are poised to fix endemic systemic failures in hospitals, as well as the code of silence instituted to keep employees quiet. We have either been unable or we have refused to deal with such matters so far, and they are now spilling into the V.A. hospitals' system. Should we be surprised? The major issue is not about bad medicine (even though it must be a part of it), as much as it is about bad management being praised as long as the hospitals increase revenues. This management problem is now manifesting in V.A. hospitals in another form, leading to the neglect of patient care. At certain point in life, we have to draw the line whether making money is more important than giving quality of care to save lives. As long as our priority is to make money instead of caring for patients, people will continue to die needlessly and anyone could be a victim!
Hospitals' medical errors are now the third leading cause of death in the U.S.
In 1999 the IOM (Institute of Medicine) reported about 98,000 preventable patient deaths annually due to medical errors. Today, some studies are reporting as high as 200,000 of them. Has the problem gotten better after the government spent an estimate of over $100 million annually fighting medical errors for the past 15 years? If the money spent by the government equals $1.5 billion, why is nobody raising a red flag since the medical errors killing patients have actually increased over the years? The systemic failure issues have gotten worse because harming and killing patients are made more profitable for healthcare institutions! The problem that's plaguing hospitals across the nation and preventing them from fixing systemic failures, is the same as the one plaguing the V.A. hospitals. The issue of management failures manifesting in V.A. hospitals happens partly because those working on the front line of care are never given the opportunity to help solve the problems. When research grants were given to academicians and healthcare leaders with no clue about what was happening on the front line of care, a solution could never be found. Some of the problems were even multiplied. Sister Jean Ryan, formerly the network CEO of SSM Hospitals System in St. Louis. MO., designed a committee approach chaired by those working on the front line of care which served as a very effective way to solve systemic problems in hospitals across the nation. However, many hospital executives refused to support such an initiative, let alone adopt it. I worked on the project with Sister Jean Ryan for 5 years and the project led to the report being sent to The White House, Department of Health and Human Services and the Congressional sub-committee on health – 101 Ways to Prevent Medical Errors in 2002. Even in the hospital where it started, the enthusiasm about the program was said to have slowed down since Sister Jean Ryan left the hospital's system. When the quality improvement program diminished, more systemic failures emerged with an increase in medical errors and kept leading to the continuation of patients’ deaths.
In most of the hospitals across the nation, there is an unspoken "code of silence” about systemic failures and errors, and "a code of denial". Any employee who violates any of these codes of silence is severely dealt with or fired, and may lose the opportunity to work in hospitals in the immediate social environment. Many of the hospital employees know about these codes. I was one of those managers who kept the code of silence and was later victimized by them. The slogan in some hospitals is "I don’t see, I don’t hear, the problem goes away." A lot of times the problems ended up killing many innocent patients. Take the case of a quality improvement officer who warned about procedure problems in a hospital lab, and was later disciplined and suspended because he was working hard to fix systemic failures. A couple of years after he resigned, a lab worker used the same procedure book and made a mistake leading to the death of a patient. This story was documented in chapter #29 of the book, “Closer Walk with Jesus”, published by Lara Publications in 2010. The book educates people about the serious management crises in many of the healthcare facilities today. The V.A. hospitals are not an exception since healthcare institution managements affect each others with style and problems alike.
Sadly, instead of fixing systemic failures raised by employees who want to resolve the problems within the hospital system, many of them were fired and those who created those problems were promoted as good employees. It is not by accident that employees who "cooked the books" were given raises in V.A. hospitals because they made the problem go away by giving false reports. This is an endemic problem in hospitals across the nation allowing the increase of medical errors kill patients.
When workers raise and pursue legitimate issues of concern for many years and fall on the deaf ears of hospital management, after a while a character of “whistle-blower” will eventually emerge. A former employee becomes a “whistle-blower” to expose irregularities within the institutions hurting patients. For many years hospital management problems haven't been addressed, let alone mentioned in the public as an issue leading to medical errors. The consequences of such problems are now observed to be manifesting in V.A. hospitals' management crises.
Another reason why we have not been able to solve systemic failure problems in healthcare facilities, is because the healthcare system changed from "mission of mercy", named after Christian saints to a "business for the greedy." The death of patients in hospitals due to an assembly line medicine is caused by greed and a relentless desire to make money at the expense of killing patients.
