Article 58. Reinventing the VA

Now that we have identified the Veterans Medical facilities as having systemic problems with a lack of respect for its primary objective in serving the medical needs of our service men its time to think about reinventing the VA system.  See Article 57. The OIG report from the Phoenix VA Medical facilities. 

It is important to realize that parts of the VA Medical system are in fact doing an excellent job so we must be careful in labeling the entire VA system as systemic.  However much of the VA Medical System has been derelict in doing its duty for years.  Now with the increased pressure from returning war vets the system has become overrun in many areas.

Why Attempts at Fixing the VA have Failed
The primary reason for failure to fix the VA is that the federal government has never had the proper tools needed to fix systemic toxic bureaucracies.  The Office of Inspector General is an audit organization which investigates misuse of funds through fraud and mismanagement. The OIG has neither the expertise nor the authority to reform a bureaucracy.   All OIGs are imbedded within their bureaucracies and are not free to investigate problems within their bureaucracy.  My solution to this problem is the establishment of a single investigative organization.  A US Inspector Generals Office with all OIGs reporting directly to it and funded by it  See Article 52.  Establishment of a Government Wide United States Inspector Generals Office.

Why  OIGs Can Not Reform a Systemic Bureaucracy
The explanation may be difficult to grasp even though the VA OIG is doing an excellent job on reporting irregularities at the Phoenix VA Medical facilities they can only achieve partial success in fixing VA Problems.  This is because they represent a piecemeal approach correcting management and scheduling problems as revealed by their audit investigations, one at time. This is like fixing the trees in a forest when the entire forests needs to be addressed. The correct approach is to completely reform the entire organization all at once.  The problem is that no one in government knows how to do this.  The DOD has discovered one of the Tools needed to reform government, Lean Six Sigma.  They have had a great deal of success in fixing high level military delivery systems. The other tools I have incorporated in My General Reform Model and Includes Enterprise Lean.

My Recommendations for Fixing US Federal Government Problems
1. Establish a US Office of Inspector General with all OIGs being funded by and reporting to it.  This will require Legislation from Congress.  This establishes an organization with the authority to investigate and fix all government problems. See my Article 52.  Establishment of a Government Wide United States Inspector Generals Office.
2. Provide the tools needed to make the proposed USOIG more than an just an audit organization but with the expertise needed to reform Government.

My Approach for Fixing current VA Problems
This is accomplished by implementing my General Reform Model starting with the implementation of Enterprise Lean through out the Phoenix Medical Facility.   The reason this is done is to transform the toxic bureaucratic environment into a positive culture focused on employees doing their jobs in serving the Vets.  To accomplish this I will train VA OIG Analysts in the skills and approach needed to make the reforms in the VA. With these skills the OIG Analysts can implement reforms in the whole of the VA.

Implementation of Enterprise Lean
The implementation begins by organizing nearly all VA employees into Lean Teams and training them to find the most effective and efficient way to do their jobs.   The process fixes all of the systems to get the highest effectiveness and efficiency possible. Once this is done we will collect the Lean data from each Lean Team which will give us process times for every operation in the facility. Now we have the management data for staffing all operations. From this we can calculate exactly how many staff members and what expertise are needed to meet patient appointment standards (14 days). 

This is followed by the final step the transformation of the toxic bureaucratic organization to a Team Managed organization.   The process of implementing Team Management will expose and eliminate incompetent and corrupt management.

Why is this Necessary
Bureaucracies such as the VA DO NOT REFORM THEMSELVES.  My proposal as an independent consultant makes the necessary changes in the VA that the current VA management can not do.  This is a low cost solution available now which can yield results in three months with full implementation within six months to a year. It permanently fixes VA problems and develops management data that can be applied in all VA hospitals.  See my  Article 56. Congressional Veterans Affairs to Tap the GAO to Fix the VA.

Article 57. Veterans Health Administration Interim Report 

Review of Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System 

Comment by Lawrence Rosier
It is important to realize that even though the Office of Inspector General's report is professional and is focused at getting to the bottom of VA Problems, the OIG does not have the expertise for implementing reforms correcting the mass systemic problems of the VA.  See My Article 56. for how sweeping reform of the VA should be approached.

I have Included only the executive summary for the entire report go to: http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf

EXECUTIVE SUMMARY

This interim report provides an overview of our ongoing review at the 
Phoenix Health Care System (HCS), identifies the allegations we have 
substantiated to date, and provides recommendations that VA should 
implement immediately. 
Allegations at the Phoenix HCS include gross mismanagement of VA 
resources and criminal misconduct by VA senior hospital leadership, 
creating systemic patient safety issues and possible wrongful deaths. 
While our work is not complete, we have substantiated that significant 
delays in access to care negatively impacted the quality of care at this
medical facility. 

The issues identified in current allegations are not new. Since 2005, the 
VA Office of Inspector General (OIG) has issued 18 reports that identified, 
at both the national and local levels, deficiencies in scheduling resulting in 
lengthy waiting times and the negative impact on patient care. As required 
by the Inspector General Act of 1978, each of the reports listed was issued 
to the VA Secretary and the Congress and is publicly available on the VA 
OIG website. These reports are identified in Appendix D. 

We initiated this review in response to allegations first reported to the OIG Hotline
 and expanded it at the request of the VA Secretary and the Chairman of the House
Veterans’ Affairs Committee (HVAC) following an HVAC hearing on April 9, 2014, 
on delays in VA medical care and preventable veteran deaths. Since receiving those 
requests we have received other congressional requests including those submitted 
by the Chair and Ranking Members of the following Committees and Subcommittees: 
HVAC Ranking Member; HVAC Subcommittee on Oversight and Investigations; House Appropriations Committee; House Appropriations Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies; Senate Veterans’ Affairs 
Committee; Senate Appropriations Committee; and Senate Appropriations 
Subcommittee on Military Construction, Veterans Affairs, and Related Agencies. In addition,we received requests from Senators John McCain, Jeff Flake, Dianne 
Feinstein, Charles Grassley, Tom Udall, and Michael Bennet; and Representatives 
Kyrsten Sinema and Jack Kingston. We also have requests from a number of Texas 
House members specific to facilities in Texas. 

