Article 96. Reforms For the US Office of Veterans Affairs

Reforms For the US Office of Veterans Affairs
by Lawrence Rosier April 24, 2017
Cell 573 578 4716   lawrencerosier4@gmail.com

 Table of Contents
1. Overview of Approach to Reforming Veterans Affairs
2. Enterprise Lean, Balanced Work Load, Continuous Improvement 
3. Fundamental Innovation at the VA
4. Restoring Management Excellence at the VA
5. Using Templates to Boost Innovation at all VA Hospitals  
6. Three levels of Patient Throughput- Current, Capable and Required 
7. Detailed Description of the Throughput Process Schedule  
8. Obtaining Maximum Patient Throughput with the Highest Effectiveness  
9. Nation Wide VA Progress Reporting System
10. References  


1. Overview of Approach to Reforming Veterans Affairs

The standard Government and Industry approach which I have developed will be used for implementing Reforms in the VA.  This is a soft approach for entities that need reform and are not overtly over-staffed.  This approach first implements Enterprise Lean facilitated by OIG Analysts.  As a part of Enterprise Lean's basic function of continuous improvement, work processes are right-sized by the Lean Team.  This activity is aided by OIG Analysts who provide Work Measurement expertise including time-study followed by a bottoms-up manpower budget.

Reorganizing for the Implementation of Reforms
This approach taps into special expertise of the VA OIG organization retraining OIG Analysts to be the primary implementers of the VA reform process.  Using Government Personnel (OIG Analysts) instead of Outside Consultants, enhances the expertise of the OIG organization and will save $ millions.  This approach will leave an ongoing OIG organization to maintain government efficiency. 

Pilot implementation 
Veterans Affaires Hospitals were selected as a likely pilot for starting the implementations of reforms. This will give a boost in helping Veterans needing healthcare and speedup Patient care through implementation of special patient throughput techniques.

I suggest that the reforms be implemented at the Hospital Facilities of the Washington DC Veterans Affairs Medical Center 50 Irving St NW, Washington, DC 20422

In addition All VA problems will be addressed.
Example: Addressing the major problem: 22 Veterans Commit Suicide Per Day‎.
PTSD symptoms from the recent wars in Iraq and Afghanistan: memory loss, cognitive problems, inability to sleep and profound, often suicidal depression. Nearly 350,000 service members have been given a diagnosis of traumatic brain injury over the past 15 years, many of them from blast exposure. The real number is likely to be much higher, because so many who have enlisted are too proud to report a wound that remains invisible.

Comment by Lawrence Rosier:
Now that we know that the extent of the brain damage can be observed through a Brain Scan.  We can separate those with Physical brain damage from those with Psychological problems.  We can also determine those most vulnerable and develop an effective treatment. This implies the use of  Mass Screening using the VA Patient through-put method to be applied through the Psychological Teams of VA Hospitals.    This is but one example how VA reforms can make a difference.


The Phases of the Reform Process
1. Simplify the VA organization
It is better to simplify government before trying to reform it.  Governmental activities, determined to be unnecessary, can be eliminated using the Effectiveness Test.  Those activities not meeting the test will lose funding.  Simplifying government is not a simple matter but this is where you get rid of unnecessary activities and Red Tape.

Using The Consolidation Model by Lawrence Rosier
A Comparison of Duplicated Services is done by OIG Analysts to determine their associated cost data.   Outcomes are compared with other duplicated Functions from all the organizations and are depicted in a matrix chart. Those duplicated services rejected for low efficiency will be declared as redundant and their budgets cut followed by reassignment or layoff of employees.  Those services with the highest efficiency will have their budgets kept in place or moved to the new final single location with employees given the opportunity to move to the final service group providing the services.

2. Implement the General Reform Model
The General Reform Model uses employee Enterprise Lean Teams to get the highest efficiency and effectiveness possible.  We will use the data developed by VA Lean Teams to Right-Size Functions.  The Lean Team data will be used by specially trained OIG Analysts to develop bottoms-up budgets which identify the actual costs of all needed systems and functions (The real meaning of draining the swamp).  This is also the data needed to manage the organization’s work load and in the determination of the level of staffing needed to meet standards. 

3. The Training and Organization of Employee Enterprise Lean Teams
Enterprise Lean Training Consultants may be brought in providing training seminars for the OIG Analysts and other Training staff (Train the Trainer).  Employee Lean training should begin immediately by the VA training staff.  I suggest that the normal training curriculum for the Department be suspended and an all out effort be made for Enterprise Lean Training.  Training should be made first for staff members followed by management, Lean Facilitators (OIG Analysts) and lastly departmental employees. The objective of this training is to get Employees organized into work teams and excited about improving government.

