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
Thursday, April 27, 2017
Thursday, March 9, 2017
Atticle 95. GSA’s 18F Problems
Problems with GSA’s 18F Information Technology Organization
The 18F IT organization exhibits both good characteristics and bad. On the good side if the software development done by the organization is truly open systems oriented, meaning for example that any proprietary computer such as IBM can be replaced with a Digital Equipment computer then that is a good start. It should also implement Relational Database Management Systems which allow queries to its databases. This means that nearly all future major Government software development will follow these rules. Only very minor tweaking of current obsolete software should be allowed.
On the bad side 18FIT solicits software development from US Government Agencies the danger is that most Agency management are not computer literate and may demand that current systems be revised to fit the needs of the Agency. This is an open door for 18F to spend years revising obsolete software billing the Agency $millions. 18F has already been cited for incorrect billing. The danger is that 18F has or will become a “Code and Bill” bureaucratic organization that has no limits in what it can charge taking years to complete a project.
Example State Government IT Recommendations
The Centralization of State Services Reform Model developed by the author
I recommend a State Central Cloud Information Technology Data Center to store all state and county data. I further recommend the implementation of a new Centralized Relational Database Management System (RDMS) similar to that implemented in Washington State. The RDMS is developed completely separate from the current obsolete Agency computer systems. No funds were wasted on trying to patch the old systems. When the New Centralized Data Center and its systems were up and running the plug was pulled on the old systems.
The State of Virginia wasted nearly a $billion on the VITA Contract with Northrop Grumman. State leaders funding VITA were naïve computer illiterate politicians who entered into a long term contract with Northrop Grumman to develop an Email system and revise their current State systems. They could have had an email system from Google for next to nothing. Most current systems can not be economically brought up to date. Northrop Grumman as a contractor worked on the state’s systems for years with what I am told was only a partial success.
Why didn’t Virginia’s VITA organization come up with the above state recommended solution? The answer is nearly all of the state’s IT personnel associated with the state’s VITA organization have training or some kind of connection to IBM. So what’s the problem with IBM? Simply this, IBM is in business to sell a proprietary system that shuts out competitors and forces the customers to use its proprietary software. The RDMS is an open software system where an IBM computer could be replaced by a competitor’s computer. Computers can then be purchased simply for their competitive computing power and not just because it will work with the software. At least some of the VITA members must have known about the RDMS solution because it has been around for more than twenty years but it is simply not good business for IBM or its friends. For all practical purposes VITA may as well have been on the IBM payroll.
The GSA’s Current Relationship with Its OIG Subsidiary
The GSA’s OIG subsidiary has the power to make recommendations to the GSA’s management and the GSA can chose to follow those recommendations as in the case of 18F’s problems or not to follow recommendations. The OIG as a subsidiary of the GSA Department has little power to implement solutions to problems it identifies.
The GSA’s Recommended Relationship with Its OIG Subsidiary
This is a key part of the recommended US Government reforms. It solves the problem that Departmental OIGs are not independent organizations and are under control of department heads. In the new independent OIG organization OIGs will remain in their present departmental physical locations but will be a part of a single OIG organization reporting directly to the OMB.
This reform will require Congressional approval for the creation of a US Office of Inspector General (USOIG) organization. It will report to the Office of Management and Budget (OMB) headed by the new position of US Inspector General appointed by the President. Each Departmental OIG organization (about 17) will report directly to the US Inspector General.
The first and primary responsibility of the new Inspector General is to lead the implantation of Federal Government Reforms. Requiring specialized training for OIG personnel in Right-sizing and Facilitator for the implementation of Enterprise lean. Current investigative activities may be put on hold until the implementation of reforms have been completed.
After Reforms have been implemented OIG Analysts will return to their normal investigative activities with strengthened oversight powers to manage staffing budgets as well.
From Fedscoop
https://www.fedscoop.com/18f-gsa-ig-report-october-2016/
David A. Shive is the Chief Information Officer for the U.S. General Services Administration.
Shive oversees GSA IT - formerly known as the Office of the Chief Information Officer (OCIO) - and information technology operations and budget, ensuring its alignment with agency and administration strategic objectives and priorities. Shive began his career at Lockheed Martin Corporation in management and consulting roles overseeing large, customer-centric, IT organizations serving state and local, federal and international government customers.
GSA IG: 18F’s financial projections need a rework
The General Services Administration’s 18F has seen a cumulative net loss of more than $31 million between fiscal year 2014 and the third quarter of fiscal year 2016, a report released Monday from the agency’s inspector general has found.
The inability to recover costs came from “18F’s inaccurate financial projections, increased staffing levels, and the amount of staff time spent on non-billable activities,” the report reads.
The evaluation started in December 2015, according to a release on the report, “after several senior GSA officials expressed concerns about the management of 18F to the OIG.”
Lawmakers have in the past expressed concerns about 18F’s little-defined role in the federal IT space and called for greater organizational transparency.
[Read more: Lawmakers crave transparency from USDS, 18F digital teams]
The report details how 18F operated at an increasing deficit, where staffing continued to balloon at the organization despite gaining smaller revenues than anticipated.