The Economics of Health Care Quality and Medical Errors:
Profits from medical errors:
When I first reported the problem in 1993, many media outlets refused to review my book even though I succeeded in getting a few radio stations to discuss the issues. Most of the media resources, including newspapers, refused to review a book that addresses medical errors because of their fear of losing advertisement revenues from hospitals. So, to My Dear Beloved Americans, the problem persisted and patients continue to die at an alarming rate, and anybody can be a victim, even you, or your loved ones! Even as a healthcare worker, I have been a victim of medical errors, my son and my wife, being a nurse, have been victims too. My father who was a healthcare worker died of untreated septicemia at the age of 60. Many people who have used healthcare services have been victimized by medical errors, unaware of it. Consider two million patients' deaths annually in hospitals caused by nosocomial infections. http://www.rightdiagnosis.com/n/nosocomial_infections/stats.htm
I want people to realize that the problem of management within the V.A. healthcare systems is not new – it has just become exposed. We are all at the mercy of the business man who wants to make money at the expense of killing people! This pathology is becoming popular today! Only the government can stop this madness, otherwise the death rate will continue to rise!
I’m not convinced that any internal investigation within the V.A. hospital system will yield credible information leading to problem identification of systemic failures and solution implementation. An independent team of private investigators or another branch of government investigators of the problem might be more helpful. This group would be given power to move very quickly to identify problems through "credible root cause analysis", design solutions, pilot test solutions, identify positive outcomes, and immediately implement the corrective actions and continue to monitor the results to sustainable positive outcomes. This can rapidly be done by those with experience in hospital quality improvement, who understand how the system had failed from the perception of front lines working directly with patients. Front line workers are more adept in the operational failures of the system compared to people pushing pen and sitting in comfortable office with no clue about the problems, let alone have ideas about solution intervention. The principle of Continue Quality Improvement in Hospitals, as designed by Sister Jean Ryan formerly of the SSM System, should be considered for implementation. The problem deactivated the power of managers and supervisors from sabotaging the process of quality improvement. If Continuous Quality Improvement - CQI, is implemented in all the V.A. hospitals across the nation, employees will be free to report problems and systemic failures without fear of being punished by the administration. Subsequently, hospital improvement would come very swiftly. However, if the problem is given to a giant celebrity, as it often happens, that person would fall into the same hole as the previous head of the V.A. hospitals' system. That person would spend the next couple of years trying to identify the problems and another couple of years to understand them and design solutions. You cannot fix what you do not understand! I have worked on these problems across the nation for 38 years and I know where they are and how to move the system to respond. Hospitals are made up of interrelated departments, working mainly in disharmony. Ego driven and all kinds of professional arrogance make solution intervention extremely difficult. Quality improvement empowered by the hospital
administration has been effective as long as it has been operated by front line workers. Poor inter-departmental communication within hospitals is another great obstacle to fixing systemic failures between departments. However, if the CEO of the hospital is unwilling to support the quality improvement initiative, the problem remains. That is what we observe today with the V.A. hospitals – a collection of systemic failures.
Dark Secrets in the Healthcare System
Sadly, many people looking at medicine from outside of the healthcare industry may be deluded thinking that physicians are the ones running the American healthcare system inside hospitals. Nothing could be further from the truth - hospital business managers run the present healthcare system, many of whom without any medical training. Even the ones with medical training have been poisoned by the gold rush of making money at the expense of killing more patients. Whosoever runs the system, has the power to control and has a direct impact over the practice of medicine, including staffing in hospitals. Consequently, hospital business managers have a greater direct impact on the quality of care than physicians. People who actually influence the quality of care are the business managers with MBA, not the MD. This is another serious issue that has been plaguing the healthcare industry for years – the MBAs have more influence over the clinical outcome of patients in many healthcare institutions than the MDs.
Both the MBAs and MDs have contributions to the quality of care. The desire to control cost by business managers should not be ignored. Such a reduction of cost should target an enormous, wasteful, endemic spending in many hospitals across the nation. Since the business managers do not work in the trenches, when cost reduction is needed they tend to target staff reduction, leading to the compromise of quality of patient care. On the other hand, a person working on the front line knows where to cut cost without compromising the quality of care. Such people hardly ever get the opportunity to contribute to decision making by business managers who had little or no medical training. In the past two decades MBAs, like the CEOs, have power to fire any healthcare worker complaining about quality of care, including physicians. As long as the person in the pilot seat flying the healthcare plane is the MBA instead of the MD, many healthcare plane crashes continue to take place killing many innocent people.
Unfortunately, many hospitals working to improve the quality of care were losing money while those with increased medical errors were being compensated with an increased revenue.
When hospitals profit from medical errors, why should they fix systemic failures?
When the medical errors problem was first announced by IOM in December 1999, one of the strategies for a solution intervention was to model a quality improvement system after the airline companies. This model was to allow employees working in the trenches, such as front line workers, to openly identify systemic failures and bring them up without retaliation by managers. As years passed by, many of the hospitals dropped this idea of openness and replaced it with the auto industry of "problem denial." The strategy of the auto industry is to "ignore the problem" and it will go away, a strategy of "don’t see and don’t tell, it costs too much to fix, just pay the injured." Any employee who dared to raise the issue of systemic failures is considered an enemy of the institution and must be severely punished. Consequently, many employees who raised issues about systemic failures were either punished or fired. Therefore, employees from such institutions became scared, so they maintained the code of silence. This is another major reason why patients are dying needlessly in hospitals and the number of patients’ deaths increased from 98,000 in 1999 to over 200,000 in 2014.