Due to the multitude and broad range of issues, we are conducting a comprehensive review

requiring an in-depth examination of many sources of information necessitating 
access to records and personnel, both within and external to VA.

We are using our combined expertise in audit, healthcare inspections, and criminal investigations, along with our institutional knowledge of VA programs and operations and legal authority to conduct a review of this nature and scope. 

A detailed assessment of the information obtained from Phoenix HCS’ medical 
records and its business practices requires a full understanding of VA’s current and
historical policies and procedures as well as the current practices, facts, and 
circumstances relating to these serious allegations. We have and will continue to 
conduct comprehensive interviews of numerous individuals to evaluate the many 
allegations, determine their validity, and if appropriate, assign individual accountability. Despite the number of allegations, each individual allegation is nothing more than an allegation.

We are charged with reviewing the merits of these allegations and determining whether sufficient, credible factual evidence exists to meet the standards

          


required by applicable laws and regulations to hold VA, or specific individuals 
accountable on the basis of criminal, civil, or administrative law and regulations.

In late April, the OIG assembled a multidisciplinary team comprised of board-
certified physicians, special agents, auditors, and healthcare inspectors from 
across the country to address numerous allegations at this and other VA medical 
facilities. Since the Phoenix HCS story broke in the national media, we have 
received allegations of similar issues regarding manipulated waiting times at other Veteran Health Administration (VHA) medical facilities through the OIG Hotline, from
 members of Congress, VA employees, veterans and their families, and the media. 
In response, we have opened reviews at other VHA medical facilities to determine 
whether scheduling practices are and/or were in use that did not comply with 
VHA’s scheduling policies and procedures. Clearly, there are national implications 
associated with inappropriate and non-compliant scheduling practices, including 
the impact on patient care and a lack of data integrity. Veterans who utilize the 
VA health care system deserve quality care in a timely manner. Therefore, it is 
necessary that information relied upon to make mission-critical management 
decisions regarding the demand for vital health care services must be based on 
reliable and complete data throughout VA’s health care networks. It is important 
to note that the information in this interim report is dynamic and changes may 
occur as our review progresses.  I have directed our teams to focus on two 
fundamental questions:

(1) Did the facility’s electronic wait list (EWL) purposely omit the names of 
veterans waiting for care and, if so, at whose direction?

(2) Were the deaths of any of these veterans related to delays in care?  To address the allegations received thus far and remain prepared to address new allegations at

medical facilities throughout VA, we are deploying Rapid Response Teams. We are 
not providing VA medical facilities advance notice of our visits to reduce the risk 
of destruction of evidence, manipulation of data, and coaching staff on how to 
respond to our interview questions. To date, we have ongoing or scheduled work 
at 42 VA medical facilities and have identified instances of manipulation of VA 
data that distort the legitimacy of reported waiting times.  When sufficient 
credible evidence is identified supporting a potential violation of criminal and/or 
civil law, we have contacted and are coordinating our efforts with the Department 
of Justice.  Our review at the Phoenix HCS includes the following actions:

Interviewing staff with direct knowledge of patient scheduling practices and policies,

including scheduling clerks, supervisors, patient care providers, management staff, 
and whistle blowers who have stepped forward to report allegations of wrongdoing.

Collecting and analyzing voluminous reports and documents from VHA 
information technology systems related to patient scheduling and enrollment.

Obtaining and reviewing VA and non-VA medical records of patients whose death

occurred while on a waiting list, or is alleged to be related to a delay in care.

Reviewing performance standards, ratings,and awards of senior facility staff.
Reviewing past and new complaints to the OIG Hotline on delays in care, as 
well as those complaints shared with us by members of Congress or reported by the media.

Reviewing other documents and reports relevant to these allegations, including
 administrative boards of investigations or reports of reviews conducted by 

VHA’s Office of the Medical Inspector.

Reviewing over 550,000 email messages and documents, extracted from over 50 
gigabytes of collected email. In addition, imaging and reviewing 10 encrypted 
computers and/or devices, and over 140,000 network files.  Our reviews at a growing number

of VA medical facilities have thus far provided insight into the current extent of 
these inappropriate scheduling issues throughout the VA health care system and have confirmed that inappropriate scheduling practices are systemic throughout 
VHA.  One challenge in these reviews is to determine whether these practices 
exist currently or were used in the past and subsequently corrected by VA 
managers.

To date, our work has substantiated serious conditions at the Phoenix HCS. 
We identified about 1,400 veterans who did not have a primary care 
appointment but were appropriately included on the Phoenix HCS’ EWLs. 
However, we identified an additional 1,700 veterans who were waiting for a 
primary care appointment but werenot on the EWL. Until that happens, the 
reported wait time for these veterans has not started. Most importantly, these 
veterans were and continue to be at risk of being forgotten or lost in Phoenix
HCS’s convoluted scheduling process. As a result, these veterans may never 
obtain a requested or required clinical appointment. 

A direct consequence of not appropriately placing veterans on EWLs is that the 
Phoenix HCS leadership significantly understated the time new patients waited 
for their primary care appointment in their FY 2013 performance appraisal 
accomplishments, which is one of the factors considered for awards and salary 
increases.  To review the new patient wait times for primary care in FY 2013, we 
reviewed a statistical sample of 226 Phoenix HCS appointments.  VA national 
data, which was reported by Phoenix HCS, showed these 226 veterans waited on 
average 24 days for their first primary care appointment and only 43 percent 
waited more than 14 days. However, our review showed these 226 veterans 
waited on average 115 days for their first primary care appointment with

approximately 84 percent waiting more than 14 days. At this time, we believe that 
most of the waiting time discrepancies occurred because of delays between the 
veteran’s requested appointment date and the date the appointment was created. 
However, we found that in at least 25 percent of the 226 appointments reviewed, 
evidence, in veterans’ medical records, indicates that these veterans received some 
level of care in the Phoenix HCS, such as treatment in the emergency room, walk in 
clinics, or mental health clinics. 

