Article  72. Restoring Management Excellence at the VA

The VA Health Care system has a clear obligation to improve its management capability through Best Practices both in the medical services it provides to Vets and in the management practices it uses to manage the Health Care system.  The OIG provides audit capability for lost and misspent funding.  This is an after the fact activity which largely misses what is really is needed in managing the VA Health Care System.  The Audit capability manages waste in funding dollars it does not manage labor expenditures or machine and facility utilization.  The VA does not have a labor management system based on the actual cost of health care processes nor does it have an adequate equipment and facility utilization system based on Resource Accounting.  But Resource Accounting can be very expensive to implement and manage I recommend that that resource management of machine and Facility utilization be tied directly to the Best Practices in health care.  Once the Best practices have been established for a medical area such as Cardiology they will determine the needed imaging equipment and the floor space for a balanced patient load.

The VA does have Quality management Services
The Quality Management Service focuses on the Veteran and organizational functions that promote positive patient outcomes by standardizing processes.  These standardized processes can be used as a starting point for the development of the cost in labor and expense for all functions of the VA.  Without this basic data VA management can not adequately determine which functions are operating with relative efficiency and which are not.  Private industry keeps tabs on the cost of parts and labor processes using time study but due to the cost of time studying they only time study manufacturing production areas. The following approach avoids the cost and the disagreeableness of time studying health care personnel.

Enterprise Lean avoids the problems of time study by empowering the employees themselves to find the most effective way including testing of current Standardized practices to arrive at a Best Practice for doing their jobs followed by determining how this can be done with the most efficiency.  In the process of doing this you will be employing the knowledge of the employees who are actually doing the work in most cases the real experts.  Facilitators Guide the Functional Lean Team through the Lean process and document the results in a Best Practices spreadsheet.  Besides the identification of the Best Practices for health care and management the lean process will also provide: the labor hours expended, the machines utilized and a basic sample of the floor space involved in the function. When all of the functions have been documented you will have a functional budget and the critical data needed to manage VA operations. But most importantly the data can be used to develop a balanced work load to minimize Wait Time. Employees waiting on other employees is the single biggest source of inefficiency.  This is addressed in the development of a Throughput Staffing Schedule which balances employee work assignments for different levels of patient appointment schedules.

Obtaining the Critical Management data Needed by the VA

I recommend that my General Reform Model be implemented in two parts.  The first part addresses the immediate need to develop the data for determining staffing and facilities expansion for all VA facilities.  This done by providing a Throughput balanced work load for each medical area with expanded steps which can match the patient requirements for any VA facility. This will be done in the areas where increased patient services are required.

The second part completes the implementation of the modified Enterprise Lean in all remaining areas of the development VA Facility.  

Part One:

The following approach addresses the immediate need to develop the data for determining staffing and facilities expansion for all VA facilities.  This is done by providing a Throughput balanced work load for each medical area with expanded steps which can match the patient requirements for any VA facility. This will be done first in the areas where increased patient medical services are required.  Think of each step as being a balanced set of Best Practices functions that eliminates wait times with the right combination of staff that can service a specified number of patients.  With each step a doctor and support and nurses are added and the functions are rebalanced servicing a larger number of patients.

This approach works in all areas where the number of Doctors is the key driving force but where Psychologists and Physical Therapists are involved an entirely different approach is needed based on the diagnosis of each individual patient and the patient's plan of recovery.  I suggest the following approach:
1. Establish a high level Doctors Lean Team to develop or adapt Best Practices for patient Recovery Plans.
2. Standardize Recovery Plans.
3. Determine the cost for each recovery Plan.
4. Determine the number of patients assigned to each Recovery Plan for an annual budget.

Overall Plan based on number of Doctors:
First two months
Each VA Medical Facility will identify all maximum patient loads in each medical area to meet required patient appointment schedules (not a part of the Consulting Agreement). This data will be needed to staff Throughput Schedules being developed at the development VA Facility.

This Consulting Agreement develops a Throughput Schedule plan for each area where medical services are needed to meet increased VA patient loads.  An OIG Analyst will be assigned to each medical area to Facilitate Hospital Employee Lean Teams in applying Best Practices to each of their Functions.  The Lean Data will be captured in a spreadsheet and used in the higher level Doctor’s Lean Team to develop the Throughput document which will be captured in a staffing spreadsheet.  The Throughput staffing spreadsheet will contain a large number of repeated reiterations of the original Best Practices balanced schedule design.  The Throughput Document will contain enough reiterations to meet any VA facility’s patient appointment schedule requirements. 

Third month
The staffing spreadsheet for each medical area will be test implemented at the development VA Medical Facility.  With the success of the test implementation each spreadsheet medical area will be stored on a thumb drive. 

Fourth Fifth and sixth months
Each OIG Analyst will depart The development VA Facility for another VA Medical Facility with the medical Thumb drives containing a spreadsheet Throughput Schedule for each medical area.  Spreadsheets have a unique capability for selecting what gets printed.  In this case the number of patients needed to meet a VA Facilities appointment Schedule can be selected from the staffing spreadsheet before printing the Throughput Schedule for a specific VA Facility.

Part Two:

The second part begins in the third month and completes the implementation of the modified Enterprise Lean in all remaining areas of the development VA Facility.  The reasons for doing this is to determine where over-staffing is occurring so employees can be retrained to fill the needs in under staffed critical medical areas and to develop a functional Budget for the development VA Facility. This will provide the data needed for management budget decisions as well as machine and floor space utilization for the entire development VA facility.

Part two should be implemented at all VA facilities this will take some time but trained OIG Analysts should be able to make these implementations in a few years. As new VA medical facilities are built any over-staffing identified by the full implementation of the General Reform Model in existing VA Facilities can be transferred to the new VA Facilities.

Organizational Reform:
To address the problem of the toxic bureaucratic culture of the VA I recommend replacing the Bureaucracy with Team Management.  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 to prevent the return to a toxic bureaucracy.  The Team Management process eliminates the need for low level supervisors saving $billions.

I suggest that VA Should Look into the expansion needs of those VA hospitals that are operating on one shift.  A two shift operation doubles the capacity and solves machine and facility requirements almost instantly.