Veterans Hospitals Systemic Problems

Project Report on Hospital Systemic Failures

(A Congressional Report Sponsored by Lara Publications, St. Louis, MO)

Release June 12, 2014

The V.A. hospitals problem is not a V.A. problem as much as 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 obstacles 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 the hospitals and healthcare facilities across the nation for many decades. What has just been exposed with the V.A. hospitals of patients’ neglect of care is very common in hospitals that are designed to generate increase in revenue at the expense of killing patients. Studies have indicated hospitals making medical errors are being compensated handsomely while removing the incentives to fix systemic failures and improve the quality of patient care. Some hospitals are performing unnecessary procedures on patients for the sake of increasing revenue. Some 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, this endemic management problems and greed have spilled over to into V.A Hospitals system.


The VA's troubled history.

100,000 veterans face long waits to see VA doctors.

By these painful revelations, hoping this 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 no exceptions. Our inability to change the status quo in hospitals because the business man wants to make money is the reason for the situations in the V.A. hospitals. Increase in medical errors across the nation is an indication of continuous systemic failures of hospital administrations across the nation.

Veterans' Malpractice Claims On the Rise: Settlements and court judgments have cost taxpayers $845 million since 2003.

These problems are not fixable no matter how much money we through at them until we are poised to fix systemic failures endemic in hospitals and the code of silence instituted to keep employees quiet. Because we have been unable, or refused to solve such problems, it is now spilling into the V.A. hospitals system. Should we be surprised? The major issue is not about bad medicine (even this may be a part of it) as much as bad management being praised as long at the hospital increases revenues. This management problem is now manifesting in V.A. hospitals in another form leading to neglect of patient care. At a point in life, we have to draw the line whether making money is more important, or giving quality of care to save lives. As long as our priority is to make money instead of caring for patients, many patients will continue to die needlessly and anybody can be a victim!

Hospital medical errors now the third leading cause of death in the U.S.

In 1999 the IOM reported about 98,000 preventable patient deaths annually due to medical errors. Today, some studies are reporting as high as 200,000 deaths due to medical errors. Has the problem gotten better after government spent an estimate of over $100 million annually fighting medical errors for the past 15 years? If money spent by government to fight medical errors for the past 15 years equals $1.5 billion, why is nobody raising a red flag in the government because the medical errors killing patients have increased over the years? The problems of systemic failures have gotten worse because harming and killing patients are made more profitable for healthcare institutions! This same problem plaguing hospitals across the nation which prevents fixing systemic failures is the same problem plaguing the V.A. hospitals. The problems of management failures manifesting in V.A. hospitals happen partly because those working on the frontline of care are never given opportunity to solving the problems. When research grants were given to academicians and healthcare leaders with no clues about what is happening on the frontline of care, the problems were never solved. Some of the problems were made worse. In many of those cases the problems were 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 frontline of care. It was a very effective way to solve systemic problem in hospitals across the nation. However, many hospitals executives refused to support such initiative, let alone adopt it. I worked on the project with Sister Jean Ryan for 5 years and the project led to the report 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 diminished since Sister Jean Ryan left the hospital system. When the quality improvement program diminished, more systemic failures emerged with increase in medical errors. The systemic failures in healthcare facilities across the nation lead 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; fired, and may lose opportunity to work in hospitals in the immediate social environment. Many of the hospitals employees know about these codes of silence and denial because I was one of those managers who kept the code of silence and later was victimized by them. The slogan in some hospitals, "I don’t see, I don’t hear, the problem goes away." Many 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. The quality improvement officer was disciplined and suspended because he was working hard to fix systemic failures. He later resigned. After the quality improvement officer left, a couple of years later 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. That story will educate people about serious management crises in many of the healthcare facilities today. The V.A. hospitals are no exceptions because healthcare institutions of management infect each other with management styles and problems alike.

Sadly instead of fixing systemic failures raised by employees who want to solve the problems within the hospital system, many of them were fired and those who created the problems were promoted as good employees. Employees or managers who retained the status-quo were called good employees and team players. 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 increase in medical errors killing patients.

When workers raise legitimate issues of concern for many years, and they fall on the deaf ears of hospital management, after a while the 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 have never been addressed, let alone mentioned in the public as an issue leading to medical errors. The consequences of such problems are now observed 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 hospital due to assembly line medicine is caused by greed and relentless desires 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 because it discusses hospital problems. I was successful in getting on some radio stations to discuss the problems. Many of these media outlets including newspapers refused to review the book discussing medical errors because of their fear of losing advertisement revenues from hospitals. So, to My Dear Beloved Americans, the problem continued and patients continue to die at alarming rate, and anybody can be a victim, even you, or your loved ones! Even as a health care worker, I have been a victim of medical errors, my wife being a nurse had been a victim of medical errors including my son. My father died of untreated septicemia at the age of 60 years. He was a healthcare worker. Many people who have used healthcare services have been victimized by medical errors unaware. Consider 2 million patients infected annually in hospitals due to nosocomial infections.

I want people to realize, the problem of management within the V.A. healthcare systems is not new, but 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 continues to rise!

