Reference:
The Book "Downsizing the Federal Government" by Chris Edwards Published by the Cato Institute 2005 On line at: Downsizing-the-Federal-Government.pdf
This book makes a good case for cutting back the federal Government. I recommend the book because it enumerates the extent of the growth in funding.
But I have the following objections to the process presented.
1. Downsizing means cutting back departmental budgets. The problem is how much can you cut back budgets and retain operations, no one knows. This leads to confrontation between those trying to cut costs and Department heads. Departments can simply slow down operations to prove the need for added funding.
2. This process will remove unwanted activities and can be used to simplify government. But it has no provision to make the government operate efficiently.
3. There is no permanent solution in this approach leading to continuous confrontation at each and every funding period.
My solution presented in Articles 82 and 84 provide a permanent solution with
the following approach:
1. First simplify government not unlike the method in Chris Edwards book. This helps to get rid of unnecessary spending and by also using my "Effectiveness Tool" and "Consolidation Model" (for duplicated operations).
2. I use the term "Right-sizing" because it identifies the work that is being done and the staffing needed to do this work. OIG Analysts collect the data from the work that is actually being done in a bottoms-up manpower budget. When all the work has been collected we know exactly what the staffing should be. When Congress funds a new government initiative it will provide startup funding followed by the OIG Analysis to determine what the actual budget should be. For the first time the Federal Government will be properly managed.
3. My approach recognizes that the main problem with the Federal government is with the Bureaucracy itself as an independent powerful organization which seeks to protect itself and get the most funding that it can. I have provided an alternative to the Bureaucratic organization.
The Right-sizing process is followed by the implementation of "Enterprise Lean" which provides Teams of government employees who meet to continuously improve their jobs. Enterprise Lean along with Six Sigma allow government employees to
participate in the management of government activities by making
continuous improvements at the work place. After a few months the Teams will become proficient in solving problems in the work place. The Top Management teams will then assume management of the Department and redundant Bureaucratic management will be removed.
Contact Lawrence Rosier
Lawrence Rosier Consulting
12143 Cedar Grove Rd.
Rolla, Missouri 65401
573 578 4716
lawrencerosier4@Gmail.com
Tuesday, January 31, 2017
Sunday, January 15, 2017
Article 91. Reprint Innovations in Healthcare
Reprint: Innovations in Health Care January 2012 by Lawrence Rosier
How to Have Effective Health Care Reform
Just when we thought that healthcare in America couldn’t get worse we get Obamacare the worst solution for providing healthcare that has ever been put forward. The problem is that their approach is dead wrong they used the same old political approach that nearly always comes up with a bad solution. They take a failing healthcare system fraught with waste largely from corruption and they expand it compounding the the waste and corruption trying to get healthcare to more people. They get together the biggest stakeholders, special interest groups, and they reach a compromise that they can live with then they pass the costs of health care to the public and make everyone pay.
The approach I recommend is to always fix the systems first and health care is a
delivery system. The key to this approach is to form an Elite Team of the best professionals with the most knowledge of our health care system without connections to special interests. Then have them go through the current health care delivery system reviewing the healthcare delivery process. They will separate the value added (needed processes) from the non-value added processes. This exercise is applied to the high level aspects of the healthcare system without getting bogged down in the details. This analysis should also compare European healthcare systems with our own they currently deliver health care more efficiently than we do.
The next step is to take a fresh look at the thousands of suggestions for fixing our health care systems. Once we have an efficient solution then, and only then, do we bring in the principal stake holders the special interests to hammer-out a final solution.
One of the major problems is how do we deliver to the individual the healthcare each of us needs. A problem occurs if the states define their own healthcare rules then insurance companies cannot operate efficiently with fifty different sets of rules. The following article offers a solution to this problem.
From: “How to Have Effective Health Care Reform” By John Huntinghouse
Ref. 2. John Huntnghouse’s website: http://www.huntinghouseblog.com
The steps needed in order to have effective health care reform using a free market approach to the topic.
Step 1.
Realize that our current system is not a free market system. We need to start off this discussion by making the point that our current system has many public policies that prevent markets from working. Such policies can be found in ill conceived federal tax policies, insurance regulation, and barriers to entry specifically have shielded the consumers from costs and greatly inhibited competition.
Step 2.
Increasing the choices we as individuals have for our own health care. Many people state that our current system gives us choice and the freedom to pick our providers but if you closely look at it, this is not the case. Look at who you get your medical insurance through. Did you pick your insurer and medical plans?
If you are employed by a company, there’s a good chance that you only had one choice of medical insurance provider and that provider may have had at max, 3-4 options on medical insurance. This lack of competition between individual consumers stifles true competition that in a natural market would bring healthcare costs down.
Step 3.
Increase co-payments and deductibles. Some will say “why would you want to increase deductibles and co-payments?” The reason why you would do this is to give consumers more “skin in the game,” by making them aware of the cost of health care and the differences between insurers and health providers.
Right now because of a low deductible you would go into any physician’s office and let them run as many tests as the doctor seems fit to do. You have no idea of the cost of the each test let a lone the cost between physicians because you pay the same co-payment regardless of where you go. Plus with such low deductibles you could care less how much extra it cost for certain tests or the difference in price between physicians because the insurance will pick up regardless. This costs the insurer more money and thus it will ultimately increase the monthly premiums and further raise the deductible in the long run.
Based on the RAND Corporation’s National Health Insurance Experiment, “if the average annual health-plan deductible were to rise from its current level of $250 to even $500 and the typical coinsurance rate were to rise from 20% to 25%, we estimate that annual health-care spending would decline by $65 billion per year.
Step 4.
Remove individual state restrictions. Even with the tax field leveled the consumers would run into the problem with the insurance markets within specific states. Obviously each state is different with their differing regulations and mandates but there are approximately 1,500 specific insurance coverage
requirement that are imposed by the various state legislatures. Some of these requirements and mandates are beneficial but not to all. Such is the case with chiropractic care and alternative medicine. These are options that should be chosen by the individual consumer and because it is not, the cost must be covered by all who are part of the plan. Insurance providers need to be allowed to go nationwide and not be so encumbered by every individual state regulations and mandates. By allowing insurance companies to go nation wide, one of the benefits is that the insurance you have would become portable. You would be able to leave one job in one state to go to another job in another state and yet still keep your insurance coverage. By removing many of the state mandates and any-willing-provider laws, the average cost savings would be around 7 – 17%. That would be around $600-$1500 a year for the average family that they could be saving each year.
Step 5.
Lower the barrier of entry. To avoid what has happened to the law industry, the medical industry and government have restricted the supply of health professionals who enter medical school or other types of higher education learning for the industry. Thousands of candidates perfectly qualified to enter medical school are not allowed in due to the fact that there are these strict regulations in place to prevent the over saturation of health professionals in the field. This is another example of basic supply and demand principle that affects many of us to timely health care. Many of the family practice physicians are no longer taking new patients because they are completely booked. Those advocates will tout the fact that they are doing quality and cost control. However, this effectively results in market participants (the doctors and hospital in charge of medical schools and residency programs) acting in cooperation with each other to
restrict competition, which is a violation of antitrust laws. The Supreme Court has previously ruled that ensuring quality is no defense against such practices. To fix this problem, no new legislation would need to be passed, the government would only need to enforce the laws are that are already on the books. There needs to be a better balance between the strictness of the standards of medical school (not quality of physicians) and the benefits of greater competition. On top of this, there are many states that have laws that restrict nurse practitioners and other qualified health providers from providing needed care that they are perfectly qualified to do. The massive shortage of health providers in rural and underrepresented areas
could be filled with such personnel.
John Huntinghouse seams to indicate that public heath care insurance should be organized more like car insurance. The selection of a car insurance provider is entirely by customer choice and is valid in any state in the union. Assuming this is the case then employers should supply a block grant of money for health care
insurance for each employee allowing them to find the health care provider that best fits their needs. The primary reason for health care insurance should be for catastrophic injury and illness and not to cover all health care costs. This allows the insured to be protected from unforeseen massive health care expenditures while having affordable insurance rates.
The author indicates that a range of copayments be charged for different medical services and tests and that the copayments should be significant enough to make the policy holder think about the cost of the service and its value to him. He also suggests that the number of graduating doctors is artificially held to a
predetermined number and should be allowed to expand to allow all graduates that are qualified to become doctors.