An alternative approach is orient OIG Analysts as facilitators and immediately implement the selected VA hospital into Teams. The facilitators will lead each team into building its first wall chart.

4. Review of Lean Team Results and Collection of Lean Data
After a period of about two months most Functional (low level) Lean Teams, those that were organized and trained by OIG Analysts acting as Facilitators, should have their Value Stream Analyses completed.   I have had success with doing the flow of the current method on long white butcher or brown wrapping paper tapped around a conference room on the walls.  The steps of the current method is completed first, followed by the proposed improved method done directly under it.  This is done to highlight the differences between the two methods and has the benefit of the team member involvement.  I suggest that some Functional Lean Teams with significant savings present their improved method to management.   The OIG Analyst will time study the new method to document savings.  After the presentation to management the rolled document is given to a OIG Analyst to document the Changes from the team proposal in a spreadsheet.

5. Activities of the Reform Consultant
The Consultant will play a key role in being sure that the employee Lean teams are properly trained.  The Consultant will insure that the activities of OIG Analysts can determine the correct staffing level through Work Measurement.  Some OIG Analysts may find the proper staffing for variable processes difficult to determine, the Consultant will make this determination when necessary. This data combined with the number of occurrences of the function over time, obtained from a daily log kept by each Lean Team, provides the basis for an accurate functional budget.  The Lean data from the documentation will be kept on a spreadsheet by the OIG Analysts and summarized in a database where all of the Department’s functional data are stored.  The data can be collected in electronic tablets using a spreadsheet program specifically designed for this process.  All tablet spread sheets will be continuously updated using a special Google App (application).  The Consultant will provide on the job training of OIG Analysts in the collection of this data and all subsequent reform steps.

6. Organizational Reform
In the final step of the General Reform Model, the Reform Consultant will begin the process of organizational reform by replacing the Bureaucratic organization with a Team Management organization with top management managing the Agency’s activities through Group Teams with each managing several Functional Teams.  The Lean Teams at the Functional level will become self managed Functional Teams with each of their elected leaders reporting directly to a Group Managed team.  Group Managed Teams will assume their management role from the pre-organized high level Lean Teams.  There is some flexibility in how this process actually occurs but it is necessary in order to eliminate the problems caused by the Bureaucratic organization.  The important advantage in changing from a Bureaucratic organization to a Team Managed organization is that the savings continues annually for years from continuous improvement without a return to the old bureaucratic methods.

7. Time of Staffing Adjustments
This is the period of time for the reduction of redundant government staff.  To attain a balanced work load is a primary objective where retraining employees to fill needed vacancies is pursued.  Where departmental staffing can be reduced layoffs or temporary reassignments should be completed within a month.




 2. Enterprise Lean, Balanced Work Load, Continuous Improvement

Enterprise Lean focuses on the big picture the balanced flow of work which is periodically interrupted by improvements to the system through Continuous improvement.  Continuous improvement can come from many different sources: improvements in the way processes are done,  the purchase of new equipment, improvements in Hygiene Rules saving time and imaging machines even the addition of another doctor where one is badly needed.  Enterprise Lean sees these efficiency improvements bringing improvement in efficiency but the big picture shows that the savings may be considerably less than purported.  The reason is that the improvements are disruptive to the balanced work flow causing many processes to wait on other processes.        

Lean implementers especially highly trained black belts tend to focus on individual areas and processes known to be inefficient and are usually successful in making individual systems efficient but only cause in-balance in the work flow causing lost time due to wait time.

For Example: Lean specialists have made a Lean Study of a Cardiac Surgery Process and have made it more efficient saving the hospital thousands of dollars.  Since the study only looked at the surgery process it did not achieve its purported savings goals because it failed to include surrounding interfacing processes causing in-balance in the work flow.  If the lab supporting the surgery process was not also made efficient the Surgeon and his entire operating staff may end up waiting for lab results.

Enterprise Lean establishes employee Lean Teams in all of the facility's processes ready to conduct a throughput study that will re-balance the flow of work when disruptions occur from continuous improvements or other causes.

The Maximum Patient Throughput Method
This is a two stage process with individual employee Functional Lean Teams (including Nurses) meeting to determine the most Effective way to do their functions. Each Lean Team will layout the scheduling process on wrapping paper with taped on colored strips of paper scaled to represent the time to do each process of the Function. The objective is to find the most effective and efficient way of doing the function.

This is followed by the above Team Leaders of the several functions meeting as a higher level team with the Doctor as Team Leader to apply the data from the individual functional teams. The color of the paper represents the key person involved: a nurse or team of nurses, doctor, or patient.  Another color represents support operations which are necessary but are separate from and not dependent on the main Scheduling process.  The support operations are used to fill in where wait times are naturally occurring By staff members.