Why are we surprised when the new General Motor's CEO comes out to admit negligence, sacks 15 executives and tells the public that investigation revealed "incompetence and neglect"?
Healthcare History of Systemic Failures and Patients’ Deaths
As a graduate student in 1976, I started observing many systemic failures in hospitals and the subsequent deaths of patients as a result. I was one of those who blew the whistle on the healthcare system by writing the book “Overcoming the Invisible Crime," – 352 pages published in 1993 by Lara Publications of St. Louis, MO.
The book was sent to some of the Congressional Representatives, Senators and President Clinton's White House. Although many lawmakers who received the book responded with compliments, including the White House, only Senator Paul Simon of Illinois promised he would do something about the problem of medical errors killing patients in hospitals across the nation. In December 1999, the IOM reported that about 98,000 patients die annually due to medical errors. After the report many of those who criticized my initial report changed their position and I was vindicated.
In 2002 the next report about medical errors and management crises in hospitals came out in the book “101 Ways to Prevent Medical Errors – A24 Year Odyssey”. The report outlined many management problems within the hospitals' systems and reported years of study of the implementation of solutions to systemic problems in hospitals leading to medical errors.
In 2010 when the nation would not listen to the devastation of medical errors killing patients, the message was taken to Christian organizations and churches. The book “Closer Walk with Jesus “ was published in 2010. Although it was designed as a Christian book, many of the chapters discussed serious management problems in hospitals, the plight of healthcare workers and how such problems led to the injury and demise of many patients.
In 2013, another book about medical errors and the endemic management problems in hospitals across the nation was published - “How to Prevent a Hospital from Killing You” features a story on how an employee was severely punished for daring to raise issues about systemic failures and danger to patients, by being forced to resign from the hospital. Because the problems of medical errors were getting worse based on national studies, the author decided to take his message directly to patients. Like in the V.A. hospital systems, many of the patients do not know where to go, how to report problems, or how to identify hospital systemic failures.
This book is the echo of Innocent Blood that exposes many shocking irregularities behind the walls of hospitals kept away from the public, and leading to many medical errors and patients’ deaths. The book educates consumers about many systemic failures inside hospitals, how to identify them, and how patients can prevent themselves from being a victim of medical mishaps. The report is from an observational study and a solution implementation program to fix medical errors in various healthcare institutions from a period of 36 years. The book discusses over 100 issues leading to patients’ harm, negligence, and medical errors.
"How to Prevent a Hospital from Killing You" is an eBook of 366 Kindle pages that educates patients and outlines what a patient should look for while seeking care in any of the healthcare facilities.
Amazon Link Page: How To Prevent A Hospital From Killing You
From Lara Publication Project Report on Medical Errors 2004:
Medical Errors Report #27
A Four-Years Solution Implementation Study
Wasting of Government Money on Useless Research Projects Adds to the Failure of Fixing Medical Errors
Since 1999, after IOM reported a number of thousands of patients dying annually from medical errors, close to $300 million in government money was allocated for research projects to finding solutions. Unfortunately, the money was given to people uninformed about the problems within hospitals that cause medical errors. Instead of this research money being spent in local hospitals by collecting information from those who work directly with patients, the grant money was given to celebrity researchers, ignorant of the leading causes of medical errors and most of it, was therefore wasted. Based on the 2002 report by Dr. Gegg Meyer of AHRQ, a government center for quality improvement and patient safety, $5.3 million was spent on a study using computers and information systems to prevent medical errors. Why are we using government money to find what had already been shown by other research projects? Medical journals are filled with articles about the successful utilization of computerized systems to reduce medical errors. Why do we need to spend $5.3 million researching a well-defined fact? The report states that $5.3 million would be spent to understand the impact of working conditions on patients' safety. Evidently, these people do not work in hospitals. All it takes is a day to question hospital workers about these facts without spending millions of dollars on already established facts. Our study, and many others already proved beyond a shred of doubt that employees working under stressful conditions resulting from staff shortage are more likely to make errors. Developing innovative research approaches to improve patient safety would cost $8.0 million, while disseminating research results would cost $2.4 million. Nice way to waste money! Lord, have mercy!