Our reviews have identified multiple types of scheduling practices that are not in compliance with VHA policy. Since the multiple lists we found were something other than the official EWL,these additional lists may be the basis for allegations of creating “secret” wait lists. We are not reporting the results of our clinical reviews in this interim report on whether any delay in scheduling a primary care appointment resulted in a delay in diagnosis or treatment, particularly for those veterans who died while on a waiting list. The assessments needed to draw any conclusions require analysis of VA and non-VA medical records, death certificates, and autopsy results. We have made requests to appropriate state agencies and have issued subpoenas to obtain non-VA medical records. All of these records will require a detailed review by our clinical teams. 

Lastly, while conducting our work at the Phoenix HCS our on-site OIG staff and OIG Hotline

received numerous allegations daily of mismanagement, inappropriate hiring decisions, sexual harassment, and bullying behavior by mid- and senior-level managers at this facility. We are assessing the validity of these complaints and if true, the impact to the facility’s senior leadership’s ability to make effective improvements to patients’ access to care.

We will make recommendations in our final report and ask the VA Secretary to submit target

dates and implementation plans. However, to ensure all veterans receive appropriate care, we submit to the VA Secretary the following recommendations for his immediate implementation.

We will address the sufficiency of the VA Secretary’s action to implement the following

recommendations in our final report.

1. We recommend the VA Secretary take immediate action to review and provide appropriate

health care to the 1,700 veterans we identified as not being on any existing wait list.

2. We recommend the VA Secretary review all existing wait lists at the Phoenix Health Care

System to identify veterans who may be at greatest risk because of a delay in the delivery

of health care (for example, those veterans  who would be new patients to a specialty clinic)

and provide the appropriate medical care.

3. We recommend the VA Secretary initiate a nation wide review of veterans on wait lists to

ensure that veterans are seen in an appropriate time, given their clinical condition.

4. We recommend the VA Secretary direct the Health Eligibility Center to run a nationwide

New Enrollee Appointment Request report by facility of all newly enrolled veterans and

direct facility leadership to ensure all veterans have received appropriate care or are shown

on the facility’s electronic waiting list.  We will provide VA with the list of the 1,700 veterans we identified as not being on any wait list so that VA can mitigate any further access delays to health care services, and deliver higher quality of health care. 

RICHARD J. GRIFFIN

Acting Inspector General

Article 56.  Reform of the OIG provides Solution to Fixing the VA

Bureaucracies with systemic problems such as the VA DO NOT REFORM THEMSELVES.  The VA has been in need of reform for years but the VA has not been able to rein-in its problems. This has occurred  primarily because the VA does not have the expertise or a method for fixing them on a mass scale.  My proposal as an independent consultant demonstrates the necessary reforms to the VA that the current management is incapable of doing.

From the Office of the Inspector General OIG May 28, 2014

Veterans Health Administration  - Interim Report -

Review of Patient Wait Times, Scheduling Practices,

and Alleged Patient Deaths at the Phoenix Health Care System

http://www.va.gov/oig/pubs/VAOIG-14-02603-178.pdf

This report demonstrates that the OIG does have the capability to investigate thoroughly wrong doing at the Phoenix VA Medical Facilities and is expanding its investigation to other VA Medical facilities.  Other reports have been made in the past but no action to correct the finding were taken.  The interim report has released the following findings:  
"Allegations at the Phoenix HCS include gross
mismanagement of VA resources and criminal 
misconduct by VA senior hospital leadership, 
creating systemic patient safety issues and 
possible  wrongful deaths."

"The issues identified in current allegations are not new. Since 2005, the VA Office of Inspector General (OIG) has issued 18 reports that identified, at both the national and local levels, deficiencies in scheduling resulting in lengthy

waiting times and the negative impact on patient care. As required by the Inspector General Act of 1978, each of the reports listed was issued to the VA Secretary and the Congress and is publicly available on the VA OIG website. These reports are identified in Appendix D. (of this report)."

"While conducting our work at the Phoenix HCS 
our on-site OIG staff and OIG Hotline received 
numerous allegations daily of mismanagement,
inappropriate hiring decisions, sexual harassment,
and bullying behavior by mid- and senior-level 
managers at this facility. We are assessing the 
validity of these complaints and if true, the impact
to the facility’s senior leadership’s ability to make 
effective improvements to patients’ access to care."

Comment by Lawrence Rosier:
The VA OIG clearly has the capacity to investigate and get to the bottom of the problems at VA Medical facilities. This brings up the problem that all OIGs have; they are not independent from the Bureaucracy they represent.  Bureaucracies can easily ignore any findings of wrongdoing by the OIG. See my solution Article 52.  Establishment of a Government Wide United States Inspector General's Office.

The real problem is that Departmental Bureaucratic Leaders can not and do not know how to fix systemic problems prompting them to ignore their OIGs reports of wrongdoing.  It Should be pointed out that OIG reports are also made available to Congress suggesting that Congress does not know how to fix these problems either.  Over the Years the situation in a toxic bureaucracy like the VA simply gets worse. 

FORTUNATELY WE NOW KNOW HOW TO FIX SYSTEMIC BUREAUCRATIC PROBLEMS
 The proposed reform of the OIG allows the use of OIG personnel in the Pilot implementation of VA reforms bringing sweeping changes throughout the VA. Authorizing Lawrence Rosier Consulting to implement a Pilot Demonstration implementation of the General Reform Model developed by Lawrence Rosier Principal Consultant at the Phoenix VA Hospital facility.

The approach uses proven industry methods such as Enterprise Lean developed by Toyota bundled in the General Reform Model.  The General Reform Model: empowers VA Employees through Lean Teams; determines the actual cost and staffing required to meet appointment standards; changes the current Bureaucratic management to a Team Managed organization; and replaces incompetent and corrupt managers.