This article assumes that private insurance is the answer to our health care problems. An alternative is the government run health care programs found in Europe which we dismiss as socialism. We have the highest health care costs among the leading nations of the world. England, France and Italy all have complete health care for all of its citizens. They are taxed pretty heavily for this and only a few have private health insurance (mostly the rich). We call this socialism because the government provides the entire health system the hospitals and health insurance and not private companies. These European systems require virtually no paperwork since all citizens are eligible. Contrast that with the mountain of paperwork we do in the US just to determine if we are eligible. The primary benefit besides to the citizens is that companies and small businesses don’t have to provide health care insurance. Many Europeans before visiting the US ask themselves the question “What do I do if I get sick?” That’s the same question many of us in US are asking.
Making Lean Teams Work in State Health Care by Lawrence Rosier
The answer is to reform government and make it operate like a private business. If this is done properly no private business can compete. No one in the past believed that a government organization could be made so efficient and effective that a private company could not make a profit and therefore not be able to compete. The following approach using Enterprise Lean makes competition with a private company unprofitable.
Enterprise Lean is a concept developed and implemented in industry by Toyota can be applied directly to a state healthcare organization. The entire healthcare organization’s Lean approach is to inspire healthcare workers and the public to participate in bringing a renewed interest in health and senior services by focusing on raising the level of quality and public awareness of health practices.
One of the first efforts of a healthcare organization is to develop an all inclusive Mission Statement. Mission statements are not easy to develop but the difficulty can be somewhat eased by developing a proposed list of accomplishments which the organization thinks it can achieve. Then try to boil these down into a single goal statement which includes all stake holders as well as the general public. Remember that volunteer workers can be a significant asset to the state. This is where the “role of state healthcare” is defined a necessary step given the limitation of state resources. Many states have differing roles especially in the area of Medicare Management.
This was the “inspiring” portion of the approach the next step is in bringing innovation in health care through Lean Teams which I would rename to something more relevant such as: Health Quality Teams (HQT). A facilitator trains and guides each HQT as it elects its own leader. The goal is to “empower” healthcare workers in each function to develop ways of improving the healthcare processes and raise the level of healthcare quality in their function.
The team should review the current processes used by the function. The best way to do this is to create a Processes Flow Chart on long sheets of wrapping paper or butcher paper taped to the conference room walls. The long sheets can be taken down and rolled at the end of each meeting. Each process is created on
8 ½ x 11 sheets and taped to the wall allowing changes and corrections to be made to the wall as the method proceeds. After discussions an improvements to the process are agreed upon by the team a second improved process flow is added to the wall chart showing the improved method. The reason for doing this is to show the costs and the time to perform each of the processes in the improved method. In the interests of improving quality the time to perform the new processes may actually be longer than the old method. If some way of getting the improved quality can not be found while reducing costs the method is still
presented to top healthcare management for approval as the improved processes to be used by the function. If approved the method is documented and given to a Budget Analyst for costing-out the processes.
Note: that there is a closer relationship developing between healthcare management and the HQT functional teams. The empowerment of HQTs inspires them do more innovation and to continuously improve the function’s processes. The second phase of government reform begins by making the HQT leaders the leaders of Functional Management teams. Top management becomes the Steering Management Team. The lower level managers at this point become redundant however some may be required as part of the Steering Management Team.
Steering Management has the role of guiding and steering the organization while
Functional Management deals with the day to day operation of the functions. Steering Management is responsible for telling Functional Management “what to do” but not “how to do it”. This is a loose-tight organization with Steering firmly in control of the budget leaving Functional Management free to determine how best to do the job. Those in industry will recognize this as straight from the book “In Search of Excellence- Lessons from America’s Best-Run Companies” by Thomas J. Peters and Robert H. Waterman Jr., Harper and Row, Iowa, 1982.
The goal is to reduce bureaucracy by removing layers of management while putting more functional employees to work thus improving health services. The overall difficulty is in finding the best balance of choices for what should be done with what can be done with limited resources.
Innovation in Health Care Nurses Become Doctors (new in 2012)
There are lots of new innovations occurring every day in health care but the acceptance and implementation sometimes takes years. Most of the time acceptance of new ways of doing things is hindered by lack of funding but human habit and established procedures also contribute and are difficult to overcome.
One of the major problems in healthcare is the lack of doctors especially in small towns. The lure of high incomes and the big cities has left many small towns without doctors. Years ago doctors would diagnose patients using his best educated guess and proscribed treatment for what he thought would cure the patient. The patients never questioned the opinion of the doctor and whether they lived or died there was nothing else that could be done. A second given was that doctors in the past were always men and nurses were always women. When I was a boy that is how you knew which was the doctor and which was the nurse.
This aura and stigma about what a doctor is still exists with us today. But times have changed doctors have many ways of testing to determine a correct diagnosis. Medical advice and prescription drug definitions are available to everyone on the Internet. Nurses today are many times more knowledgeable than doctors were when I was a boy. The bottom line is to let experienced Nurses by taking a special state board examination become General Practitioner Doctors. I can hear the bloody scream from the American Medical Association (AMA) already. If in fact you had to wait for the approval of the AMA it would never happen in our lifetime. They have the duty to protect the medical profession but this also means protecting the income of doctors. If the AMA will not approve this change then it must be done by fiat. Get the approval of the nursing profession and just do it. The need is too great to wait for AMA approval.
There is another related problem there is also a shortage of nurses. But when you put these two problems together a shortage of doctors and a shortage nurses the solution isn’t obvious and here is why. There is high dropout rate for trained nurses over the years they burnout from shift work and in just a few years they
reach the top of their pay grade. In short though highly trained there is nowhere to go in the nursing profession. If nurses especially supervision nurses with at least ten years of experience could take a board examination and become a doctor the glass ceiling would be broken. More nurses will enter the profession and stay in the profession longer if there is the possibility of becoming a doctor. You can also make the condition that nurses who become doctors must practice in a small town for five years before final approval and permanent status as a doctor.
Poka-Yoke in Health Care
Poka-Yoke, a Japanese term, one of the Lean tools that has recently become very important to the health care industry because it focuses on making systems error proof. Drug to patient delivery systems are very important because of life threatening errors which can occur at any point in the process. Now we have a
system that replaces a doctor’s Rx with the drugs numbered eliminating the chance of error with the pharmacy. Poka-Yoke can be used almost anywhere but it has its greatest value in life threatening cases and where the cost of damaged materials is high.
Approach to Out of Control Health Care Costs
The nation is struggling with the high cost of healthcare and prescription drugs. We have become a second rate country in the area of healthcare. But other nations that provide free healthcare are nearly going bankrupt and will soon cut their services. The first thing to do is to look at how we got into this mess. In the
1980’s most large employers provided dental and health insurance with a co-payment. In the 1990’s they moved to HMO’s forcing physicians to get an ok with the HMO before expensive treatment could be undertaken.
The biggest mistake being made is in not finding out where the money is really going. Is it going to new facilities, new equipment, salaries (doctors, nurses, specialists), special services (sports medicine, nursing home services, etc.) or increased medicine costs. You must know where a disproportionate amount of the funds are going and the best way to this is through state auditing. Simply increasing funding clearly has not and will not solve the problem as costs explode. The crisis is real hospitals have increasingly taken to illegally adding false services and unnecessary items to patients bills.
Once we find where the funds are going we can pick those items that the state legislature can deal with and bring under control. For example doctor’s salaries driven by high liability insurance premiums. The legislature can cap proceeds from medical malpractice law suits and form a state insurance pool for doctors
to pull premium costs down.
Auditors can survey hospital room costs and salaries to determine if they are out of line with national averages. A survey of facilities funding will determine if funds are spent on giant atriums instead of hospital rooms. Do area hospitals have reciprocal agreements to share the latest technological equipment or does each try to get all the new technologies which are then under utilized?
The nation is struggling with the high cost of healthcare and prescription drugs. We have become a second rate country in the area of healthcare. But other nations that provide free healthcare are nearly going bankrupt and will soon cut their services. The first thing to do is to look at how we got into this mess. In the
1980’s most large employers provided dental and health insurance with a co-payment. In the 1990’s they moved to HMO’s forcing physicians to get an ok with the HMO before expensive treatment could be undertaken.
The biggest mistake being made is in not finding out where the money is really going. Is it going to new facilities, new equipment, salaries (doctors, nurses, specialists), special services (sports medicine,nursing home services, etc.) or increased medicine costs. Auditors can survey hospital room costs and salaries to determine if they are out of line with national averages. A survey of facilities funding will determine if funds are spent on giant atriums instead of hospital rooms. Do area hospitals have reciprocal agreements to share the latest technological equipment or does each try to get all the new technologies which are then under utilized?