Instead of wasting government’s money, why don’t we invest it in local hospitals working hard to improve quality and lacking the funds to support an effective intervention? Such a hospital needs a bar code system for patient identification costing only $200,000, depending on the size of the hospital. If 100 hospitals are selected across the nation, two from each state, such a bar code system would cost a total of $20 million and would be money well spent as opposed to the $80 million granted annually for research, most of which is being wasted. Computerized bar codes for patient identification system have been known to reduce patient identification errors since 1999. If some of the grant money had been spent on computerized bar code systems, 400 hospitals across the nation would have benefited by now. Instead, the research money is wasted because the money was given to those who distributed it to their friends for doing worthless research projects. So far, over $500 million grant money has gone for useless research projects instead of fixing medical errors.
As long as we are unwilling to confront the real problems, we would never solve the medical errors. Solutions will not come from pen-pushers sitting in offices and shuffling papers, but from those who work on the process-line of patient care. They are the ones currently being ignored. When we ask the wrong questions from the wrong people, we get the wrong answers, which is why patients are still dying due to medical errors. - Excerpt from the 2004 project report.
Possible Solutions to V.A. Hospital Problem
The government can help by issuing immediate directives to allow qualified medical professionals as resident aliens, to apply for jobs within the V.A. hospitals, previously opened only to citizens. This will reduce the backlog of many patients waiting to see physicians and help to fill many open positions within the V.A. hospitals' system. Using outer physicians from the V.A. hospitals' system may eventually become very expensive.
Every medical facility within the V.A. hospitals' system should be implemented "Continuous Quality Improvement –C.Q. I", which uses a committee approach in each hospital to address the problems of systemic failure. Front line workers with direct contact with patients MUST chair the committee, not business managers and supervisors of CEOs. This program will allow employees to raise issues of quality improvement and systemic failures affecting direct patient care without being subjected to the punitive action by business managers, or the hospital's administration.
One of the key components added to the operation of C.Q.I that makes it work, is the design of "a policing system" in each institution through the committee, to be sure of the sustainability of positive outcomes in solution implementation. Without the policing system in place, any achievement attained in solution implementation will be short-lived. Angry managers within the system can decide to overturn the directives of the committee without a policing system supported by the CEO of the hospital.
V.A. patients and relatives should be educated on where they can report problems of care or file complaints if their needs are not being met. This is in reference to a large number of veterans who commit suicide annually when their emotional therapy or psychiatric help are too inadequate to address their situations. This is a serious problem which needs immediate intervention.
The V.A. hospitals' system should use outer consultants, "NOT business consultants" for goodness' sake. Those outer consultants should be those who are adept in understanding the problems of quality improvement in hospitals, and how to identify and fix systemic failures using a committee approach, or other effective approaches with the involvement of front line workers. Internal investigation in a culture infected with denial and plagued with the code of silence would hardly yield any useful information, considering that many of these workers have been subjected to the threat of losing their jobs if they dared to complain. How easy would it be for such employees to open up and start talking to their peers about the same problems they have both overlooked and denied over the years?
My last report, "How to Prevent a Hospital from Killing You" discusses how punitive actions by the managers underscore the reason why some of the employees refused to bring issues of concern and systemic failures to the attention of hospital administrations. Those employees are either punished severely, or get fired!
Report prepared by Victor ‘Yinka Vidal, Lara Publications.
With 40 years of experience working in the healthcare industry, 38 of which working to fix systemic failures in hospitals, the author of four books discusses the plight of patients and employees in healthcare facilities due to management crises and the death of patients by systemic failures.
Twitter: Yinka Vidal's Official Twitter
Hard copies of “Overcoming the Invisible Crime,” “101 Ways to Prevent Medical Errors”, “Closer Walk with Jesus” can be obtained from Lara Publications at 314-653-0467314-653-0467 or email Lara Publication manager at YinkaVidal@gmail.com
The email book format of the books can be obtained from Amazon.com by entering the name of the author "Yinka Vidal" on the Amazon books' website.
Lara Publications Sponsored National Day of Prayer, Oct 28, 2011
Special Thank You to some of the Congressional Representatives and Senators who responded to the call for prayer for the nation. May God bless you all.
If you want the president to investigate the healthcare crisis at the VA, sign at the link, I did and it only takes a little more than a minute.
Investigations into the V.A. Scandal revealed that there were deliberate cover-ups.
Perhaps absolute immunity for healthcare administrators along with no-oversight is not a preferable status quo.
The VA-Hospitals-Scandal is not isolated to one hospital. In addition, the term is actually misleading, becuase it is not strictly a Veteran's Administration issue, but occurs routinely throughout the Healthcare industry.Some in my family were members of the American Legion, an organization of Veterans, and they ones that made this illustrative map.
The beneficient author of this insightful article on the VA Scandal, Yinka Vidal, BS., MA., H(ASPC) wrote an excellent book on "How to prevent a hospital from killing you."