This is a low cost solution available now which can yield results in the Phoenix VA Hospital in three months with full implementation within six months to a year. The process develops management data that can be applied in all VA hospitals with cultural changes that can be replicated in all VA Hospitals permanently fixing VA problems.

Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness

This example can be used for training Analysts as Facilitators in the implementation of Enterprise Lean.  The Ophthalmologist operation is broken down into Lean Teams.  Each Lean Team will meet for an hour once a week to do the lean process facilitated by an Analyst.  After their preliminary work is complete in finding the most effective and efficient way of doing their processes.  The several individual Lean Team Leaders are combined into a much larger Team led by the Ophthalmologist to complete the scheduling chart in the above example.  This chart will be documented by the Analyst in a spreadsheet along with the time to do each process and the name of the employee doing each part of the process.  The spreadsheet will become part of a database including all operations in the entire facility.  The total labor hrs is the functional budget for the facility excluding Management and overhead.  The total work hours for each employee will be used in the right-sizing process to be sure each employee has a full time job.

When the entire operation of collecting the Lean Data is completed a copy of the first data base will be made with employee names and personal data removed.  This database will act as Best Practices Database to be used in other facilities.

Example of Lean Team with Maximum Throughput
Some VA Hospitals it has been reported have a waiting list of up to one year for cataract surgery.  The following example is an approach for finding the maximum patient throughput with the highest effectiveness for a Medical Doctor of Ophthalmology.  The most critical parts of the approach is in how the Ophthalmologist uses his time in combination with the sets of patient processes, equipment and the activities of nurses.

The Main Objective:
To get the highest efficiency without compromising effectiveness.  Put another way to find the maximum flow of patients without compromising medical standards. 

The approach is in two parts:
Part A. implements Lean Teams to review the sets of patient processes found in cataract surgery with the Ophthalmologist and his nurses using lean to examine his own processes relative to an individual patient.

The nurses supporting the Ophthalmologist are organized into a Lean Team which will meet once a week until the review of all their sets of patient processes have been completed.  For each set of patient processes the current set approved for effectiveness by the Ophthalmologist is placed on a wall chart.  The improved method with increased efficiency is placed under the current method. The nurses will be reviewing the placement and use of equipment and procedures all within the context of effectiveness guidelines. The time for each process and the total time for the set of processes is carefully noted in minutes.

The second Lean Team lead by the Ophthalmologist with all attending nurses will place the current activities of the Ophthalmologist on a wall chart.  The improved method will show improvements for getting the highest effectiveness and efficiency.  These two Lean Teams will establish a base line for the scheduling of patients with a balanced work load.


Part B. We will use a manual scheduling system that is superior to a computer generated systems because it focuses on the main objective, Patient Throughput, and allows for team involvement.

What often happens in day to day activities the Ophthalmologist is concentrating on the processes that matter most in being effective and less on those things that are needed to backup the key processes. This is not bad, effectiveness always trumps efficiency but when efficiency is ignored it prevents us from getting to the goal of achieving maximum patient throughput.

The following manual scheduling method is used to demonstrate the plan for getting the maximum patient load:
1. Have each nurse and the Ophthalmologist set a time in minutes for each and every process that is done.
 
2. Then put the information on colored card stock using the color codes below with a time scale of approx ¼ inch for each minute in the process.  Identify clearly exactly what the process of steps describe.  Now you have a representation for each and all of the processes the nurses and the doctor do over several weeks with patient involvement color coded. 

3. List all staff members on the vertical left of the chart and layout all the processes into the sequence they should be done. Start by finding those processes that can be done in parallel (at the same time) followed by the next sequence.

4. Now look at patient access and equipment access.  With more patients you may need more equipment.  What you are looking for is the elimination of bottlenecks of wait time.
  
5. Because the number of patients available for cataract surgery can vary you may be able to put off doing those support processes that may have been included in an automated schedule and thought to be necessary to schedule.  These may a be set aside during periods of high patient flow and only done in periods of low patient flow or wait times.  For example when the Ophthalmologist is "in" and meeting with patients all non-patient support activities are to be done only when the Ophthalmologist is "away" in surgery operating on patients at another location.

6. Now we want to make a daily plan which extends several weeks showing the maximum number of patients that can be processed.  We will build the plan based on the activities of the Ophthalmologist.  Start by taking the card stock representations and collapse them into the shortest time span do not overlay equipment usage or the Ophthalmologist’s time. The result will equal the longest continuous process.  This may also be the patient's time, to process a patient for preliminary testing by the nurse followed by the time with the Ophthalmologist.  The plan will cover all activities based on Ophthalmologist/patient availability.

7. The key is in focusing on the Ophthalmologist’s operations to get the maximum number of patients.  There will always be lost time when times are slow because of a variable patient schedule.  This time is to be used for routine support activities that do not involve patients.

8. The efficient use of equipment may be simply be cycling through patients by appointment times but for the maximum number of patients you may want to buy more equipment to be sure the Ophthalmologist has a full schedule and is not waiting for the next patient.
 
9.  The final card stock layout will become the plan to be followed when processing the maximum number of patients.  The result from a computerized schedule will not produce the same results because it includes all activities.   Not considered in the automated schedule is the fact that the maximum number of patients are not always available.

The Real Manual Plan should show only the key operations for the maximum number of patients. Because we don’t care about being efficient in slow or lax times. 

10. A benefit is the staff involvement in the process which brings understanding of why and how processes can be done during maximum patient volume flow.

11. The economic benefit is that when there is a backlog of patients you have a plan to absorb the maximum number of patients knowing exactly how many you can process effectively and efficiently.


Color Codes:
1. White- all doctor activities with the patient color code pasted on it during all Ophthalmologist patient interactions.
2. Gray- all activities except for the Ophthalmologist that are related to all patients (done only in slow times).
3. Red- Patient number one.  Nurses will put hash marks on the coded process indicating steps involving nurse patient interaction.
4. Green- Patient number two.
5. Yellow- patient number three.
6. Blue- patient number four.