We don’t need auditors to know that Medicaid costs are out of control and linked directly to the increasing costs of prescription drugs. My solution which I have stated elsewhere is to form a Federal Government lead consortium of states to negotiate directly with drug manufacturers to obtain pricing at least as low as that found in Canada. As long as the states are divided and have no negotiating power the sky seems to be the limit on prescription drug prices.
How to Have Effective Health Care Reform
Just when we thought that healthcare in America couldn’t get worse we get Obamacare the worst solution for providing healthcare that has ever been put forward. The problem is that their approach is dead wrong they used the same old political approach that nearly always comes up with a bad solution. They take a failing healthcare system fraught with waste largely from corruption and they expand it compounding the the waste and corruption trying to get healthcare to more people. They get together the biggest stakeholders, special interest groups, and they reach a compromise that they can live with then they pass the costs of health care to the public and make everyone pay.
The approach I recommend is to always fix the systems first and health care is a
delivery system. The key to this approach is to form an Elite Team of the best professionals with the most knowledge of our health care system without connections to special interests. Then have them go through the current health care delivery system reviewing the healthcare delivery process. They will separate the value added (needed processes) from the non-value added processes. This exercise is applied to the high level aspects of the healthcare system without getting bogged down in the details. This analysis should also compare European healthcare systems with our own they currently deliver health care more efficiently than we do.
The next step is to take a fresh look at the thousands of suggestions for fixing our health care systems. Once we have an efficient solution then, and only then, do we bring in the principal stake holders the special interests to hammer-out a final solution.
One of the major problems is how do we deliver to the individual the healthcare each of us needs. A problem occurs if the states define their own healthcare rules then insurance companies cannot operate efficiently with fifty different sets of rules. The following article offers a solution to this problem.
From: “How to Have Effective Health Care Reform” By John Huntinghouse
Ref. 2. John Huntnghouse’s website: http://www.huntinghouseblog.com
The steps needed in order to have effective health care reform using a free market approach to the topic.
Step 1.
Realize that our current system is not a free market system. We need to start off this discussion by making the point that our current system has many public policies that prevent markets from working. Such policies can be found in ill conceived federal tax policies, insurance regulation, and barriers to entry specifically have shielded the consumers from costs and greatly inhibited competition.
Step 2.
Increasing the choices we as individuals have for our own health care. Many people state that our current system gives us choice and the freedom to pick our providers but if you closely look at it, this is not the case. Look at who you get your medical insurance through. Did you pick your insurer and medical plans?
If you are employed by a company, there’s a good chance that you only had one choice of medical insurance provider and that provider may have had at max, 3-4 options on medical insurance. This lack of competition between individual consumers stifles true competition that in a natural market would bring healthcare costs down.
Step 3.
Increase co-payments and deductibles. Some will say “why would you want to increase deductibles and co-payments?” The reason why you would do this is to give consumers more “skin in the game,” by making them aware of the cost of health care and the differences between insurers and health providers.
Right now because of a low deductible you would go into any physician’s office and let them run as many tests as the doctor seems fit to do. You have no idea of the cost of the each test let a lone the cost between physicians because you pay the same co-payment regardless of where you go. Plus with such low deductibles you could care less how much extra it cost for certain tests or the difference in price between physicians because the insurance will pick up regardless. This costs the insurer more money and thus it will ultimately increase the monthly premiums and further raise the deductible in the long run.
Based on the RAND Corporation’s National Health Insurance Experiment, “if the average annual health-plan deductible were to rise from its current level of $250 to even $500 and the typical coinsurance rate were to rise from 20% to 25%, we estimate that annual health-care spending would decline by $65 billion per year.
Step 4.
Remove individual state restrictions. Even with the tax field leveled the consumers would run into the problem with the insurance markets within specific states. Obviously each state is different with their differing regulations and mandates but there are approximately 1,500 specific insurance coverage
requirement that are imposed by the various state legislatures. Some of these requirements and mandates are beneficial but not to all. Such is the case with chiropractic care and alternative medicine. These are options that should be chosen by the individual consumer and because it is not, the cost must be covered by all who are part of the plan. Insurance providers need to be allowed to go nationwide and not be so encumbered by every individual state regulations and mandates. By allowing insurance companies to go nation wide, one of the benefits is that the insurance you have would become portable. You would be able to leave one job in one state to go to another job in another state and yet still keep your insurance coverage. By removing many of the state mandates and any-willing-provider laws, the average cost savings would be around 7 – 17%. That would be around $600-$1500 a year for the average family that they could be saving each year.
Step 5.
Lower the barrier of entry. To avoid what has happened to the law industry, the medical industry and government have restricted the supply of health professionals who enter medical school or other types of higher education learning for the industry. Thousands of candidates perfectly qualified to enter medical school are not allowed in due to the fact that there are these strict regulations in place to prevent the over saturation of health professionals in the field. This is another example of basic supply and demand principle that affects many of us to timely health care. Many of the family practice physicians are no longer taking new patients because they are completely booked. Those advocates will tout the fact that they are doing quality and cost control. However, this effectively results in market participants (the doctors and hospital in charge of medical schools and residency programs) acting in cooperation with each other to
restrict competition, which is a violation of antitrust laws. The Supreme Court has previously ruled that ensuring quality is no defense against such practices. To fix this problem, no new legislation would need to be passed, the government would only need to enforce the laws are that are already on the books. There needs to be a better balance between the strictness of the standards of medical school (not quality of physicians) and the benefits of greater competition. On top of this, there are many states that have laws that restrict nurse practitioners and other qualified health providers from providing needed care that they are perfectly qualified to do. The massive shortage of health providers in rural and underrepresented areas
could be filled with such personnel.
John Huntinghouse seams to indicate that public heath care insurance should be organized more like car insurance. The selection of a car insurance provider is entirely by customer choice and is valid in any state in the union. Assuming this is the case then employers should supply a block grant of money for health care
insurance for each employee allowing them to find the health care provider that best fits their needs. The primary reason for health care insurance should be for catastrophic injury and illness and not to cover all health care costs. This allows the insured to be protected from unforeseen massive health care expenditures while having affordable insurance rates.
The author indicates that a range of copayments be charged for different medical services and tests and that the copayments should be significant enough to make the policy holder think about the cost of the service and its value to him. He also suggests that the number of graduating doctors is artificially held to a
predetermined number and should be allowed to expand to allow all graduates that are qualified to become doctors.
This article assumes that private insurance is the answer to our health care problems. An alternative is the government run health care programs found in Europe which we dismiss as socialism. We have the highest health care costs among the leading nations of the world. England, France and Italy all have complete health care for all of its citizens. They are taxed pretty heavily for this and only a few have private health insurance (mostly the rich). We call this socialism because the government provides the entire health system the hospitals and health insurance and not private companies. These European systems require virtually no paperwork since all citizens are eligible. Contrast that with the mountain of paperwork we do in the US just to determine if we are eligible. The primary benefit besides to the citizens is that companies and small businesses don’t have to provide health care insurance. Many Europeans before visiting the US ask themselves the question “What do I do if I get sick?” That’s the same question many of us in US are asking.
Making Lean Teams Work in State Health Care by Lawrence Rosier
The answer is to reform government and make it operate like a private business. If this is done properly no private business can compete. No one in the past believed that a government organization could be made so efficient and effective that a private company could not make a profit and therefore not be able to compete. The following approach using Enterprise Lean makes competition with a private company unprofitable.
Enterprise Lean is a concept developed and implemented in industry by Toyota can be applied directly to a state healthcare organization. The entire healthcare organization’s Lean approach is to inspire healthcare workers and the public to participate in bringing a renewed interest in health and senior services by focusing on raising the level of quality and public awareness of health practices.
One of the first efforts of a healthcare organization is to develop an all inclusive Mission Statement. Mission statements are not easy to develop but the difficulty can be somewhat eased by developing a proposed list of accomplishments which the organization thinks it can achieve. Then try to boil these down into a single goal statement which includes all stake holders as well as the general public. Remember that volunteer workers can be a significant asset to the state. This is where the “role of state healthcare” is defined a necessary step given the limitation of state resources. Many states have differing roles especially in the area of Medicare Management.
This was the “inspiring” portion of the approach the next step is in bringing innovation in health care through Lean Teams which I would rename to something more relevant such as: Health Quality Teams (HQT). A facilitator trains and guides each HQT as it elects its own leader. The goal is to “empower” healthcare workers in each function to develop ways of improving the healthcare processes and raise the level of healthcare quality in their function.
