Highlights of the VA Audit Findings Released June 9, 2014
Now with results of audits taken in 731 VA Medical facilities by the Inspector Generals Office throughout the VA the following discoveries were made:
1. 57,000 Veterans waiting 90 days or more for first appointments
2. 64,000 Never had appointments scheduled after registering and requesting medical care
3. Thirteen percent of Schedulers say supervisors asked them to falsify appointment schedules
4. The 14 Day target wait times “not attainable”
From PBS NEWS Hour Gwen Ifill Interview with Ralph Ibson and Dr. Sam Foote.
My Approach to fixing the VA Now
The solution of the VA problems should be seen as a short term solution to immediately serve the Veterans who have waited for appointments and in a long term solution making a final implementation of reforms that changes the culture and makes the entire VA system effective and efficient. This will require Congress to enact Legislation for outside contractors to implement the reforms.The Short Term Approach for all VA Medical Facilities
1. Make sure all Vets Who want an appointment are added to the electronic appointment Schedule.2. Make a detailed assessment of each patient’s medical needs to determine where and by how much the VA Medical Facility will be impacted.
For example at the Phoenix VA Medical Facility I recommended a mass screening of the 1700 new patients entered into the system with patient interviews and blood tests. By reviewing 100 patients a day the task of finding what the patients health care needs are can be completed in a month.
3. VA leaders who have compromised the VA scheduling system should be removed or disciplined before mass hiring of needed staff is initiated.
4. The OIG Analysts and others in the VA can now make estimates of where staffing is needed and begin the hiring process.
5. If a VA Medical facility can not meet staffing requirements for Patient Appointment standards then the following immediate steps to correct the problem may be put in place.
(a). Retrain nursing staff from other over staffed areas if possible to fill some of the requirements. This is beyond the current capability of OIG auditors.
(b). Hirer nursing and doctors as quickly as possible.
(c). Allow Vets with critical needs such as cancer patients to go to private Medical facilities at government expense.
Special Implementation of Lean at Phoenix Facility
The Initial Implementation of employee Lean Teams at the Phoenix Medical Facility is followed by collection of Lean Team data.Those areas identified as needing increased staffing at the Phoenix Medical Facility will be addressed first. This is a preliminary start by finding through employee Lean Teams as quickly as possible where exactly increased staffing is needed and the level of staffing that should to be hired to meet appointment standards. The data for increased staffing at the Phoenix Medical Facility can be replicated in all VA facilities.
The Approach:
A. Identify all systems processes affected by increased patient loads from the mass screening and establish an employee Lean Team for each set of processes. Empower Lean Teams (Preceding the long term Enterprise Lean implementation) to come up with the most effective and efficient approach for doing the process. This approach will also identifies the needed equipment and machines to be purchased by the Phoenix VA. In doing this approach the Team will have also determined the time for doing the entire set of processes and the staffing required.
As Principal Consultant I will take the lead in this endeavor with the help of OIG Analysts. Informal training in Lean is provided by myself and the trained OIG Analysts for the employee Lean Teams. To understand how the process works to get the maximum patient throughput see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness.
B. The time for doing the processes developed by the employee Lean Teams will be added to the time for each and every system affected by patient impact in a particular area within the Phoenix VA medical Facility. The required staffing can not only be determined for the Phoenix Medical Facility but the data can be used in all VA medical facilities to arrive at staffing requirements calculated to meet any patient appointment standard.
Long Term implementation in all VA Health Care Facilities
The long term approach begins with the full implementation of my General Reform Model in the Phoenix VA Medical Facility. The implementation is primarily a training mission for preparing OIG Analysts to replicate the reforms in the entire VA health care system. It is step by step process beginning with Part 1. the implementation of Enterprise Lean throughout the entire Phoenix Facility and in all other VA Health Care Facilities. After OIG Analysts have been trained at the Phoenix Facility they will be able to implement the remaining Parts of the General Reform Model in all VA Medical Facilities.Implementation of the General Reform Model at all VA Facilities
Part 1. Implement Enterprise Lean in all VA Medical Facilities
I recommend the mass implementation of Enterprise Lean in every VA Medical Facility in the US. The reason for doing this is that it brings a culture change in the VA employee environment converting the current negative toxic bureaucratic environment to a positive productive environment and focuses employee attention on serving Veterans health needs with effectiveness and efficiency. Enterprise Lean is proven industry method developed by Toyota and is the initial step in my General Reform Model.
The General Reform Model: Empowers VA Employees through Lean Teams(Enterprise Lean); determines the actual cost and staffing required to meet appointment standards; changes the current Bureaucratic management to a Team Managed organization; and identifies incompetent management.
This is a low cost solution available now which can yield results in the Phoenix VA Medical Facility within three months with full implementation within six months to a year. The process develops the management data that can be replicated in all VA Medical Facilities.
Implementation of Reforms at the Phoenix VA Medical Facility
The VA Inspector General will also have oversight of this part of the 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 Lean Data work Load.
Selection of VA Analysts for Training at the Phoenix Facility
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 full implementation 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 of redundant employees including management staff.
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 suggest replacement of incompetent management including adding and reducing staff where required to balance work loads at the Phoenix Medical Facilities. The VA will be responsible for hiring all management and staff.
The General Reform Model at the Phoenix Facility:
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.
Phase 1. The VA Inspector General's Office will have 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.
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 VA and those that interact with other VA facilities 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.
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.
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