Arranging the processes in the order that they may be completed some in parallel with the Doctor’s time as key to obtaining the Maximum patient throughput Schedule. The method also determines the equipment utilization of the process.  Besides determining the maximum throughput of patients the process also establishes a cost for labor and equipment depreciation and a budget for each Function.  The data can also be used to determine the exact increase in staffing and equipment needed to meet a desired Patient appointment and processing schedule.

Government Bureaucracies both State and Federal as well as many companies in the private sector have failed to recognize the problem of a balanced work load by continuing to focus Lean studies on individual problem systems.   Enterprise Lean focuses on the big picture and provides a solution for balancing the work flow with continuous improvement.  See Article 8. Twenty Five Case Studies Using Lean in Government.

Benefits to the VA from the General Reform Model
Because of the obvious need for increased VA staffing any savings is relative to achieving the goals of the VA in meeting the needs of Veterans.  The General Reform Model generates the following benefits: 
1. Enterprise Lean provides a way to change the toxic culture of the VA to a focused positive culture.
2. Enterprise lean develops the data needed for right-sizing, and determines where staffing is needed.
3. The reforms provide a balanced work flow with continuous improvement for all systems.
4.  A bottoms up budget is made for all functions in a facility (not including Management and Overhead).
5.  The Bureaucratic organization is replaced with a Team Management organization. This is done to prevent the return of the current toxic Bureaucratic management.

All of the above implementations of the General Reform Model develops bottom line savings and reduces the cost to the VA significantly over that of not implementing the General Reform Model.  Actual savings are relative in that funding is reduced for implementing the fixes for the VA but it is not known by how much.  An estimate places the savings at more than one billion dollars.


 3. Fundamental Innovation at the VA

With all innovation there exists a fundamental component, having accurate cost data for making the key decisions about which innovative proposals and adventures are cost effective.  Accurate cost data in most government operations including the VA simply does not exist. Yes; you will find cost data everywhere in government but not the kind of cost data I am referring to.  What you will find is after-the-fact cost data what was actually spent on the operation not what should have been spent by employing practices and innovation to get the highest efficiency with a balanced work load. The Development of a balanced work load in each medical area is the key to determining the minimum staffing needed to meet patient appointment schedules.

Meeting the VA’s Mission objectives
When we hear of mass hiring of VA personnel doctors and staff we must ask the fundamental question of how many staff members with what expertise and where should they be located?  Innovation begins here, how do we develop the fundamental cost data so that the above question can be answered in the shortest possible time to dramatically solve the problem of meeting patient appointment schedules.  Serving the current Veteran’s patient needs is an obvious first objective.   In the following I have addressed how the needed cost data can be generated and used to create a balanced work load.  

Now that we have established a cost basis for the VA the VA can move on to examining what we normally think of as innovation:
1. Evaluating current VA Medical functions to determine the correct staffing using Right-Sizing.
2. Converting a Clinic’s first shift operation to a two operation.
3. Establishing Mobile Clinics for under served areas especially in our Western states.
4. Developing  hardened prefabricated hospital units such as that used in prefabricating housing units.
5. Assembling the best medical minds in a high level advisory council.
6. Establish a Federal Program to certify skilled nurses as doctors.  Be prepared for a flood of highly skill nurses from the public sector.
7. Establish a job training program for Vets undergoing extensive physical therapy to certify them as Physical Therapists for jobs in the private sector.

This list is far from being complete and misses the important innovations generated by VA employees through innovation and continuous improvement of their jobs resulting from the implementation of Enterprise Lean.


4.  Restoring Management Excellence at the VA

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

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

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

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

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

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

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

Overall Plan based on number of Doctors:
First two months
Each VA Medical Facility will identify all maximum patient loads in each medical area to meet required patient appointment schedules. This data will be needed to staff Throughput Schedules being developed at the DC development VA Facility.

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

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

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

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

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

Organizational Reform:
To address the problem of the toxic bureaucratic culture of the VA I recommend replacing the Bureaucracy with Team Management.  The Principal Consultant will begin the process of organizational reform by replacing the Bureaucratic organization with a Team Management organization with top management managing the Agency’s activities through Group Teams with each managing several Functional Teams.  The Lean Teams at the Functional level will become self managed Functional Teams with each of their elected leaders reporting directly to a Group Managed team.  Group Managed Teams will assume their management role from the pre-organized high level Lean Teams.  There is some flexibility in how this process actually occurs but it is necessary in order to eliminate the problems caused by the Bureaucratic organization.  The important advantage in changing from a Bureaucratic organization to a Team Managed organization is to prevent the return to a toxic bureaucracy.  The Team Management process eliminates the need for low level supervisors saving $millions.