I’m not convinced 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 investigating the problem may be very helpful. This group will 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 has failed from the perception of frontlines working directly with patients. Frontline workers are more adept in the operational failures of the system compared to people pushing pen and sitting in comfortable office with no clue as to 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 will come very swiftly. However, if the problem is given to a giant celebrity as we always do, that person will fall into the same hole as the previous head of the V.A. hospitals system. He will spend the next couple of years trying to identify the problems and another couple of years to understand the problems and design solutions. You cannot fix what you do not understand! I worked on these problems across the nation for 38 years and know where the problems are within the hospitals system and how to move the system to respond. Hospitals are made up of interrelated departments working many times 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 is operated by frontline workers. Poor inter-departmental communication within hospitals is another greater 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 them do not have 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 power to controls the system. Whosoever controls the system is the one with 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. The person who actually influences the quality of care are the business managers with MBA not the MD. This is another serious problem plaguing healthcare industry for years. Sadly, 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 reduction of cost should target enormous wasteful spending very endemic 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. However, a person working on the frontline 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 as 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 like the one with the V.A. hospitals.

Unfortunately many hospitals working to improve the quality of care were losing money while those with increase medical errors were being compensated with increase 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, part of the strategies of solution intervention was to model a quality improvement system after the airline companies. This model is to allow employees working in the trenches – frontline 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 cost too much to fix, just pay the injured." Any employee who dared to raise the issue of systemic failure 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. Employees from such institutions were therefore 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 Motors CEO comes out to admit negligence, sacked 15 executives telling the public 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 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 Institute of Medicine – IOM reported that about 98,000 patient 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 hospital came out in a book, 101 Ways to Prevent Medical ErrorsA24 Year Odyssey – 307 pages. The report outlined many management problems within the hospitals systems and also reported years of study of the implementation of solutions to systemic problems in hospitals leading to medical errors.

Amazon Link Page

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 – 472 pages was published in 2010. Although it was designed as a Christian book, but 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.

Amazon Link Page

In 2013 another book How to Prevent a Hospital from Killing You, was published about medical errors and the endemic management problems in hospitals across the nation. One of the featured stories is how an employee was severely punished for dared to raise issues about systemic failures and danger to patients. That employee was forced to resign from the hospitals. Because the problems of medical errors was 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 or how to report problems, or how to identify hospital systemic failures.

This book is the echoes 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 a patient can prevent himself or herself from being a victim of medical mishaps. The report is from an observational study and solution implementation programs 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, 366 Kindle pages. It educates patients and outlines what a patient should look for while seeking care in any of the healthcare facilities.

Book Link Page on Amazon


From Lara Publication Project Report on Medical Errors 2004

Medical Errors Report #27

A Four-Year Solution Implementation Study

Wasting of Government Money on Useless Research Projects Adds to the Failure of Fixing Medical Errors

Since 1999, after IOM reported on the thousands of patients dying annually from medical errors, close to $300 million in government money was allocated for research projects to find 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. Most of the grant monies were therefore wasted. Based on the 2002 report of Dr. Gegg Meyer of AHRQ, a government center for quality improvement and patient safety, $5.3 million was being spent on a study using computers and information systems to prevent medical errors. Why are we using government money to find what has already been shown by other research projects? Medical journal 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 $5.3 million would be spent to understand the impact of working conditions on patient 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 improving 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 put it into local hospitals working hard to improve quality, that lack the funds to support effective intervention? Perhaps such a hospital needs a barcode 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 barcode system would cost a total of $20 million and would be money well spent as opposed to the $80 million granted annually for research that most of which is being wasted. Computerized barcode for patient identification systems have been known to reduce patient identification errors since 1999. If some of the grant money had been spent on computerized barcode systems, 400 hospitals across the nation would have benefited by now. But, the research money is being 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 for fixing medical errors.

 As long as we are unwilling to confront the real problems, we will never solve the problems of medical errors. Solutions to medical errors will not come from pen-pushers sitting in offices and shuffling papers, but from those who work on the process-line of patient care. These 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 may 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 outside physicians from the V.A. hospitals System may eventually be very expensive.

Every hospital 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. Frontline workers with direct contact with patients MUST chair the committee, not business managers, 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 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. Some 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 as to 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 inadequate to address their situations. Very importantly, this is a serious problem which needs immediate intervention.

The V.A. Hospitals system should use outside consultants, "NOT business consultants" for goodness sake. Those outside consultants should be those that 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 approach with the involvement of frontline workers. Internal investigation in a culture infected with denial and plagued with the code of silence will hardly yield any useful information. Remember, many of these workers have been subjected to the threat of losing their jobs if they dared to complain. How easy 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 hospitals 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 and 38 of those years working to fix systemic failures in hospitals. The author of four books discussing the plight of patients and employees in healthcare facilities due to management crises and the death of patients by systemic failures.

Twitter: @YinkaVidal

Books hard copies of Overcoming the invisible Crime, 101 Ways to Prevent Medical Errors, Closer Walk with Jesus can be obtained from Lara Publications at 314-653-0467 or email Lara Publication manager at

The email book format of the books can be obtained from by entering the name of the author "Yinka Vidal" on amazon books website.

Lara Publications Sponsored National Day of Prayer, Oct 28, 2011

Thanks to some of the Congressional Representatives and Senators who responded to the call for prayer for the nation. May God bless you all.


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