Article 54. Fixing the VA from the Ground Up

THIS IS THE SOLUTION TO THE VA CRISIS THAT YOU ARE LOOKING FOR!
The alleged disclosure of 40 veterans deaths while waiting to get an appointment at a VA hospital is representative of a VA management problem and not a regular VA employee problem.  Most VA employees are doing the best they can under adverse conditions.  It is unfortunate that our service men and women have to give their lives again to get us to fix a government bureaucracy.

Most past fixes for the VA have been in replacing top management, we know this hasn’t worked. Now I am proposing a new approach using industry developed tools with empowerment of VA employees to make a difference, ending in the changing of the VA bureaucracy to a Team Managed organization.

What happens during an OIG investigation?

The Office Of Inspector General (OIG) conducts criminal and administrative investigations involving allegations of wrongdoing affecting VA programs and operations. Special Agents, who are Federal law enforcement officers with full investigative and arrest authority analogous to Federal criminal investigators in other agencies, investigate allegations of violations of Federal or other criminal law. Examples of criminal cases include murder; rape; theft; assault; patient abuse; conflict of interest; embezzlement; fraud in a variety of forms such as contract overcharges, false claims, bid-rigging, product substitution; drug diversion; and illegal drug use. 

Administrative investigators are specially trained to examine and report on serious allegations of misconduct involving senior officials within VA that do not violate criminal laws. Examples of administrative investigations include misuse of funds, improper hiring and other prohibited personnel practices, preferential treatment, misuse of official time and resources, and criminal conduct in which criminal prosecution has been declined by the prosecutor.

What the above VA approach has missed is that it can not correct a systemic Bureaucratic organization by intervention alone.  Only sweeping reform using modern industry developed tools such as Enterprise lean can change the culture and practices of the VA.

My proposal: empowers VA Employees through Lean Teams; changes the current Bureaucratic management to a Team Managed organization;  determines the actual cost and staffing required to meet appointment standards; replaces incompetent and corrupt managers; provides for Cultural Change that protects whistle blowers. 

About The Proposed Consulting Agreement Between the VA and Lawrence Rosier & Associates

The following proposal is intended to address the immediate needs for VA services and demonstrate the best solution in a timely manner avoiding months of blaming and finger pointing.

The proposal is for a demo of my General Reform Model.  The steps of the model have been successfully proven in industry but have not been assembled into unified approach for reform until now. The Principal Consultant (myself) will train and supervise Office of Inspector General (OIG) VA Analysts during the implementation of the reform with the intention of the continuation of the reforms in other VA facilities by the trained VA Analysts. This is a low Cost solution that permanently fixes VA problems.  The implementation generates Lean Data that can be used for Management Standards that can be applied anywhere in the VA.  One of the Management tools is the balancing of the VA staffing work load and determining how many staff members are required for a level of service.  This is an immediate proposal which can develop results in a short time.   



Lawrence Rosier & Associates
Management Consultants Government Reform
12143 Cedar Grove Rd. Rolla, Missouri 65401
Phone (573) 364-8789  Cell (573) 578-4716

Cover Letter  May 31, 2014
To: Sloan Gibson Acting Secretary Department of Veterans Affairs
From: Lawrence Rosier Principal Consultant Government Reform

Subject:  Example Consulting Agreement Addressing VA Medical Facility Reform

I am proposing a major breakthrough solution in government reform using VA Medical Facility employees to implementation Enterprise Lean, originally developed by the Toyota Corp. This is the first step of my General Reform Model which leads to the highest possible effective and efficient organization, develops the data needed to manage, adjusts staffing levels to meet public appointment requirements and ends with the replacement of the Bureaucratic organization structure with a Team Management organization.  The Lean Team data is collected in a Database of Management Standards to be made available to all VA hospitals.

The Consulting Agreement is expected to achieve successful returns within three months and will be completed within six months to one year. 

I recommend that The VA Inspector General’s Office have oversight of this Agreement with the Principal Consultant managing the implementation of the General Reform Model at the Client’s facilities. The VA Inspector General’s Office will supply  VA Analysts who will be trained and lead by the Principal Consultant during the implementation of this Agreement.   The VA Analysts  are expected to continue VA reforms in other facilities after this Consulting Agreement has been completed.

Suggested Approach:
I. The Principal Consultant will arrive the Client's Phoenix VA Medical facilities on June 23, 2014 to begin organizing for the implementation of the General Reform Model.  Preliminary planning will be coordinated with the VA's current Management.  The Inspector General's VA Analysts should arrive on the same date and will be briefed with an overview their role in the implementation of the General Reform Model.

2. The reform begins with the implementation of Enterprise Lean with nearly all employees of the VA hospital being trained in the Lean process.  It organizes employees in to Lean Teams and empowers them to find to the most effective way to do their jobs with an analysis of each process of the system they are working on.  Lean will be introduced in some existing medical teams as required.

3. During the above steps the Principal Consultant will be training and leading VA Analysts in making the implementation of the General Reform Model at the Phoenix VA Medical facility.  The implementation is expected bring changes to the processes done within the facility and to its bureaucracy by implementing Team Management.

Please Review the following Example Consulting Agreement.  The document is intended to be used to promote understanding and to start discussion on consulting activities and not as a final document.

Kindest Regards Lawrence Rosier Principal Consultant

Example: Consulting Agreement       Released  May 31, 2014
Consulting for the Implementation of the General Reform Model.  This Consulting Agreement may be modified before signatures or afterward by written agreement between signatories.


CONSULTING AGREEMENT
US DEPARTMENT of VETERANS AFFAIRS and
LAWRENCE ROSIER & ASSOCIATES
A Pilot demonstration For the
Reform of Government Services

This Agreement is made effective as of June 2, 2014, (or an agreed upon finalized date) by and between The US Department of Veterans Affairs and Lawrence Rosier & Associates, of 12143 Cedar Grove Rd., Rolla, Missouri 65401 (573) 364 8789 cell (573) 578 4716.

In this Agreement, the party who is contracting to receive services is the Veterans Administration  referred to as the “VA” and the party who will be providing the services Lawrence Rosier shall be referred to as the “Principal Consultant”.