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



5. Using Templates to Boost Innovation at all VA Hospitals

My General Reform Model begins step one with the implementation of a modified Enterprise Lean implementation which may be better explained as the development of work Load balancing templates to be used for all VA Health Care functions at all VA Medical Facilities.  The templates when installed at all VA medical facilities creates a baseline where continuous improvement can begin by all teams in the VA system improvements made by the teams are shared with all VA hospitals.  The templates are not considered to be best practices and therefore not to be challenged.

Step 1. of the General Reform Model, Implementation of Modified Enterprise Lean
A.  Establish a breakdown of the entire VA Medical Facility into sets of processes we will call Functions.
B.  Organize Employee Lean Teams based on who does a Function or related Functions.
C.  Trained Facilitator Analysts will assist each Lean Team in determining the Best Practice and the most efficient way of doing each Function.
D.  The Maximum Patient Throughput Method
This is a two stage process with individual Lean Teams (Nurses) meeting to determine the most Effective way to do their functions. Each Lean Team will layout the scheduling process on wrapping paper with taped on colored strips of paper scaled to represent the time to do each process of the Function. The objective is to determine the most effective and efficient way of doing the function.

This is followed by the Team Leaders of the several functions meeting as a higher level team with the Doctor's Team to apply the data from the individual functional teams. The color of the paper represents the key person involved being: a nurse or team of nurses, doctor, or patient.  Another color represents support operations which are necessary but are separate from and not dependent on the main Scheduling process.  By arranging the processes in the order that they may be completed some in parallel with the Doctor’s time as key to obtaining the Maximum patient throughput Schedule. The method also determines the equipment utilization for the process.  Besides determining the maximum throughput of patients the process also establishes a cost for labor and equipment depreciation and a budget for each Function.  The data can also be used to determine the exact increase in staffing and equipment needed to meet a desired Patient appointment and processing schedule.

Step 2. Documentation and Collection of Lean Team Data by Analysts
A.  Documentation of the Lean Team’s Data: the improved method, the time to do each Function, the employee’s name labor rate and time involved in the function, and the equipment and its depreciation cost. The Documentation and collection is done by each Facilitator Analyst.  The Lean Team Data is Collected on a spread sheet for each Function.  As the Data is collected the sum of the data is accumulated using a Google App on a tablet and is available for all facilitators to see.

B. The employee work force is Right-Sized to fit the workload (making sure each employee has a full time job). this step uses the Lean Team Data to Right-size the organization. If an employee does not have a full time job an effort is made to increase the employees tasks.  It is important that redundant employees must be removed from the work environment and retrained for new jobs.  Every effort to retrain employees from overstaffed areas and move them to where they are needed will be done.

C. Improving the Efficiency of variable workloads through the use of Workload Planning and Scheduling methods.  This is done by developing a weekly Work Load Plan. As actual data is developed the plan is revised for continuous improvement.

Step 3.The Bureaucratic organization is replaced with a Team Managed organization.
The conversion is a simple process because we already have Lean Teams in place at the lower level and in Management.  Many of the lower level teams will be self managed with their leaders being elected by secrete ballot.  How ever many Professional Teams such as surgeons with attending nurses are already in place.

An important Example of where Significant Savings can be Gotten using Continuous Improvement
REF: Burma Cataract Surgeons- CBS 60 Minutes April 16, 2017

The 60 minutes show “Out of Darkness” aired last week, was about two eye surgeons Sanduk Ruit and Geoffrey Tabin who together did cataract surgery on 350,000 patients.  5 minutes/eye @ $20 ea. 100/day vs. in the US 5 eyes/day @ $2000 ea. Yet the Burma cataract surgeries followed all the rules of hygiene. 

What we can learn from this is that US rules for hygiene have nothing to do with time.  In fact time is allowed just to prevent mistakes.  This means that VA Enterprise teams have a wide open field to bring down the cost of hospital operations using Continuous Improvement but they must overcome a mountain of bureaucratic regulations. The savings may be in the $millions.

The Template establishes the current efficiency and leaves open the closing of the gap between the maximum efficiency used in Burma that can be attained and what the current rules and regulations will allow in the US. The teams can chip away at these rules through Continuous Improvement in the operations rather than  accept the current process rules as being carved in stone.



6.  Three levels of Throughput- Current, Capable and Required 

When we examine Throughput we find that there are three levels of Throughput:
1. Current Throughput (number of patients processed in specific areas) determined by hospital records.
2. Capable Throughput determined by employee Lean Team studies and a Throughput Schedule using current staffing.
3.  Required level of throughput to meet Veteran schedules.  This is arrived at by expanding the Capable Throughput Schedule adding staffing until the Required level is reached to satisfy appointment schedules.