The team should review the current processes used by the function. The best way to do this is to create a Processes Flow Chart on long sheets of wrapping paper or butcher paper taped to the conference room walls. The long sheets can be taken down and rolled at the end of each meeting. Each process is created on
8 ½ x 11 sheets and taped to the wall allowing changes and corrections to be made to the wall as the method proceeds. After discussions an improvements to the process are agreed upon by the team a second improved process flow is added to the wall chart showing the improved method. The reason for doing this is to show the costs and the time to perform each of the processes in the improved method. In the interests of improving quality the time to perform the new processes may actually be longer than the old method. If some way of getting the improved quality can not be found while reducing costs the method is still
presented to top healthcare management for approval as the improved processes to be used by the function. If approved the method is documented and given to a Budget Analyst for costing-out the processes.
Note: that there is a closer relationship developing between healthcare management and the HQT functional teams. The empowerment of HQTs inspires them do more innovation and to continuously improve the function’s processes. The second phase of government reform begins by making the HQT leaders the leaders of Functional Management teams. Top management becomes the Steering Management Team. The lower level managers at this point become redundant however some may be required as part of the Steering Management Team.
Steering Management has the role of guiding and steering the organization while
Functional Management deals with the day to day operation of the functions. Steering Management is responsible for telling Functional Management “what to do” but not “how to do it”. This is a loose-tight organization with Steering firmly in control of the budget leaving Functional Management free to determine how best to do the job. Those in industry will recognize this as straight from the book “In Search of Excellence- Lessons from America’s Best-Run Companies” by Thomas J. Peters and Robert H. Waterman Jr., Harper and Row, Iowa, 1982.
The goal is to reduce bureaucracy by removing layers of management while putting more functional employees to work thus improving health services. The overall difficulty is in finding the best balance of choices for what should be done with what can be done with limited resources.
Innovation in Health Care Nurses Become Doctors (new in 2012)
There are lots of new innovations occurring every day in health care but the acceptance and implementation sometimes takes years. Most of the time acceptance of new ways of doing things is hindered by lack of funding but human habit and established procedures also contribute and are difficult to overcome.
One of the major problems in healthcare is the lack of doctors especially in small towns. The lure of high incomes and the big cities has left many small towns without doctors. Years ago doctors would diagnose patients using his best educated guess and proscribed treatment for what he thought would cure the patient. The patients never questioned the opinion of the doctor and whether they lived or died there was nothing else that could be done. A second given was that doctors in the past were always men and nurses were always women. When I was a boy that is how you knew which was the doctor and which was the nurse.
This aura and stigma about what a doctor is still exists with us today. But times have changed doctors have many ways of testing to determine a correct diagnosis. Medical advice and prescription drug definitions are available to everyone on the Internet. Nurses today are many times more knowledgeable than doctors were when I was a boy. The bottom line is to let experienced Nurses by taking a special state board examination become General Practitioner Doctors. I can hear the bloody scream from the American Medical Association (AMA) already. If in fact you had to wait for the approval of the AMA it would never happen in our lifetime. They have the duty to protect the medical profession but this also means protecting the income of doctors. If the AMA will not approve this change then it must be done by fiat. Get the approval of the nursing profession and just do it. The need is too great to wait for AMA approval.
There is another related problem there is also a shortage of nurses. But when you put these two problems together a shortage of doctors and a shortage nurses the solution isn’t obvious and here is why. There is high dropout rate for trained nurses over the years they burnout from shift work and in just a few years they
reach the top of their pay grade. In short though highly trained there is nowhere to go in the nursing profession. If nurses especially supervision nurses with at least ten years of experience could take a board examination and become a doctor the glass ceiling would be broken. More nurses will enter the profession and stay in the profession longer if there is the possibility of becoming a doctor. You can also make the condition that nurses who become doctors must practice in a small town for five years before final approval and permanent status as a doctor.
Poka-Yoke in Health Care
Poka-Yoke, a Japanese term, one of the Lean tools that has recently become very important to the health care industry because it focuses on making systems error proof. Drug to patient delivery systems are very important because of life threatening errors which can occur at any point in the process. Now we have a
system that replaces a doctor’s Rx with the drugs numbered eliminating the chance of error with the pharmacy. Poka-Yoke can be used almost anywhere but it has its greatest value in life threatening cases and where the cost of damaged materials is high.
Approach to Out of Control Health Care Costs
The nation is struggling with the high cost of healthcare and prescription drugs. We have become a second rate country in the area of healthcare. But other nations that provide free healthcare are nearly going bankrupt and will soon cut their services. The first thing to do is to look at how we got into this mess. In the
1980’s most large employers provided dental and health insurance with a co-payment. In the 1990’s they moved to HMO’s forcing physicians to get an ok with the HMO before expensive treatment could be undertaken.
The biggest mistake being made is in not finding out where the money is really going. Is it going to new facilities, new equipment, salaries (doctors, nurses, specialists), special services (sports medicine, nursing home services, etc.) or increased medicine costs. You must know where a disproportionate amount of the funds are going and the best way to this is through state auditing. Simply increasing funding clearly has not and will not solve the problem as costs explode. The crisis is real hospitals have increasingly taken to illegally adding false services and unnecessary items to patients bills.
Once we find where the funds are going we can pick those items that the state legislature can deal with and bring under control. For example doctor’s salaries driven by high liability insurance premiums. The legislature can cap proceeds from medical malpractice law suits and form a state insurance pool for doctors
to pull premium costs down.
Auditors can survey hospital room costs and salaries to determine if they are out of line with national averages. A survey of facilities funding will determine if funds are spent on giant atriums instead of hospital rooms. Do area hospitals have reciprocal agreements to share the latest technological equipment or does each try to get all the new technologies which are then under utilized?
The nation is struggling with the high cost of healthcare and prescription drugs. We have become a second rate country in the area of healthcare. But other nations that provide free healthcare are nearly going bankrupt and will soon cut their services. The first thing to do is to look at how we got into this mess. In the
1980’s most large employers provided dental and health insurance with a co-payment. In the 1990’s they moved to HMO’s forcing physicians to get an ok with the HMO before expensive treatment could be undertaken.
The biggest mistake being made is in not finding out where the money is really going. Is it going to new facilities, new equipment, salaries (doctors, nurses, specialists), special services (sports medicine,nursing home services, etc.) or increased medicine costs. Auditors can survey hospital room costs and salaries to determine if they are out of line with national averages. A survey of facilities funding will determine if funds are spent on giant atriums instead of hospital rooms. Do area hospitals have reciprocal agreements to share the latest technological equipment or does each try to get all the new technologies which are then under utilized?
We don’t need auditors to know that Medicaid costs are out of control and linked directly to the increasing costs of prescription drugs. My solution which I have stated elsewhere is to form a Federal Government lead consortium of states to negotiate directly with drug manufacturers to obtain pricing at least as low as that found in Canada. As long as the states are divided and have no negotiating power the sky seems to be the limit on prescription drug prices.
Thursday, January 12, 2017
Article 90. Reforming Local Government
Reforming Local Government is Easier than Thought
The key is in knowing what the cost of all city jobs should be.
How to calculate the staffing requirement for an office job using Time Study.
We want to start by Implementing Enterprise Lean to find the best way to do the job, the most efficient and effective way. You should never put a time on a job that has not gone through the Lean process. Now knowing that you have determined the best way to do the Job the Lean data can be turn over to a Budget Analyst for determining the proper staffing. The Lean study data should provide the Budget Analyst with the time to do the job if it doesn’t then time-study work may be required. The Budget Analyst will total the time to do the job and then he will multiply it by 125%. This effectively adds 25% more time to the calculated time. This will allow the worker some breathing space between jobs if this were not done the worker would soon fall hopelessly behind in getting his work done. I have discussed in other Articles about how to deal with variable times for a job. Generally the time for the job is adjusted by historical data from a daily log kept by the Team Leader of the Function. The important thing to remember is that you don’t need the accuracy for staffing that is needed for building widgets in industry. The reason, when you are staffing an office function you must staff with a full person you can’t staff with half a person.
Suggestions for Those Who Want to Go It Alone Without Consultants
The following suggestions for those who want to implement the Reform Models presented in this blog without Consulting help.
A. I recommend that those responsible for the implementation be those who have budgetary responsibility for the organization and are willing to fully implement the Reform Models. Internal managers will generally not go along with reducing staffing or making any changes to the Bureaucracy’s organization.