The Veterans Administration  “VA” Desires to have Lawrence Rosier “Principal Consultant” provide these services.

Therefore the Parties agree as follows:

1. DESCRIPTION OF SERVICES.  Beginning on June 23, 2014 (or an agreed upon date) Principal Consultant will provide the following services (collectively, the “Services”).  Consulting  for the Implementation of the “General Reform Model” developed by  Lawrence Rosier and the “Consolidation Model” if required for the elimination of  Duplicated Services in a selected VA Agency.  The Principal Consultant hereby agrees to provide and perform for the VA these Services Set forth in Exhibit’s A.

2. PERFORMANCE OF SERVICES.  The manner in which the Services are to be performed and the specific weeks to be worked by the Principal Consultant Shall be Determined by the Principal Consultant.  The VA will rely on the Principal Consultant to work as many weeks as may be reasonably necessary to fulfill the Principal Consultant’s obligations under this agreement.
Exhibit A. Description of Services Supplied to the VA by Lawrence Rosier & Associates
Prepared by Lawrence Rosier Principal Consultant  
Tasks to be Followed Upon the Signing of this Consulting Agreement

The VA Inspector General will have oversight of this Agreement.  The Principal Consultant Lawrence Rosier will manage and have complete control of the implementation of the General Reform Model at the Phoenix Medical Facility separate from investigations conducted by the OIG. He will also train and supervise VA Analysts provided by the Inspector General‘s office according to this Agreement.  The Principal Consultant will be able at his discretion to identify and remove incompetent management and reduce redundant management and staff where required at the Phoenix Medical Facility.  He will recommend retraining of redundant employees to fill needed positions where possible.  The OIG representative at the Phoenix Medical Facility shall have the authority and responsibility to hire new personnel to fill vacancies identified by the Principal Consultant.

Selection of VA Analysts
The Principal Consultant will participate with the Inspector General in the selection of VA Analysts to receive training in Lean.  Policies and procedures for the analysts will be developed jointly by the VA and the Principal Consultant.  Specialized training in Lean for all VA Analysts by a certified Lean instructor is recommended at VA expense.

Training in Specific Technologies Provided by the Principal Consultant:
The development of a Pedagogy for class room instruction of VA Analysts in special technologies by the Principal Consultant.  VA Analysts selected for this Agreement will receive an overview of the reform models with classroom training in the following supporting skills and on the job training during the implementation of the reform models
 1.  Team Management-  by the Principal consultant
 2.  Enterprise Lean-  by the Principal Consultant
 3.  Variable Function Analysis-  by the Principal consultant
 4.  Time studies (a necessary basic skill)- by the Principal consultant
 5.   Statistical Sampling-  by the Principal consultant
 6.  Right-Sizing (makes sure all employees have a full time job)- by the Principal consultant
 7.  Bottoms-up budgeting-  by the Principal consultant
 8.  Staffing-  by the Principal consultant
 9.  Workload Balancing (management of the work flow)- by the Principal consultant   
10.  Short Interval Scheduling-  by the Principal consultant
11. Operation Sequence Charts-  by the Principal consultant
12.  Productivity Reporting Techniques-  by the Principal consultant
13. Effectiveness Evaluation Team training-  by the Principal consultant


Goals:
The main Goal is to provide a demonstration of the General Reform Model at the Phoenix VA Hospital fixing Identified problems and getting the highest efficiency and effectiveness possible.  The method empowers VA employees in the new organization through Lean Teams involving them in work process decisions and continuous improvement to their jobs.

A second Goal; is to balance the work load primarily through retraining current employees and by hiring needed staffing to meet desired service levels and laying off redundant employees.

A third Goal; is the collection of Lean Team management data into a universal database of management standards with the highest effectiveness and efficiency that can be applied in all VA hospitals.  The Database is open by approval for continuous improvement.

A fourth Goal; of the implementation is to strengthen the VA Budgeting process by providing transparency of the Functional activities of the new organization to the VA budget leaders enabling them to control budgets through the knowledge of the correct Functional staffing and its budget.  

A fifth Goal;  the Principal Consultant will be able at his discretion to hire and replace incompetent management including adding and reducing staff where required to balance work loads at the Phoenix Medical Facilities.


The General Reform Model:
The General Reform Model  begins with the implementation Enterprise Lean throughout the Phoenix Medical Facility involving nearly all employees tasked to make all functional systems efficient and effective.  To get the highest efficiency and effectiveness possible we will use the data developed by the employee Functional Lean Teams.  The lean data will be collected and documented by VA Analysts in a spreadsheet program. When all of the data for the entire Agency has been collected it will be used to Right-Size the organization making sure all personnel have a full time job.  The employee Lean Team data will also be used for staffing and to develop bottoms-up budgets which identify the actual costs of a systems functions.  This is also the data needed to manage an organization’s work by balancing its work load.   The lean data will also be used to determine the staffing required to meet patient appointment requirements (14 days).

Phase 1. The VA Inspector General's Office will have Oversight of this Agreement
The VA Inspector General will oversight of this agreement for the implementation of the General Reform Model and will provide VA Analysts that have received classroom training to assist in the implementation of the General Reform Model.  The VA Analysts will become Facilitators for the implementation of Enterprise Lean as required until it has been implemented in its entirety throughout the Phoenix Medical Facility.  When the implementation of enterprise Lean has been completed the VA Analysts will collect the Lean Data in spreadsheets from all of the Agencies Functions. The Lean data will then be used to Right-Size the Agency (making sure that all employees have a full time Job) followed by staffing and Bottoms-up Budgeting.  The VA will maintain the new Bottoms-up Budget databases.  The Agency’s budget databases may be stored in cloud storage at little or no cost.

Phase 2. The Training and Organization of Employee Enterprise Lean Teams
The Principal Consultant recommends that an Enterprise Lean Training specialist be brought in from a local University to Kick off the implementation with training seminars for the Agency‘s employees.  Lean training should begin immediately by the Agency’s training staff.  I suggest that the normal training curriculum for the Agency be suspended and an all out effort be made for Enterprise Lean Training.  Training should be made first for staff members followed by management, Lean Facilitators (VA Analysts) and general employees.