How this process can be implemented
The problem: determine waiting Veterans Health Care Needs and the added impact on VA hospital capabilities followed by the increased staffing to meet requirements.

Approach for Quickly meeting Veterans’ Health Care Needs
1. Make sure all Vets Who want an appointment are added to the electronic appointment Schedule.

2. Make a detailed assessment of each patient’s medical needs to determine where and by how much the VA Medical Facility will be impacted.  I recommend a mass screening of the 1700 new patients at the Phoenix VA with interviews and blood tests.  By reviewing 100 patients a day the task of finding what the patients health care needs are can be completed in a month.  The impact on the Medical Facility will be an estimate because more precise numbers are beyond the expertise of the VA.

3. For the Identification of exactly where the VA hospital is going to be impacted with the required increased staffing I recommend that immediate attention be given to the following:

A. Identify all systems processes affected by increased patient loads from the mass screening and establish an employee functional Lean Team for each set of processes.  Empower the Lean Teams in these areas to come up with the most effective and efficient approach for doing the process.

B. Establish a second level Doctors Lean Team to determine the Capable Throughput with current staffing using the data developed by the Functional Lean Team to create a balanced work flow Throughput Schedule.

C.  Find the Required level of throughput to meet Veteran schedules.  This is arrived at by expanding the Capable Throughput Schedule adding staffing in balanced sets until the Required level meets Veterans Appointment Schedules.

This approach will also identify the need for equipment and machines to be purchased by the VA.
 
Note that the objective of the balanced work flow is to eliminate excessive waste time due to members of a Team waiting on other members.  This a staffing balance with each employee's duties rated at 75% this means that the time to do a process at 100% is increased to 125%.  The reason for this is that it avoids delays caused by inexperience employees or other reasons that may impact the entire Team.  The absence of a team member can significantly impact the entire Team causing all members to wait.  To avoid this problem I would have a standby nurse who will do routine support activities such as ordering supplies that can be available to fill the void.  It is possible although not required that an experienced Team can work consistently at 100% increasing the number of patients served.   

Example of Psychiatric Veteran Needs
Because the level of need in this area is so great to prevent suicides and domestic violence.  I recommend the following approach:

Follow the above approach for immediate action then Convene a Medical Advisory Board of the best minds in the Psychiatric field for recommendations and suggestions.  This is followed by a second Required level of Throughput Schedule to implement the new recommendations and suggestions as templates which can be applied in all VA Health Care Facilities.  Note that Psychiatric and Physical Therapy patients are dependent on the condition of the patient and not on the time spent with the doctor.

Each VA Health Care Facility will have a different Vets appointment Schedule.  Only the building of the Required level of Throughput to meet the new Facility's Veteran schedules is needed.  This is arrived at by duplicating the original Capable Throughput Schedule and expanding it to meet the new Facilities staffing requirements level thus satisfying the new appointment schedules while providing the highest effectiveness  and the greatest efficiency.

If the original Capable Throughput Schedule is expanded each time a Doctor is added we can determine the corresponding: number of nurses needed, equipment needed, and number of patients for a balanced work load.  Also with each step we can determine the added floor space required. Now we have the data needed for all VA Medical facilities by matching the increased patient load for each medical area to one of the balanced steps based on the number of doctors required yielding the patient load that meets the appointment schedule requirements.  This is not an estimate but an actual balanced work flow of doctors, nurses, and equipment for given patient load.

Before new computer systems can be built to estimate Staffing requirements at VA facilities there must be a solid footing of actual data to backup the new systems. The quicker this data is generated and proven the sooner computer systems can be developed.  The problem is that the data can be quickly generated within two months but the computer systems will take as much as a year to develop time that the VA does not have.

Addressing the major problem: 22 Veterans Commit Suicide Per Day‎.

What if PTSD Is More Physical Than Psychological? Dr.Perl’s  findings 
A new study supports what a small group of military researchers has suspected for decades: that
modern warfare destroys the brain. By ROBERT F. WORTH  Credit Nick Oza for The New York Times NYT JUNE 10, 2016

Dr. Perl’s findings, published in the Scientific Journal 2012.  The Lancet Neurology, may represent the key to a medical mystery first glimpsed a century ago in the trenches of World War I. It was first known as shell shock, then combat fatigue and finally PTSD, and in each case, it was almost universally understood as a psychic rather than a physical affliction.

