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Robert and Lilly Balaka-Long. Lehna Brewer. Mychelle Williams. Paris Bessard. Now, Devin Valenzuela.

The front page of this morning’s Los Angeles Times has the chilling story of baby Devin Valenzuela. Baby Devin was the second baby, a boy, born in April to Sarah Valenzuela. Unlike his twin, though, Baby Devin passed away. And the cause of the death of Sarah Valenzuela’s baby is horrifying:

Though the baby was not in distress, Kaiser Permanente perinatologist Hamid Safari attached a vacuum extractor to the boy’s head to draw him out. Again and again he tugged, but still the baby would not come. He vigorously shook the vacuum, up and down, side to side… It took 90 minutes and six tries — the last with Safari on his knees, pulling. Horrified staffers — and the boy’s father — looked on as baby Devin finally emerged. His skin was a bloodless white, his neck elongated and floppy. His spinal cord had been severed.

This was not a single incident, though. And Baby Devin Valenzuela was apparently not the first baby to needlessly die under Dr. Safari’s care. “As far back as 2002, a physician review committee at the hospital concluded that Safari provided ‘inappropriate’ care.”

[After Baby Devin's death,] staffers at the Fresno birthing center were devastated and angry — and not just because of the twin lost that night in 2005. Over the years, doctors and nurses repeatedly had complained to higher-ups — including Kaiser’s top medical officer in Northern and Central California, [Dr. Robbie Pearl], — about problems they saw in Safari’s skills and behavior, according to interviews and documents.

The Los Angeles Times is clear: “This is a story not just of tragic medical outcomes, but of a health plan that did not prevent them.”

Perhaps most shocking? “Still, the doctor continues to work at Kaiser Fresno, practicing under restrictions that staffers say have not been explained to patients.”

The story doesn’t end there, though. After Baby Devin’s death, two Kaiser Permanente doctors recognized something had to be done. “‘We do not feel that our perinatologist is competent,’ reads an August 2005 petition signed by eight of Safari’s peers, about half of the ob-gyn department. ‘Over and over again he put our patients at risks and most recently with the undeniably terrible outcome.’”

What happened to the physicians who pushed for Hamid Safari’s practice to be restricted? Dr. Gilbert Moran and Dr. Robert Rusche and the other physicians were punished for their vigilance and commitment to ensuring the integrity of Permanente medicine. “In the months that followed, the hospital administration chastised the eight obstetricians who submitted the petition warning administrators…” Dr. Moran and Dr. Rusche were treated especially harshly for bringing the issues to light. “[Dr.] Moran was suspended for two weeks without pay, had his salary cut by $20,000 a year and was denied a year-end bonus, while [Dr.] Rusche was suspended for one week without pay and denied a bonus, according to their disciplinary letters.”

After that, Dr. Rusche and Dr. “Moran gave up on resolving matters internally. They took their complaints to the medical board.” Finally, “late last month, the state medical board accused [Hamid] Safari of gross negligence, seeking to revoke or suspend his license.”

This is a bastardization of what Kaiser Permanente once stood for. It’s to cut spending on care, to protect reputations, at whatever cost. Preventive medicine? Responsible medicine?

Dr. Robert Pearl knew that this man was accused of killing babies. He did nothing.

Dr. Pearl needs to resign. Today. And George Halvorson needs to follow him out the door.

This story was originally posted at justendeal.com.

The gist: Yogi Berra perhaps knows something about where Kaiser Permanente is now heading under George Halvorson: “We’re lost. But we are making good time.” Mr. Halvorson has taken to devoting his time to writing weekly email messages to remind Kaiser Permanente employees that he is still in charge, and his book tour has managed to sell a few dozen of his books. He may not be a great author, but he’s an even worse chief executive. Mr. Halvorson is moving Kaiser Permanente further and further away from the principles of Dr. Sidney Garfield, and he has nearly stripped the organization of any semblance of charitable motive or mission. If the response to Mr. Halvorson’s book is any indication, we all now recognize him for the buck naked emperor he is. It’s unfortunate that the Kaiser Foundation Health Plan board of directors doesn’t seem to know or care what’s going on at Kaiser Foundation Health Plan.