B. The first Phase of the implementation of the General Reform Model involving implementing Enterprise Lean throughout the organization can be implemented by the organizations own training personnel. They should bring in a Lean consultant to train the trainers in teaching Enterprise Lean to employees. The second Phase with Budget Analysts using the Lean study data for Work Measurement will probably need some consulting assistance in dealing with processes that vary in time length. If this problem can be overcome and the Enterprise Lean tools are well understood the entire implementation may be lead by a Budget Analyst leading a Lean team. Remember when all employees are involved with Lean teams the culture of the organization will begin to shift to Teams making the transition to Team Management a whole lot smother than you might think. Still you should always expect that those who are losing their positions will object strongly. It is always easier to find positions for managers who buy into the implementation early on and get Lean training. Those who don’t are usually slated for early retirement.
C. If you are going it alone I recommend that you start with a pilot first this will give you a chance to work out some kinks before you get spread too thin.
Bringing Reform to Local Government
In rural America most county seats were placed within one day’s travel by buggy. In the West rural populations did not decline until the great depression and the 1930’s drought. But today’s Western and Midwest rural and small town populations have decreased to the point that county services and facilities can no longer be maintained. Most Western States are looking for ways to provide health care and other needed services to rural areas economically. Part of the solution is to reduce the number of counties referred to as consolidation. In this Part we will review the application of my Consolidation Reform Model when applied to county governments and to city governments. We will also review my Election Reform template proposal. There a literally hundreds of ways to bring better service to the public and lower taxes. The best way to approach any reform problem is in using Enterprise Lean to find the best solution.
How to get Efficiency in City Government
Budgeting for small cities means balancing of revenues and reserves against planned expenditures. Most city budgets are organized into primary activities called Funds, that are self-balancing accounts, used to record and maintain the assets, liabilities, fund equity, revenues, and expenditures for each. The following Funds are typical: General Fund, Sewer Fund, Parks Fund, Airport Fund, Solid Waste Fund, Cemetery Fund, Street fund and Capital Improvement Fund. Municipal Utilities usually has a separate budget under the Board of Public Works and operates the electric and water systems. A Capital Improvement Plan usually for five years is used to determine the future planned expenditures for improvements within each fund and the revenues expected to pay for each improvement.
Annually each Fund’s budget provides the details of the budgets for the Departments within the Fund. Within each Department is one or more Functions which the department performs usually providing some service to the public.
The approach here is to find the best way of doing the function, document it, then determine real cost of each Function in providing the service.
I recommend the use of a high level Lean Team to study all cross-functional process flows. The main objective of the Lean team is to find the best way of doing the service or the function and to document the process flow on a spread sheet. Where this works best is in studying the document flow of an application through the city office processes.
A time study analyst may also be used to time-study a Function’s processes. This process works best for repeated Functions such as mowing a public park. The time study analyst will determine the best method for doing the work and will determine the correct allowed time for each process. From this data the correct staffing can be determined and ultimately the correct budget for the Function.
Functional Lean Teams are also organized one for each function and meet once a week. These are the employees who actually do the work in performing the function. The main goal is in finding the best way to do each of the processes of the Function. The Lean team would depict both the detailed processes for the current method and the improved method of performing the Function on a flow chart. The best way I have found for doing this is to tape up white butcher paper around the walls of a conference room. The processes to be shown on the butcher paper are created on separate small pieces of paper and are taped to the butcher paper allowing the processes to be easily repositioned without permanently damaging the butcher paper. When a meeting is over the butcher paper can be easily rolled up and taken away. A flow chart on the wall has an advantage over that in a book when it is presented to the city administrator and the city council by the Lean Team.
The most important part of the flow chart is in getting each process time to the nearest (15) minutes in time length detailed enough for team members to more easily determine the best method. The flow chart is then turned over to the budgeting department to be used in determining the staffing required and the function’s budget. Note that this method though not as exact as the Time-Study analyst method can be just as valid for staffing purposes in determining whether another person should be added or removed from the payroll. As in the high level Lean Team a Funding Formula can be developed for each function and used in developing the budget.
The Lean Team approach costs less to implement and is generally better accepted by employees because they are empowered to solve their own work related problems.
I recommend the budgeting of Functions rather than Departments which gives greater control of the budget to the city administrator. I also recommend that a Budget Analyst review each of the Lean Teams’ process flows and estimate the hours and other costs incurred in doing the function and document the data on a spread sheet. I call this the Funding Formula for the function. The budget is determined multiplying the number of expected times that the function is to be done during the budget period by the Funding Formula. Note that once defined a Funding Formula can be used, with minor tweaking for cost of living increases, for budgeting until its processes change which may be for several years.
I also recommend that the reform of a Cities obsolete IT Systems be delayed until the State has the opportunity to implement my recommended Cloud IT data system. This will give the City the up grade it needs in its IT systems at virtually no cost. The Cloud System will provide data processing for the city. All the city will have to do is to connect to the States Cloud system through the internet.
Los Angeles Embraces Google’s Gmail
Los Angeles has adopted Google’s Gmail throughout the entire city. But not without some difficulty many in the city were afraid of having an outsider in control of their email. This is a breakthrough for the first cloud computing application in a major city.
An innovative technology deal turns political for the Los Angeles City Council president.
By Steve Towns February 2010
Ref. 1. Steve Towns is Government Technology’s editor. E-mail him at sthowns@govtech.com
Comment by the author
I recommend that each state government develop their own Centralized Cloud IT systems. The center would be storm and earth quake proof with battery and generator backup systems. From this facility the state can provide IT cloud systems for itself and city and county governments within the state including email.
Recommendation 1. Make Schools Safe for Learning.
Move police stations to the schools across the street if possible. Place cameras everywhere there might be violence in the school. Make the schools the safest place in the city. Open the school libraries and gymnasiums using volunteers after school and at night for tutoring and adult education.
Recommendation 2. Make the School the hub of the Community.
Emphasize cradle to grave education. Education should start with babies in the “Parents as Teachers Program” progress through kindergarten and into the public schools and beyond. The recently enacted “No Child Left behind Program” holds public schools, more correctly teachers, responsible for the educational progress of their students. This is a controversial mandate in the inner city because it will take super human effort by the best teachers to meet the requirements. The corollary to this should be that no bright child should be held back allowing them to skip grades until they are challenged.
This should be the environment which nurturers the students which will attend charter high schools and job training technical schools.
Recommendation 3. Bolster Neighborhoods by Creating a “Sense of Community”.
We need to recognize the importance of the “Sense of Community”. Most high rise tenements built for welfare families fail for this reason. The “sense of community” fails when the majority of the people living in an urban community cannot recognize those who actually live in the area. With increased anonymity comes increased crime that forces the elderly to barricade themselves in their apartments.
The idea of a “sense of community” can be developed by fencing off floors within a high rise apartment building providing a safe haven for those who live there. Place cameras in public areas. Block off through streets creating urban enclaves and provide local police stations with foot or bicycle patrols. Provide recreation facilities for the youth and encourage the development of a micro economy. Active community organizations provide involvement opportunities for citizens of the enclaves developing a source of community pride.
Extreme high crime communities should be gated and fenced with surveillance cameras everywhere. As more and more of the community enclaves are developed gangs and their accompanying crime can be forced into a small enough area where police can get control of the situation.
Recommendation 4. Encourage the Development of Community Micro Economies
A micro economy occurs when local people get together to form small businesses that fill the needs of the community. In many cases the county extension offices as a part of the states university system nurture these small businesses. The State and or the Federal Government may provide the necessary seed money for the startup of the businesses. Micro economies are important because they provide a safety net for the families in the community. The positive micro economy is a much more desirable and less expensive than the crime and drug dealers, which form the negative economy.
Examples of micro economy businesses are day nurseries, home run catalog businesses, gift shops and craft manufacturing. Often festivals and annual community events aimed at bringing tourists to the area bolster these businesses. But for the most part they should be self-sustaining and provide day to day services in the community.
Recommendations 5. Form Community Volunteer Groups to Cleanup the City.
Cleanup city streets especially vacant city lots where community gardens can be established. One innovative way of doing this is to have local contractors establish fenced brick yards where used bricks can be purchased from the public. It won’t be long before vacant lots will be brick free for gardeners.
Recommendation 6. City Government Reform.
Lowering city property and business taxes establishes a growth program that attracts residents and businesses back to the city. This fuels the creation of needed jobs and bolsters the cities economy. Raising property and business taxes does just the opposite. The revenue to lower taxes is made available when city government is reformed and downsized.