PTSD symptoms from the recent wars in Iraq and Afghanistan: memory loss, cognitive problems, inability to sleep and profound, often suicidal depression. Nearly 350,000 service members have been given a diagnosis of traumatic brain injury over the past 15 years, many of them from blast exposure. The real number is likely to be much higher, because so many who have enlisted are too proud to report a wound that remains invisible.

Comment by Lawrence Rosier:
Now that we know that the extent of the brain damage can be observed through a Brain Scan.  We can separate those with Physical brain damage from those with Psychological problems.  We can also determine those most vulnerable and develop an effective treatment. This implies the use of  Mass Screening using the VA Patient through-put method to be applied through the Psychological Teams of VA Hospitals.    This is but one example how VA reforms can make a difference.




7. Detailed Description of the Throughput Process

What is a Throughput Schedule?
A Throughput Staffing Schedule is a visual graphic representation of functional processes where the staff members name can be assigned to the process.  The interaction of the processes of the function is depicted such that a sequential representation is maintained showing the activities of nurses, doctors and patients.  The objective is to balance the activities of the function such that no staff member is delayed by having to wait for another staff member to complete his job.  This is a team effort with all staff members working together according to the Throughput Schedule.  The Throughput Schedule is a depiction on a large wall chart designed to allow visibility and understanding of the process by all of the team members.  The Throughput Schedule is a “staffing schedule” meaning that it provides allowances for delays from: equipment and supplies and inexperienced staff members.  It does this by increasing the standard time for each process by 25%.

The Throughput Development Project
My most recent proposal to the Secretary of the VA to develop the Throughput Process specifies that a contingent of ten OIG Analysts be assigned to the Development Project at the Temple Texas VA Medical Facility as early as in the next few weeks (August or September 2014).  The OIG Analysts will be given overview of the project followed by background training before being assigned to a specific medical area such as Cardiology and Endocrinology.  The medical areas receiving prompt attention are those that have been identified in a review of all Vets that have been excluded from the Temple VA Medical Facility's appointment Schedule and represent an overload of patients on the VA Facility.

 VA Quality Management Services Depart
As the Consultant on the project I will work closely with the VA Quality Management Services department using their data and expertise to expedite the project.  The Quality Management Service focuses on the Veteran and organizational functions that promote positive patient outcomes by standardizing processes.   The Quality Management Team has identified the functions and standardized the processes within each function.

The intent is to use their Standardized data first to identify functions so we can organize Functional Lean Teams of those who do the processes.   Then the OIG Analysts as Facilitators will test each Function Lean Team to see if they are following the standardized processes and make updates as required.  The standardized processes will then become a Template to be shared with other VA hospitals.  

The first assignment for the OIG Analysts is to act as Facilitators for the Employee Functional Lean Teams in their medical areas.  The Facilitator will organize the Functional Lean Team and aid in the election of the team leader by secret ballot.  The Team will meet once a week for one hour.  After they have been organized and orientated by the Facilitator the Lean Team will review and verify the quality process standards.  Each Functional Lean Team may have several functions they do but these are the only functions that they do.  The next step is to graphically study the relationships of the functions to each other and and those doing the work including nurses, doctors and patients.
I recommend that the Team be brought in on a Saturday to jump start the process of putting together the graphic representation of the functions and their relationships.  The OIG Analyst will capture the data developed by the Functional Lean Team on a spreadsheet including the graphical representation of functional relationships.

The graphic representations created by the Functional Lean Teams is given to a higher level Doctor’s Lean Team, Facilitated by the OIG Analyst, to be used as the foundation for the development of the Throughput Staffing Schedule.  The Lean Data will be captured in a spreadsheet and used in the higher level Doctor’s Lean Team to develop the Throughput document which will be captured in a staffing spreadsheet.  The Throughput spreadsheet will be expanded to contain a large number of repeated reiterations of the original Template creating a balanced schedule design.  The Throughput Document will contain enough reiterations to meet any VA facility’s patient appointment schedule requirement.  The spreadsheet for each medical area will be test implemented at the DC VA Medical Facility.  With the success of the test implementation each spreadsheet medical area will be stored on a thumb drive. Spreadsheets have a unique capability for selecting what gets printed.  In this case the number of patients needed to meet a particular VA Facilities appointment Schedule can be selected from the spreadsheet before printing the Throughput Schedule for the VA Facility.

Each OIG Analyst will depart The development VA Facility for another VA Medical Facility with the medical Thumb drives containing a spreadsheet Throughput Schedule for each medical area. At the VA new medical facility the OIG Analyst will select the required patient appointment schedule matching the number of patients on the spreadsheet and print that number.  This will be done from the staffing spreadsheet thumb drive in each medical area.  The spreadsheets are expected to be quit large and will have to be assembled and taped on a back ground sheet of wrapping paper.  The reason for this is to allow the staff at the new VA facility to become familiar with the staffing plan by assigning staff member names to the staffing Schedule.  The staffing schedule will determine the required staff yet to be hired. The Staffing Schedule can be conveniently rolled up and used again as necessary.