The whole story: You might have noticed that George Halvorson recently wrote a new book. You might also have noticed that Mr. Halvorson has yet again been wasting Kaiser Permanente member resources to try and promote his (latest) new book! Thankfully, all that hard work has paid off. Mr. Halvorson’s book has landed at the impressive spot of 36,024 on the Amazon Bestseller List. In doing my part to help the cause of promoting Mr. Halvorson’s plan of unaffordable (but) mandatory healthcare for all, here’s a link to the page where you can purchase the book. (Thankfully, Amazon also sells matches, so in case of a power outage, Health Care Reform Now! should be good for something.)

Charles Andrews over at Monthly Review is taking a critical eye to Mr. Halvorson’s supposed “leadership” of Kaiser Permanente, too. Writes Andrews, sarcastically: “Certainly, Kaiser executives are not of a non-profit mind. Kaiser chief executive officer George Halvorson takes around $2 million a year…” (Which would be about enough to cover at least a thousand poor California kids, in case that matters.) Mr. Andrews goes on to call Mr. Halvorson’s plan out for what it is: “phony health reform.”

The truth is, with membership stagnant, Mr. Halvorson’s only hope for holding onto his job much longer would be a windfall of millions of new members through mandatory health coverage. Hiding Kaiser Permanente’s true financial picture behind leasebacks and self-insurance schemes and ever-higher premiums can only last so long. What a sad state George Halvorson will be leaving Kaiser Permanente in.

Finally, an update: Baby Andrew Balaka-Long has finally been transfered from Kaiser Permanente to the neonatal intensive care unit at San Diego’s Rady Children’s Hospital, after a DMHC physician reviewer and a judge had ordered Kaiser Permanente to transfer the baby to a “better-equipped” hospital. The baby’s transfer comes “weeks” after his parents first requested the transfer, precious weeks for severely premature Baby Andrew. Once again, Dr. Garfield must be rolling in his grave. All of this so so George Halvorson’s “financial leadership” of Kaiser Permanente could look a little better than it should.

This story was originally posted at justendeal.com.

The gist: The bad news George Halvorson seemed to be preparing for is in today’s Los Angeles Times: the parents of seven-week-old Andrew Balaka-Long are trying desperately to have their baby transferred to a non-Kaiser Permanente hospital. Baby Andrew is a triplet, but his two other siblings passed away. His parents obtained a court order forcing Kaiser Permanente to allow Baby Andrew to be transferred to a non-Kaiser Foundation Hospital. And, Baby Andrew’s parents are suing Kaiser Permanente for wrongful death and medical malpractice in the death of Baby Andrew’s two siblings.

The whole story: I recently commented on the bizarre message George Halvorson sent earlier this week, and how he was seemingly excusing medical errors as inevitable. I wrote that the message seemed to almost be preparing Kaiser Permanente employees for another round of bad news. Is the death of Baby Andrew’s brother, Robert, and sister, Lilly, the bad news George Halvorson already knew about?

While Baby Andrew’s parents were able to have Kaiser Permanente’s refusal to allow his transfer to a “better-equipped [non-Kaiser] hospital,” overturned, the sad situation didn’t end there. Unfortunately, no other hospital has so far been “willing to accept the infant,” leaving Baby Andrew in a hospital that has, according to the baby’s father, “bungled the boy’s care.” (The baby’s father is a gynecologist.)

As always, Kaiser Permanente’s spokesman seemed to be a little short on empathy, only saying that “Whether [the other hospitals] accept the child or not is out of our hands.” Of course, forcing the parents of the baby to take Kaiser Permanente to court to ensure the baby is treated in the most adept facility, wasting precious time… The decision to put his parents through that ordeal, that decision was in Kaiser Permanente’s hands. Baby Andrew, instead, has spent precious this time in a facility where his two other siblings died, in a Kaiser Permanente facility that, his parents argue, can’t provide him the care he needs.

Sidney Garfield believed Kaiser Permanente should exist to remove the complication of the “cost of care” from medical decisions. In Baby Andrew’s case, money was undoubtedly front and center in Kaiser Permanente’s denial of his transfer to a better facility. The cost to Baby Andrew’s family, for the time wasted in fighting Kaiser Permannete? It could be astronomical. The cost to Kaiser Permanente? Virtually nothing.