Consolidation of City Governments or Urban Secession?
Its all about how to provide better services to urban dwellers with the most efficiency. Most large cities do not provide adequate crime prevention and protection to their city residents fueling the desire for some communities to secede. At the same time there are movements to combine city governments so that services such as fire and police can gain economy of scale. Whether to combine or to secede depends largely on local conditions such as tax bases and economies. Which brings up a third possibility “Government Reform” by allowing local ward committees to manage some local services. And a fourth possibility is for city governments to gain the economies of scale they desire through reciprocal agreements with other cities to share city services.
By not asking the right questions cities and suburban communities can find themselves with even greater problems than they have now. For example an urban community that wishes to secede from a greater metropolitan city to gain local control of its services will need to know if they have enough of a tax base to provide those services. If they don’t then they should pursue the third option to gain local control of some services provided to their community. In other words the metropolitan government should be reformed by allowing decisions on local services to be made at the local level. This is the same Japanese management principle that I have recommended elsewhere to make bureaucracies more responsive by “driving down the decision making power to the lowest level of effectiveness”. This type of arrangement works well where inner city crime is high. and local control can be established by blocking off through streets and in forming gated communities. These communities should have their own police station. The goal here is to establish a “Sense of Community” which I would define as when a majority of the community knows if someone either lives in the community or is an outsider. I have recommended that this method be used to drive crime out of a major metropolitan area by establishing small communities one at a time. Each community would need a micro economy to make it sustainable.
It is to the advantage of some more affluent suburban cities to annex a neighboring depressed city. Especially those that prevent it from growing through expansion.
Community Development and Economic Growth
Many small towns and communities often confuse “Community Development” and “Economic Growth” as going hand in hand. They seem to think that all community development projects lead to economic growth. While it is true that enhancement of community services can encourage economic growth indirectly a more focused approach will yield better results.
For example many communities seek out large chain store mall developments while discouraging manufacturing as being undesirable. This may be a good policy if there are nearby manufacturing facilities or tourist sites that can draw outside revenue. True economic growth comes from revenues brought into the community from outside. While large chain stores in fancy malls bring customers from surrounding communities and encourage people to move to the community they also replace the mom and pop stores, which were the foundation of the community. The sales employees may be better off through higher wages and benefits but what you are really seeing happening is a kind of churning of the community’s economy. When the communities leaders grant special tax incentives and other giveaways such as free land to the mall developers there can be a near zero result in economic growth.
The economic churning while for the most part may bring improvement to the community but it cannot match the manufacturing and tourist revenues that is needed for real economic growth. The bottom line is to provide tax incentives for the manufacturing and tourist industries that will bring in revenues from outside the community. The big chain store malls will follow these revenues to the community without the extra incentives.
A “Sense of Community” and Micro Economies in Depressed Areas
A micro economy occurs when local people get together to form small businesses that fill the needs of the community. In many cases the county extension offices as a part of the states university system nurture these small businesses. The State and or the Federal Government may provide the necessary seed money for the startup of the businesses. Micro economies are important because they provide a safety net for the families in the community. The positive micro economy is a much more desirable and less expensive than the crime and drug dealers, which form the negative economy.
Examples of micro economy businesses are day nurseries, home run catalog businesses, gift shops and craft manufacturing. Often festivals and annual community events aimed at bringing tourists to the area bolster these businesses. But for the most part they should be self-sustaining and provide day to day services in the community.
We need to recognize the importance of the “Sense of Community”. Most high rise tenements built for welfare families fail for this reason. The “sense of community” fails when the majority of the people living in an urban community cannot recognize those who actually live in the area. With increased anonymity comes increased crime that forces the elderly to barricade themselves in their apartments.
The idea of a “sense of community” can be developed by blocking off through streets in urban environments, providing a local police station with foot or bicycle patrols, providing recreation facilities for the youth and encouraging the development of a micro economy. Active community organizations provide involvement opportunities for its citizens developing a source of community pride. In extreme high crime areas communities should be gated and fenced with surveillance cameras everywhere. As more and more of the communities are developed gangs and their accompanying crime can be forced into a small enough area where police can get control of the situation.
Breathing New Life into Contiguous Depressed City Suburbs
Many older metropolitan cities especially in the mid-west and eastern US have for the last sixty to seventy years experienced the decline of the suburban towns encircling it. These neighborhood towns are mostly independent with each having its own city government charter and school district. The main difference between them is that unlike small rural towns each is composed of a unique socioeconomic level. Some are wealthy prosperous towns contiguous with lower socioeconomic towns that have been in decline for decades. The most prosperous communities unable to expand their city limits have fueled the flight to new suburban communities far from the metropolitan center. Now with wealthy inner cities surrounded by blighted neighboring towns it is time for them enter into a type of “suburban renewal” once thought only done in metropolitan city centers.
The approach here is for a wealthy community to annex a neighboring town disbanding its city government charter and integrating its school district with its own. The advantage for the wealthy city is in obtaining space to expand and grow. While the advantage for the annexed city would be to experience new life and enhanced property values. In some cases just an image change is enough to bring new life to a community. The most viable situations would be where most of the blighted areas would be bulldozed and new homes and businesses built. This whole process has become more capable through the recent US Supreme Court’s ruling on condemning private property for private redevelopment. Before this ruling this would have been difficult if not impossible. While many states have recently enacted laws restricting the application of this new ruling law makers have failed to see the benefits of the ruling.
The process of designing out crime is the method called CPTED used in high crime areas in Seoul Korea. The method calls for blocking off areas of the city and providing lights and cameras.
Contact me for more information: lawrencerosier4@gmail.com
The key is in knowing what the cost of all city jobs should be.
How to calculate the staffing requirement for an office job using Time Study.
We want to start by Implementing Enterprise Lean to find the best way to do the job, the most efficient and effective way. You should never put a time on a job that has not gone through the Lean process. Now knowing that you have determined the best way to do the Job the Lean data can be turn over to a Budget Analyst for determining the proper staffing. The Lean study data should provide the Budget Analyst with the time to do the job if it doesn’t then time-study work may be required. The Budget Analyst will total the time to do the job and then he will multiply it by 125%. This effectively adds 25% more time to the calculated time. This will allow the worker some breathing space between jobs if this were not done the worker would soon fall hopelessly behind in getting his work done. I have discussed in other Articles about how to deal with variable times for a job. Generally the time for the job is adjusted by historical data from a daily log kept by the Team Leader of the Function. The important thing to remember is that you don’t need the accuracy for staffing that is needed for building widgets in industry. The reason, when you are staffing an office function you must staff with a full person you can’t staff with half a person.
Suggestions for Those Who Want to Go It Alone Without Consultants
The following suggestions for those who want to implement the Reform Models presented in this blog without Consulting help.
A. I recommend that those responsible for the implementation be those who have budgetary responsibility for the organization and are willing to fully implement the Reform Models. Internal managers will generally not go along with reducing staffing or making any changes to the Bureaucracy’s organization.
B. The first Phase of the implementation of the General Reform Model involving implementing Enterprise Lean throughout the organization can be implemented by the organizations own training personnel. They should bring in a Lean consultant to train the trainers in teaching Enterprise Lean to employees. The second Phase with Budget Analysts using the Lean study data for Work Measurement will probably need some consulting assistance in dealing with processes that vary in time length. If this problem can be overcome and the Enterprise Lean tools are well understood the entire implementation may be lead by a Budget Analyst leading a Lean team. Remember when all employees are involved with Lean teams the culture of the organization will begin to shift to Teams making the transition to Team Management a whole lot smother than you might think. Still you should always expect that those who are losing their positions will object strongly. It is always easier to find positions for managers who buy into the implementation early on and get Lean training. Those who don’t are usually slated for early retirement.
C. If you are going it alone I recommend that you start with a pilot first this will give you a chance to work out some kinks before you get spread too thin.
Bringing Reform to Local Government
In rural America most county seats were placed within one day’s travel by buggy. In the West rural populations did not decline until the great depression and the 1930’s drought. But today’s Western and Midwest rural and small town populations have decreased to the point that county services and facilities can no longer be maintained. Most Western States are looking for ways to provide health care and other needed services to rural areas economically. Part of the solution is to reduce the number of counties referred to as consolidation. In this Part we will review the application of my Consolidation Reform Model when applied to county governments and to city governments. We will also review my Election Reform template proposal. There a literally hundreds of ways to bring better service to the public and lower taxes. The best way to approach any reform problem is in using Enterprise Lean to find the best solution.