OIG Analysts will be on a tight schedule and expected to move to the next assigned VA Medical Facility until all of the VA Facilities have the their needed Throughput Staffing Schedules for critical medical areas.

The second part of my proposed Consulting Agreement with the VA using Enterprise Lean specifies that the entire Temple Texas VA Facility will use Functional teams in the remaining non critical medical areas (Those not identified as needing immediate increased staffing).  The areas will also have Throughput Staffing Schedules however these staffing schedules may show that a medical area has too many staff members.  If this is the case then the redundant staff can be retrained to fill areas of need at the Temple Texas VA Medical  Facility.

The Throughput spreadsheets on thumb drives for the remaining non critical medical areas can be sent to all VA Facilities by snail mail.  This will allow all VA facilities to use redundant staff by retraining them to fill needed jobs.

Team Management replaces the current toxic Bureaucracy. The result of this in my experience has been an increased excitement among employees by allowing them to participate in the management of their work areas.  This will result in fewer supervisory personnel being required.  These supervisors will remain in the Functional Teams and will have the opportunity to relocate to a new facility being built by the VA.

The implementation of Team Management in all VA Facilities can be done by OIG Analysts over the next year.

8. Obtaining Maximum Patient Throughput with The Highest Effectiveness  

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

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

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

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

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

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

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

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

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

The following manual scheduling method is used to demonstrate the plan for getting the maximum patient load:
1. Have each nurse and the Ophthalmologist set a time in minutes for each and every process that is done.
2. Then put the information on colored card stock using the color codes below with a time scale of approx ¼ inch for each minute in the process.  Identify clearly exactly what the process of steps describe.  Now you have a representation for each and all of the processes the nurses and the doctor do over several weeks with patient involvement color coded.
3. List all staff members on the vertical left of the chart and layout all the processes into the sequence they should be done. Start by finding those processes that can be done in parallel (at the same time) followed by the next sequence.
4. Now look at patient access and equipment access.  With more patients you may need more equipment.  What you are looking for is the elimination of bottlenecks of wait time.
5. Because the number of patients available for cataract surgery can vary you may be able to put off doing those support processes that may have been included in an automated schedule and thought to be necessary to schedule.  These may a be set aside during periods of high patient flow and only done in periods of low patient flow or wait times.  For example when the Ophthalmologist is "in" and meeting with patients all non-patient support activities are to be done only when the Ophthalmologist is "away" in surgery operating on patients at another location.
6. Now we want to make a daily plan which extends several weeks showing the maximum number of patients that can be processed.  We will build the plan based on the activities of the Ophthalmologist.  Start by taking the card stock representations and collapse them into the shortest time span equipment usage such as the operating room will overlap the Ophthalmologist’s time. The result will equal the longest continuous process.  This may also include the patient's time, to process a patient for preliminary testing by the nurse followed by the time with the Ophthalmologist’s surgery.  The plan will cover all activities based on Ophthalmologist/patient availability.
7. The key is in focusing on the Ophthalmologist’s operations to get the maximum number of patients.  There will always be lost time when times are slow because of a variable patient schedule.  This time is to be used for routine support activities that do not involve patients.
8. The efficient use of equipment may be simply be cycling through patients by appointment times but for the maximum number of patients you may want to buy more equipment to be sure the Ophthalmologist has a full schedule and is not waiting for the next patient.
9.  The final card stock layout will become the plan to be followed when processing the maximum number of patients.  The result from a computerized schedule will not produce the same results because it includes all activities.   Not considered in the automated schedule is the fact that the maximum number of patients are not always available.  The Real Manual Plan should show only the key operations for the maximum number of patients. Because we don’t care about being efficient in slow or lax times.
10. A benefit is the staff involvement in the process which brings understanding of why and how processes can be done during maximum patient volume flow.
11. The economic benefit is that when there is a backlog of patients you have a plan to absorb the maximum number of patients knowing exactly how many you can process effectively and efficiently.

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




9. Nation Wide VA Progress Reporting System                              

 Proposal of  a Nation Wide VA Progress Reporting System which starts with selected manual reporting from each VA Medical Facility of patient loads and operating expenses in each medical area such as Cardiology and Endocrinology.