Kaiser Permanente needs leaderships that believes in the values of Sidney Garfield, leadership that believes in providing, not withholding care. Leadership that spends its time making healthcare more affordable, and more universal, rather than cutting staff, cutting resources, and writing and promoting books. When will Kaiser Permanente have leadership again?

This story was originally posted at justendeal.com.

The gist: Diminishing the seriousness of the work that is done at Kaiser Permanente may seem fine to George Halvorson, but it’s another example of his misleadership of an organization that once was led by a man, Dr. Sidney Garfield, who would have been horrified at the thought of a non-physician nonchalantly excusing medical errors. This remarkably embarrassing message has to make it absolutely clear to every Kaiser Foundation Health Plan director and every Permanente physician that George Halvorson has no right and no ability to lead the foremost healthcare institution in America.

The whole story: George Halvorson is so pleased to be celebrating five troubled years at Kaiser Permanente that he decided to send a message to all 162,000 of his employees, congratulating himself on his anniversary. (See Kaiser Thrive Exposed for the whole story.)

I don’t have much to say about the message, except that I found it to be completely bizarre, and somewhat defeatist. Mr. Halvorson points out that Kaiser Permanente has tens of millions of patient encounters each year, so things have to go wrong somewhat regularly. Umm. Uhh… (Hearing the crickets yet?)

If the message was meant to boost morale, well, the good news didn’t stop there. Mr. Halvorson says HealthConnect is beating the socks off the electronic systems at the Mayo Clinic. Oh, wait. Actually, he said it will beat their socks off in a few years. Maybe by 2009 or so. Maybe.

George Halvorson started out as a newspaper writer, but his anniversary note really could have used the touch of a good editor (or, perhaps, a whole team of them). I’m no big fan of George Halvorson (as you might have guessed), but reading his blathering, blabbering email was painful even for me.

Mr. Halvorson called his email message “good news,” but the bad news this week didn’t stop there for Kaiser Permanente. According to Tim, the ongoing hemorrhaging of senior leadership at KP-IT has now seen Adrienne Edens out the door. She was most recently vice president and information officer, heading up the Business Partnership Group. She’s apparently being replaced by Diane Comer, who was CTO at the Fireman’s Fund.

After Phil Fasano, and then Carol Rizzo, you probably won’t be surprised to know that Ms. Comer has built her reputation on outsourcing IT jobs. If the strategic direction KP-IT is heading in wasn’t obvious to anybody before, I really don’t know how much crystal clearer it’s going to get. The buck doesn’t stop anywhere at Kaiser Permanente, but you know where the fish rots from… The lack of ethical leadership at Kaiser Permanente, combined with the lack of competency (and stability) at the head of KP-IT left most folks to do their jobs as best as they could with the resources they had. Now, it looks more and more like the people fixing Kaiser Permanente’s ailing IT infrastructure won’t be Kaiser Permanente employees at all.

I gave up thinking, a while ago, that positive change was coming anytime soon to Kaiser Permanente or HealthConnect. The board is completely out of touch and unaccountable. George Halvorson is running the organization into the ground. And the kids are now in charge of the candy store over at KP-IT. (Seriously, Fasano, Rizzo, and now Comer have about as much healthcare experience, combined, as Zach Braff.) Until KP starts to run even further off the rails, there’s not going to be enough momentum to dislodge the ridiculously callous, careless, and incompetent board and chairman of Kaiser Foundation Heath Plan.

There was public outcry over the horrific kidney transplant nightmare. There was public outcry (and criminal charges) over the shocking mistreatment of indigent patients. But until Kaiser Permanente has an accountable board, or processes to hold its board and its executives accountable, this will not stop.

George Halvorson’s message was saying just that, almost excusing that, or perhaps preparing us for another round of Kaiser Permanente patient nightmares. He knew the kidney transplant scandal was coming long before the Los Angeles Times broke the story. He knew the tragic story of Carol Reyes was coming before the video footage of her stumbling down skid row in nothing more than a hospital gown made national news. He probably even knew of the heinous accusations against Dr. Hootan Roozrokh before the sad story of Ruben Navarro made headlines.

After five years of his “leadership” at Kaiser Permanente, it’s time for George Halvorson to go.

This story was originally posted at justendeal.com.