How to get Efficiency in City Government
Budgeting for small cities means balancing of revenues and reserves against planned expenditures. Most city budgets are organized into primary activities called Funds, that are self-balancing accounts, used to record and maintain the assets, liabilities, fund equity, revenues, and expenditures for each. The following Funds are typical: General Fund, Sewer Fund, Parks Fund, Airport Fund, Solid Waste Fund, Cemetery Fund, Street fund and Capital Improvement Fund. Municipal Utilities usually has a separate budget under the Board of Public Works and operates the electric and water systems. A Capital Improvement Plan usually for five years is used to determine the future planned expenditures for improvements within each fund and the revenues expected to pay for each improvement.
Annually each Fund’s budget provides the details of the budgets for the Departments within the Fund. Within each Department is one or more Functions which the department performs usually providing some service to the public.
The approach here is to find the best way of doing the function, document it, then determine real cost of each Function in providing the service.
I recommend the use of a high level Lean Team to study all cross-functional process flows. The main objective of the Lean team is to find the best way of doing the service or the function and to document the process flow on a spread sheet. Where this works best is in studying the document flow of an application through the city office processes.
A time study analyst may also be used to time-study a Function’s processes. This process works best for repeated Functions such as mowing a public park. The time study analyst will determine the best method for doing the work and will determine the correct allowed time for each process. From this data the correct staffing can be determined and ultimately the correct budget for the Function.
Functional Lean Teams are also organized one for each function and meet once a week. These are the employees who actually do the work in performing the function. The main goal is in finding the best way to do each of the processes of the Function. The Lean team would depict both the detailed processes for the current method and the improved method of performing the Function on a flow chart. The best way I have found for doing this is to tape up white butcher paper around the walls of a conference room. The processes to be shown on the butcher paper are created on separate small pieces of paper and are taped to the butcher paper allowing the processes to be easily repositioned without permanently damaging the butcher paper. When a meeting is over the butcher paper can be easily rolled up and taken away. A flow chart on the wall has an advantage over that in a book when it is presented to the city administrator and the city council by the Lean Team.
The most important part of the flow chart is in getting each process time to the nearest (15) minutes in time length detailed enough for team members to more easily determine the best method. The flow chart is then turned over to the budgeting department to be used in determining the staffing required and the function’s budget. Note that this method though not as exact as the Time-Study analyst method can be just as valid for staffing purposes in determining whether another person should be added or removed from the payroll. As in the high level Lean Team a Funding Formula can be developed for each function and used in developing the budget.
The Lean Team approach costs less to implement and is generally better accepted by employees because they are empowered to solve their own work related problems.
I recommend the budgeting of Functions rather than Departments which gives greater control of the budget to the city administrator. I also recommend that a Budget Analyst review each of the Lean Teams’ process flows and estimate the hours and other costs incurred in doing the function and document the data on a spread sheet. I call this the Funding Formula for the function. The budget is determined multiplying the number of expected times that the function is to be done during the budget period by the Funding Formula. Note that once defined a Funding Formula can be used, with minor tweaking for cost of living increases, for budgeting until its processes change which may be for several years.
I also recommend that the reform of a Cities obsolete IT Systems be delayed until the State has the opportunity to implement my recommended Cloud IT data system. This will give the City the up grade it needs in its IT systems at virtually no cost. The Cloud System will provide data processing for the city. All the city will have to do is to connect to the States Cloud system through the internet.
Los Angeles Embraces Google’s Gmail
Los Angeles has adopted Google’s Gmail throughout the entire city. But not without some difficulty many in the city were afraid of having an outsider in control of their email. This is a breakthrough for the first cloud computing application in a major city.
An innovative technology deal turns political for the Los Angeles City Council president.
By Steve Towns February 2010
Ref. 1. Steve Towns is Government Technology’s editor. E-mail him at sthowns@govtech.com
Comment by the author
I recommend that each state government develop their own Centralized Cloud IT systems. The center would be storm and earth quake proof with battery and generator backup systems. From this facility the state can provide IT cloud systems for itself and city and county governments within the state including email.
Ideas for Rebuilding Inner Cities
An examination of the situation of inner city residents yields only one positive thing all many residents have is free time along with an enormous desire to change their current prospects. What they don’t have is nearly everything else.
The approach I recommend for rebuilding inner cities is the creation of safe havens. Environmental enclaves where one is relatively safe and nurturing, education and commerce can be protected.Recommendation 1. Make Schools Safe for Learning.
Move police stations to the schools across the street if possible. Place cameras everywhere there might be violence in the school. Make the schools the safest place in the city. Open the school libraries and gymnasiums using volunteers after school and at night for tutoring and adult education.
Recommendation 2. Make the School the hub of the Community.
Emphasize cradle to grave education. Education should start with babies in the “Parents as Teachers Program” progress through kindergarten and into the public schools and beyond. The recently enacted “No Child Left behind Program” holds public schools, more correctly teachers, responsible for the educational progress of their students. This is a controversial mandate in the inner city because it will take super human effort by the best teachers to meet the requirements. The corollary to this should be that no bright child should be held back allowing them to skip grades until they are challenged.
This should be the environment which nurturers the students which will attend charter high schools and job training technical schools.
Recommendation 3. Bolster Neighborhoods by Creating a “Sense of Community”.
We need to recognize the importance of the “Sense of Community”. Most high rise tenements built for welfare families fail for this reason. The “sense of community” fails when the majority of the people living in an urban community cannot recognize those who actually live in the area. With increased anonymity comes increased crime that forces the elderly to barricade themselves in their apartments.
The idea of a “sense of community” can be developed by fencing off floors within a high rise apartment building providing a safe haven for those who live there. Place cameras in public areas. Block off through streets creating urban enclaves and provide local police stations with foot or bicycle patrols. Provide recreation facilities for the youth and encourage the development of a micro economy. Active community organizations provide involvement opportunities for citizens of the enclaves developing a source of community pride.
Extreme high crime communities should be gated and fenced with surveillance cameras everywhere. As more and more of the community enclaves are developed gangs and their accompanying crime can be forced into a small enough area where police can get control of the situation.
Recommendation 4. Encourage the Development of Community Micro Economies
A micro economy occurs when local people get together to form small businesses that fill the needs of the community. In many cases the county extension offices as a part of the states university system nurture these small businesses. The State and or the Federal Government may provide the necessary seed money for the startup of the businesses. Micro economies are important because they provide a safety net for the families in the community. The positive micro economy is a much more desirable and less expensive than the crime and drug dealers, which form the negative economy.
Examples of micro economy businesses are day nurseries, home run catalog businesses, gift shops and craft manufacturing. Often festivals and annual community events aimed at bringing tourists to the area bolster these businesses. But for the most part they should be self-sustaining and provide day to day services in the community.
Recommendations 5. Form Community Volunteer Groups to Cleanup the City.
Cleanup city streets especially vacant city lots where community gardens can be established. One innovative way of doing this is to have local contractors establish fenced brick yards where used bricks can be purchased from the public. It won’t be long before vacant lots will be brick free for gardeners.
Recommendation 6. City Government Reform.
Lowering city property and business taxes establishes a growth program that attracts residents and businesses back to the city. This fuels the creation of needed jobs and bolsters the cities economy. Raising property and business taxes does just the opposite. The revenue to lower taxes is made available when city government is reformed and downsized.
Consolidation of City Governments or Urban Secession?
Its all about how to provide better services to urban dwellers with the most efficiency. Most large cities do not provide adequate crime prevention and protection to their city residents fueling the desire for some communities to secede. At the same time there are movements to combine city governments so that services such as fire and police can gain economy of scale. Whether to combine or to secede depends largely on local conditions such as tax bases and economies. Which brings up a third possibility “Government Reform” by allowing local ward committees to manage some local services. And a fourth possibility is for city governments to gain the economies of scale they desire through reciprocal agreements with other cities to share city services.
By not asking the right questions cities and suburban communities can find themselves with even greater problems than they have now. For example an urban community that wishes to secede from a greater metropolitan city to gain local control of its services will need to know if they have enough of a tax base to provide those services. If they don’t then they should pursue the third option to gain local control of some services provided to their community. In other words the metropolitan government should be reformed by allowing decisions on local services to be made at the local level. This is the same Japanese management principle that I have recommended elsewhere to make bureaucracies more responsive by “driving down the decision making power to the lowest level of effectiveness”. This type of arrangement works well where inner city crime is high. and local control can be established by blocking off through streets and in forming gated communities. These communities should have their own police station. The goal here is to establish a “Sense of Community” which I would define as when a majority of the community knows if someone either lives in the community or is an outsider. I have recommended that this method be used to drive crime out of a major metropolitan area by establishing small communities one at a time. Each community would need a micro economy to make it sustainable.