Agency Management Lean Teams
There are two major Lean Team groups, high level Management Lean Teams (which will become Steering Teams) and at-the-work-place employee Functional Lean Teams.   Management Lean Teams are organized and lead by members of management.   They are tasked to study individual high level systems within the Agency and those that interact with other Agencies mostly document flows.  A key element of the High level Lean Teams is their role in management when converting from the bureaucratic organization to the Team Managed organization.


Phase 3.  Review of Lean Team Results and Collection of Lean Data
After a period of about two months most Functional Lean Teams, those that were organized and trained by VA Analyst Facilitators, should have their Value Stream Analyses completed.   I have had success with doing the flow of the current method on long white butcher or brown wrapping paper tapped around a conference room on the walls.  The steps of the current method is completed first followed by the proposed improved method done directly under it.  This is done to highlight the differences between the two methods.  I suggest that some Functional Lean Teams with significant savings present their improved method to management.   After the presentation the rolled document is given to a VA Analyst to document the savings from the proposal in a spreadsheet.  

Phase 4. Activities of the Principal Consultant
The Principal Consultant will play a key role in being sure that the employee Lean teams are properly trained and in the selection and approach of the high level Lean Teams.  The Principal Consultant will insure that the activities of VA Analysts can determine the correct staffing level through Work Measurement and any expenses needed during the process.  Some VA Analysts may find the proper staffing for variable processes difficult to determine, the Principal Consultant will make this determination when necessary. This data combined with the number of occurrences of the function over time, obtained from a daily log kept by each Lean Team, provides the basis for an accurate functional budget.  The Lean data from the documentation will be kept on a spreadsheet by the VA Analysts and summarized in a database where all of the Agency’s functional data is stored.  The activities of VA  Analysts are important and will be followed closely by the Principal Consultant.

Details of the Data Collection and Reform Process
The technical reform process begins after the decision to implement Enterprise Lean and after the functional Lean teams have completed their Value Stream Mapping (VSM) studies.  The important data that is necessary for reform is the functional cost data developed by the Functional Lean Teams from their individual functions.  The data will be collected in electronic tablets  using a spreadsheet program specifically designed for this process.  All tablet spread sheets will be continuously updated using a special Google App (application).  The Principal Consultant will provide on the job training of VA Analysts in the collection of this data and all subsequent reform steps.

Lean Team Data that is collected and allowed to accumulate
The following steps show how the Lean Team Data is collected and allowed to accumulate in the spreadsheet program and how the summarized data is used.  This approach to reform meets all of the VA’s criteria for an Agency: efficient, effective, ethical, equitable and responsive .

1. The VSM (Value Stream Mapping) for each function will be documented in the spreadsheet.

2. All labor and expense cost data will be documented and allowed to accumulate as functions are added to the spreadsheet until all of the Agency’s functions have been accounted for.

3. The names of the employees working on the function will be documented with any special expertise they are using in performing the function.  Each employee’s labor hours expended in doing the function will be documented and allowed to accumulate.  This data will be used during the Right-Sizing process.

4. Where there is interaction between several employees during the performance of the function as a part of the VSM a work load balancing chart will be a part of the documentation.  This work load chart can be used later to balance the function’s work load.

5. When all of an Agencies Functions have been logged into the spread sheet the final labor hours and expense numbers will have been automatically tallied in the spread sheet along with the total hours worked by each employee in the particular function.

6. A key question asked of employees is the estimate for the number of times that the function is done per week and recorded in the spread sheet.   This number is authenticated by history and other knowledgeable personnel including the enumeration of purchased goods consumed by the function.

7. The total annual accumulated functional hours is at 100% productivity and must be converted to provide a realistic number at 75% productivity.  To make this conversion you will add 25% more time to the total or multiply the total time by 125%.   This becomes the labor hours for staffing and budgeting and is what is referred to as a Gross Load among consultants.  When all of the Agency’s functional labor hours have been accumulated at 125%  and we add in the total annual expenses we have what I call a Bottoms-up Functional Budget.

8. Next we want to compare the Bottoms-up Budget with the current Top-Down Agency Budget.  To do this we remove all management and overhead expenditures from the Agency’s Top-Down Budget to obtain an equal expenditure.  Then we compare the Bottoms-up Budget with the Top-Down Budget.  The Bottoms-up Budget should be 20% or more less than the Top-Down Budget.  If this is not the case then we have introduced an error more than likely in the number of times that a Function is being performed annually.  This should be resolved by reviewing the Lean data in the Agency’s spreadsheet.

9.  We can now do Right-Sizing using the employee accumulated Lean data from the spreadsheet.  As a rule of thumb the employee accumulated hours is separated between those who have accumulated more than 20 hours per week average and those who have accumulated less than 20 hours per week.  Those who have accumulated less than 20 hours per week are considered to be redundant and slated for layoff.   Their accumulated hours are spread among those with more than 20 hours per week increasing their hours to at least 37 hours per week.  This involves reviewing each function and reassigning tasks to employees according to their capability and availability.

10. We now need to review the spreadsheet for those jobs noted as occurring on a random basis.  These special jobs need to be separated form those jobs that occur on a continuing basis.  An individual employee is specially trained to do the job of Work Planning, forecasting scheduling these jobs on a weekly basis.

11. The spreadsheets are stored on thumb drives for each Agency and protected.  The labor data for each function is stored in a Database at 100% to be used for calculating productivity where required.  The Database also includes the staffing and bottoms-up budgeting data.  I recommend that the data be protected by an independent organization such as the VA.  This allows availability of the data for all who want to review the actual labor and expense cost of an Agency function including the Agency’s Bottoms-up Budget.