I have shown how the Throughput Staffing Schedule spreadsheet developed for each VA Medical Facility in specific medical areas provides a balanced work load and specifies the required staffing to meet patient appointment schedules.  Labor Costs and expenses in each medical area can be developed in each VA Medical Facility.   When these expenditures are compared with actual patient throughput in each medical area each month you will have a partial manual reporting system that can be in place within six months.  Reports from each VA Medical Facility can be compared for anomalies manually at first and then automated in the second year.

As Lean Data is developed using Enterprise Lean for an entire VA Medical Facility the remaining overhead cost areas (largely office support areas, Pharmacies and Laboratory areas) will have balanced work load schedules developed which can be implemented throughout the VA Medical Facility System.  The manual reporting system can be supplemented by Progress Reports on staff hiring activities and Facility Construction from each VA Medical Facility.  Automation of the reporting system should be delayed until all manual systems have been proven.

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

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

Part One:
Overall Plan based on number of Doctors From
First two months
Each VA Medical Facility will identify all maximum patient loads in each medical area to meet required patient appointment schedules. This data will be needed to staff Throughput Schedules being developed at a development VA Facility.

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

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

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

Approach based on Patient Diagnosis
The above approach works in all areas where the number of Doctors is the key driving force but where Psychologists and Physical Therapists are involved an entirely different approach is needed based on the diagnosis of each individual patient and the patient's plan of recovery.  I suggest the following approach:
1. Establish a high level Doctors Lean Team to develop or adapt Templates for patient Recovery Plans.
2. Standardize patient recovery plans (may be available from other sources).
3. Determine staffing and costs for each recovery plan.
4. Determine the number of patients assigned to each Recovery Plan for a VA Medical Facility's staffing requirements and an annual budget.

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

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

About Automated System Reporting:
The problem in past years and to some extent today is that there are few government leaders who have the knowledge to make the proper decisions related to IT implementations.  The result is that they most always rely on their own IT personnel to make the decisions on future implementations.  These are the vary people one should not ask because these are the people who have spent years working on their obsolete hardware.  95% of all government IT programs are obsolete but even worse government continues to build or add to the present obsolete systems using the same obsolete software approach.

Most government systems use an obsolete IBM Base Systems Application from which all other application programs must be compatible.  These government systems have never been up graded and are more than 50 years old.  Most of these systems were coded before the present Systems Analysts were born.  These systems are similar in function to Microsoft’s Windows 8 where all application  programs must be compatible with it but it gets periodically up graded to Windows 10 etc.   With cell phones becoming obsolete within a year, one can only begin to see the inefficiency of these obsolete systems

I recommend avoiding obsolete IT systems by using Cloud technology and implement modern Relational Databases in a new facility using the SQL language and dump the obsolete systems.

Washington State is one of the few states who has come to grips with this IT problem.  A few years ago while planning for the new IT facility at Olympia Washington.  The then IT State Manager was planning on reinstalling their current obsolete application programs into the new facility.  Fortunately a computer knowledgeable Congressman got wind of the scheme and persuaded the Governor to implement modern Relational Databases into the new facility using the SQL language.  Unfortunately  it was too late for failed systems installed in: Indiana, Virginia, Texas and others.  The Indiana and Texas failures were catastrophic yet they were able to spend enough money to make the systems work.  But the biggest failure was in Virginia where nearly a $billion was spent just for the develop a statewide email system which they could have had for next to nothing using Google's Gmail. 



 Adaptations of Private Industry to Government References:

“In Search of Excellence-Lessons from America’s Best Run Companies” by Thomas J. Peters and Robert H. Waterman Jr., 1982.
“Innovation and Entrepreneurship-Practice and Principles” by Peter Drucker, 1985.
“Kaizen (Ky’zen) The Key to Japan’s Competitive Success” by Masaaki Imai 1986.
“Thriving on Chaos-Handbook for a Management Revolution” by Tom Peters, 1987.
“Attaining Manufacturing Excellence - Just In Time -Total Quality -Total People Involvement 1987”
By Robert W. Hall.
“American Business A Two Minute Warning” by C. Jackson Grayson, Jr. and Carla O’Dell 1988.
“Reinventing Government-How the Entrepreneurial Spirit is Transforming the Public Sector” by David Osborne and Ted Gaebler 1992.
“Banishing Bureaucracy-Five Strategies For Reinventing Government” by David Osborne and Peter Plastrik 1997.
“The Price of Government-Getting the Results We Need in an age of Permanent Fiscal Crisis” by David Osborne and Peter Hutchinson 2004.
“We Don't Make Widgets: Overcoming the Myths That Keep Government from Radically Improving”  by Ken Miller 2006.

 
Contact Lawrence Rosier
Lawrence Rosier Consulting
12143 Cedar Grove Rd.
Rolla, Missouri 65401
573 578 4716
lawrencerosier4@Gmail.com