It is to the advantage of some more affluent suburban cities to annex a neighboring depressed city. Especially those that prevent it from growing through expansion.
Community Development and Economic Growth
Many small towns and communities often confuse “Community Development” and “Economic Growth” as going hand in hand. They seem to think that all community development projects lead to economic growth. While it is true that enhancement of community services can encourage economic growth indirectly a more focused approach will yield better results.
For example many communities seek out large chain store mall developments while discouraging manufacturing as being undesirable. This may be a good policy if there are nearby manufacturing facilities or tourist sites that can draw outside revenue. True economic growth comes from revenues brought into the community from outside. While large chain stores in fancy malls bring customers from surrounding communities and encourage people to move to the community they also replace the mom and pop stores, which were the foundation of the community. The sales employees may be better off through higher wages and benefits but what you are really seeing happening is a kind of churning of the community’s economy. When the communities leaders grant special tax incentives and other giveaways such as free land to the mall developers there can be a near zero result in economic growth.
The economic churning while for the most part may bring improvement to the community but it cannot match the manufacturing and tourist revenues that is needed for real economic growth. The bottom line is to provide tax incentives for the manufacturing and tourist industries that will bring in revenues from outside the community. The big chain store malls will follow these revenues to the community without the extra incentives.
A “Sense of Community” and Micro Economies in Depressed Areas
A micro economy occurs when local people get together to form small businesses that fill the needs of the community. In many cases the county extension offices as a part of the states university system nurture these small businesses. The State and or the Federal Government may provide the necessary seed money for the startup of the businesses. Micro economies are important because they provide a safety net for the families in the community. The positive micro economy is a much more desirable and less expensive than the crime and drug dealers, which form the negative economy.
Examples of micro economy businesses are day nurseries, home run catalog businesses, gift shops and craft manufacturing. Often festivals and annual community events aimed at bringing tourists to the area bolster these businesses. But for the most part they should be self-sustaining and provide day to day services in the community.
We need to recognize the importance of the “Sense of Community”. Most high rise tenements built for welfare families fail for this reason. The “sense of community” fails when the majority of the people living in an urban community cannot recognize those who actually live in the area. With increased anonymity comes increased crime that forces the elderly to barricade themselves in their apartments.
The idea of a “sense of community” can be developed by blocking off through streets in urban environments, providing a local police station with foot or bicycle patrols, providing recreation facilities for the youth and encouraging the development of a micro economy. Active community organizations provide involvement opportunities for its citizens developing a source of community pride. In extreme high crime areas communities should be gated and fenced with surveillance cameras everywhere. As more and more of the communities are developed gangs and their accompanying crime can be forced into a small enough area where police can get control of the situation.
Breathing New Life into Contiguous Depressed City Suburbs
Many older metropolitan cities especially in the mid-west and eastern US have for the last sixty to seventy years experienced the decline of the suburban towns encircling it. These neighborhood towns are mostly independent with each having its own city government charter and school district. The main difference between them is that unlike small rural towns each is composed of a unique socioeconomic level. Some are wealthy prosperous towns contiguous with lower socioeconomic towns that have been in decline for decades. The most prosperous communities unable to expand their city limits have fueled the flight to new suburban communities far from the metropolitan center. Now with wealthy inner cities surrounded by blighted neighboring towns it is time for them enter into a type of “suburban renewal” once thought only done in metropolitan city centers.
The approach here is for a wealthy community to annex a neighboring town disbanding its city government charter and integrating its school district with its own. The advantage for the wealthy city is in obtaining space to expand and grow. While the advantage for the annexed city would be to experience new life and enhanced property values. In some cases just an image change is enough to bring new life to a community. The most viable situations would be where most of the blighted areas would be bulldozed and new homes and businesses built. This whole process has become more capable through the recent US Supreme Court’s ruling on condemning private property for private redevelopment. Before this ruling this would have been difficult if not impossible. While many states have recently enacted laws restricting the application of this new ruling law makers have failed to see the benefits of the ruling.
The process of designing out crime is the method called CPTED used in high crime areas in Seoul Korea. The method calls for blocking off areas of the city and providing lights and cameras.
Contact me for more information: lawrencerosier4@gmail.com
Sunday, January 1, 2017
Article 89. Why Reforming the Federal Government is Necessary
It is important to understand why we need to reform the Federal Government after all it has been around for more than two hundred years. The Federal Government has always been a difficult problem to get a hold of for newly elected Presidents and department head appointees since they are there for only a short time. In many cases the heads of the departments appointed by an incoming President never get to fully understand the real workings of the department while the Bureaucratic Managers of the departments have had years to tighten their grip on the organization. The best example was with the Veteran’s Administration in 2013 when veterans were dying before they could get an appointment to see a doctor in the Phoenix Veteran’s Hospital while the Head of Veteran’s Affairs was given false information about the inner workings of the VA. A second example is of Hurricane Katrina, Aug 26, 2015, a bureaucratic disaster which compounded the natural disaster caused by the hurricane.
It is necessary to understand what is wrong with the Federal Government in order to implement the changes that are needed. I see the main problem as the “Bureaucratic organization” itself, not so much the average employee involved because all employees are caught in the web of the bureaucratic organization. But the Bureaucratic Top Managers control the organization with an iron fist because the department is very afraid of scandal leading to congressional oversight and budget cuts. Good news can also lead to an increase in budget. This means that the most important thing that Bureaucratic Managers do is to manage their public image to protect and get the largest budget possible. The Mission of the department and its service to the public takes second place.
The above Federal Government problems are solved by the following Reforms
1. Eliminate the use and abuse of power by the Bureaucratic top management by changing the organization to a Team Management organization with layers of unnecessary Bureaucratic management removed. The Team Management organization has only a few top managers reporting to the department Head appointed by the President. Mid management is also reduced with Team Leaders managing segments of the organization. At the working level Team leaders are elected by their peers. Employees participate in Enterprise Lean Teams to make continuous improvements to their work.
2. By implementing Work Measurement and Management Controls to the budgeting process for the first time we can manage the work of government and bring it under control.
These are the reasons for the implementation of my General Reform Model but these address just the major known problems. The recommendations for a US Inspector General with the OIG organization provide an oversight organization that besides the implementation of reforms is flexible enough to address any new problem that arises, providing a permanent solution to the management of our Federal Government. See articles 82. & 84.
It is important to remember that If the Bureaucratic organization is not replaced all savings gained will be lost in just a few years with a return to business as usual.
Questions can be sent to me by Email: LawrenceRosier4@gmail.com or by Phone: 573 364 8789 Cell 573 578 4716
It is necessary to understand what is wrong with the Federal Government in order to implement the changes that are needed. I see the main problem as the “Bureaucratic organization” itself, not so much the average employee involved because all employees are caught in the web of the bureaucratic organization. But the Bureaucratic Top Managers control the organization with an iron fist because the department is very afraid of scandal leading to congressional oversight and budget cuts. Good news can also lead to an increase in budget. This means that the most important thing that Bureaucratic Managers do is to manage their public image to protect and get the largest budget possible. The Mission of the department and its service to the public takes second place.
The above Federal Government problems are solved by the following Reforms
1. Eliminate the use and abuse of power by the Bureaucratic top management by changing the organization to a Team Management organization with layers of unnecessary Bureaucratic management removed. The Team Management organization has only a few top managers reporting to the department Head appointed by the President. Mid management is also reduced with Team Leaders managing segments of the organization. At the working level Team leaders are elected by their peers. Employees participate in Enterprise Lean Teams to make continuous improvements to their work.
2. By implementing Work Measurement and Management Controls to the budgeting process for the first time we can manage the work of government and bring it under control.
These are the reasons for the implementation of my General Reform Model but these address just the major known problems. The recommendations for a US Inspector General with the OIG organization provide an oversight organization that besides the implementation of reforms is flexible enough to address any new problem that arises, providing a permanent solution to the management of our Federal Government. See articles 82. & 84.
It is important to remember that If the Bureaucratic organization is not replaced all savings gained will be lost in just a few years with a return to business as usual.
Questions can be sent to me by Email: LawrenceRosier4@gmail.com or by Phone: 573 364 8789 Cell 573 578 4716
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