Phase 5. Organization Reform
In the final step of the General Reform Model the Principal Consultant will begin the process of organizational reform by replacing the Bureaucratic organization with a Team Management organization with top management managing the Agency’s activities through Group Teams with each managing several Functional Teams.  The Lean Teams at the Functional level will become self managed Functional Teams with each of their elected leaders reporting directly to a Group Managed team.  Group Managed Teams will assume their management role from the pre-organized high level Lean Teams.  There is some flexibility in how this process actually occurs but it is necessary in order to eliminate the problems caused by the Bureaucratic organization.  The important advantage in changing from a Bureaucratic organization to a Team Managed organization is that the savings continues annually for years.

This is also the period of time for the reduction of redundant of management and staff.  To attain a balanced work load is the primary objective where retraining employees to fill needed vacancies is pursued. Once it is known where staffing can be reduced layoffs or temporary reassignments should be completed within a month.


The Consolidation Model by Lawrence Rosier Principal Consultant
Comparison of Duplicated Services (If required).  The VA Lean Team is used to evaluate the efficiency of the duplicated Function and its associated cost data.   Outcomes are to be compared with all the other duplicated Functions from all the organizations depicted in a matrix chart where duplicated Functions are to be compared. Those duplicated services rejected for low efficiency will be declared as redundant and their budgets cut followed by reassignment or layoff of employees.  Those services with the highest efficiency will have their budgets moved to the new final single service group and the employees will be given the opportunity to move to the final service group providing the services.



Exhibit B. The VA Employee Support for this Agreement
This Agreement requires the VA to follow the Principal Consultant’s General Reform Model and the requirements therein as outlined below:

Enterprise Lean Support Requirements provided by the VA.

1. The VA Inspector General will have oversight of this Agreement.

2. To meet VA’s Training obligations for the General Reform Model it will bring in a qualified Enterprise Lean Seminar presenter to make several presentations of the process of Enterprise Lean to Management and government employees of the Client Agency.

3. Five to Ten VA Analysts will be provided by the VA Inspector Generals Office and will be trained and lead by the Principal Consultant in the implementation of the General Reform Model of this Agreement.
The number of VA Analysts provided will impact the length of time required to complete this Agreement.

4. The VA Analysts will also act as Facilitators during the implementation of Enterprise Lean to work with Functional Lean Teams where required.  Each Functional Lean Team will meet once a week to do their Value Steam Mapping of their function or functions.  Each Analyst Facilitator can meet with about 30 Functional Lean Teams each week for about 4 weeks.  The Total number of Analyst Facilitators required depends upon how fast the VA wishes to complete the implementation of Enterprise Lean.

 5. The OIG representative at the Phoenix Medical Facility shall have the authority and responsibility to hire new personnel to fill vacancies identified by the Principal Consultant.



Exhibit C. Intellectual Property Owned by Lawrence Rosier & Associates
The primary Intellectual property which Lawrence Rosier & Associates own exclusively is their Approach using the following:
1. General Reform Model (The primary Model of this Agreement).

The General Reform Model 
The General Reform Model uses Enterprise Lean to Right-Size the organization getting the highest efficiency possible while improving the effectiveness of the organization. It uses the Lean study data for Work Measurement to determine the proper staffing and budgeting.  The method trains the organization’s managers in Enterprise Lean forming teams to do high level studies. All Functional employees are trained in Lean forming Self-Managed Lean Teams to study each of their functions.   After the Teams have gained in sufficient skill level the bureaucratic organization is replaced by a Team Management organization.  The Method empowers employees to make continuous improvements to the company’s operations.  The method reforms the company while improving employee morale. 

Although Enterprise Lean is a part of the General Reform Model it is not the intellectual property of Lawrence Rosier & Associates but the use of the data developed through the implementation of Enterprise Lean is the exclusive intellectual Property of Lawrence Rosier & Associates.

The Consolidation Model
The Consolidation Model will require approval before implementation by the Inspector General as required by this Agreement. The Consolidation Reform Model is a method of approach that is general enough to be applied to most situations in government requiring consolidation.  The Consolidation Model is to be implemented by the Principal Consultant the model’s developer Lawrence Rosier.  The Model is composed of three major phases.  Phase I.  Implements Lean Teams in each service area where duplication occurs to develop accurate functional data for making decisions.  Phase II. Provides a method to expediently and efficiently evaluate the Functions performed in all of the services to be consolidated.  Phase III. Selects those Functions worthy of performing and builds an efficient Team Managed consolidated organization.

Contact Information:
Lawrence Rosier & Associates 12143 Cedar Grove Rd. Rolla Missouri 65401 
(573) 364 8789    cell (573) 578 4716 Website: http://lawrencerosierconsulting.blogspot.com
I am always available to answer confidential questions. Email: lawrencerosier4@gmail.com 

About: Lawrence Rosier Principal Management Consultant Government Reform

Lawrence Rosier is a Management Consultant specializing in Government Reform. He was formerly a Management Consultant with Alexander Proudfoot and Scheduling Corp. both firms located in Chicago. He has served on the staffs of: the Manager of Special Projects, Boeing Co., President of McDonnell Douglas Missile Systems Co. and Vice President of Manufacturing of McDonnell Douglas Missile Systems Co. Education includes degrees in Industrial Engineering and Secondary Education. He was a graduate instructor at the University of Washington Experimental Education Unit where he studied Behavioral Modification for exceptional children. He was also the Manager of Manufacturing Engineering for Multiplex Company in St. Louis.

His most significant achievement was the proposal and acceptance by Sanford McDonnell CEO of McDonnell Douglas Corp. of a modification to the company’s Quality of Work Life (QWL) implementation (the forerunner of Lean Manufacturing). The modification replaced the existing Bureaucratic organization with a Team Management organization consisting of Steering Management Teams and Functional Management Teams for the McDonnell Douglas Missile Systems Co. This Team Management style was enthusiastically received by employees and inspired employee innovation. It was used successfully for over ten years until the sale of the company to Boeing in the 1990’s.

Lawrence married Sharon White a former school teacher and has no children.  He is from a well respected family which is one of the largest private land owners in Missouri which recently installed 19 wind generators.