“18F senior managers have established a pattern of overestimating revenue projections,” according to the release.
An example: Projected annual revenue for fiscal year 2014 was $4.76 million, but the year closed with a grand total of zero revenue billed or collected, according to the report.
The report also found 18F’s billing process was not always accurate and resulted in “a series of inaccurate charges to their clients.”
“If billing discrepancies are left unresolved, GSA could be held accountable for augmenting appropriations for other federal agencies,” the release says.
Breaking even
The report found internal discussions among senior management “that raise doubts about their intent to break even.”
“To be frank, there are some of us that don’t give rip about the losses,” said 18F’s director of operations in February when 18F management was discussing three breakeven scenarios.
And in response, the report notes Regional Administrator for GSA’s Region 9, Andrew McMahon said, “Sure, in the end, I could care less. ASF loses money all over the place. That’s the decision we should reiterate with Denise [GSA Administrator Roth], do you care about losing +$2.5M in order to bring in 100 more great hired [sic] into government?”
The report also details in particular an internal struggle on one approach potentially breaking even more quickly: freezing hiring.
From April 2014 to March 2016, the 18F staff expanded from 33 to 201 full time employees.
Federal Acquisitions Service Commissioner Thomas Sharpe advised Administrator Denise Turner Roth and the former Technology Transformation Service Commissioner at least three times to pause hiring, but the IG found through internal records that 18F management and the administrator’s office did not support it.
Roth wrote to Sharpe in January 2016, “Demand for 18F services continues to be strong, the utilization rate is increasing, and there is other activity in place that justifies staying the course on hiring at this time,” according to the report.
The report says former Executive Director Aaron Snow said “18F continued to hire to meet demand for projects because they did not have the staff in place to accept all project requests. Also, he wanted to ensure 18F had enough staff to mitigate the impact of occasional staff turnover.”
The OIG also found that staff spent little time working on projects billed to federal agencies — less than half of their time.
The report notes 18F’s timekeeping system showed that nonbillable time was spent on activities such as “outreach promoting 18F projects and accomplishments, developing an 18F brand and developing an internal timekeeping system.”
What’s next?
GSA management agreed with the report’s seven recommendations and told the OIG they had intentions to take action.
The report’s seven recommendations were for GSA leadership to:
o Establish a viable plan to ensure full cost recovery of Acquisition Services Fund monies expended by 18F;
o Ensure that internal 18F projects have appropriate supervisory review;
o Implement controls over 18F’s reimbursable agreement process to ensure that work is not performed outside of a fully executed agreement;
o Ensure that GSA CIO reviews and approves, in writing, all 18F IT-related work performed for GSA internal organizations;
o Implement a comprehensive review of 18F’s past work to ensure accuracy of all billings;
o Establish reliable internal controls to ensure that 18F’s future billings are accurate; and
o Ensure that 18F’s billing records are retained in accordance with GSA records management standards.
In response, 18F’s Dave Zvenyach writes in a blog post that the office has taken numerous steps to correct the issues brought up in the report: “We take these issues seriously and have taken significant steps to strengthen 18F’s operations.”
The blog post states the office has instituted dashboards for real-time management of financial performance and staff utilization, conducted a reconciliation of past agreements to ensure accurate billing and “standardized the relationship between 18F and the CIO by, among other things, having a CIO lead who reviews all internal technology projects for 18F.”
“Our mission requires us to be relentlessly focused on helping our agency partners, and that means we need to ensure that we continuously improve on our controls and processes to meet that mission,” the blog post reads.
Snow recently told FedScoop 18F’s long-term impact is about more than money — particularly in things that are “intangible.”
“The measure of 18F’s value is not just the dollars saved on the projects we’re working on right now with an agency any more than the measure of its value is the number of dollars it makes or loses,” he said then. “The measure of its value is how much we help agencies evolve how they think about the delivery of digital services in government across all of their work.”
“And I don’t think anybody has done a fantastic job yet of measuring the success of the intangibles that we are ultimately after,” he added.
At the time, Snow also said 18F is going to be around for a long time, in spite of a changing administration.
“It seems clear there is support for what we do from all sides, all points on the political spectrum,” he said then. “I don’t think that a change in administration substantially changes what we do, how we do it or the scale of impact we can have.”
The 18F IT organization exhibits both good characteristics and bad. On the good side if the software development done by the organization is truly open systems oriented, meaning for example that any proprietary computer such as IBM can be replaced with a Digital Equipment computer then that is a good start. It should also implement Relational Database Management Systems which allow queries to its databases. This means that nearly all future major Government software development will follow these rules. Only very minor tweaking of current obsolete software should be allowed.
On the bad side 18FIT solicits software development from US Government Agencies the danger is that most Agency management are not computer literate and may demand that current systems be revised to fit the needs of the Agency. This is an open door for 18F to spend years revising obsolete software billing the Agency $millions. 18F has already been cited for incorrect billing. The danger is that 18F has or will become a “Code and Bill” bureaucratic organization that has no limits in what it can charge taking years to complete a project.
Example State Government IT Recommendations
The Centralization of State Services Reform Model developed by the author
I recommend a State Central Cloud Information Technology Data Center to store all state and county data. I further recommend the implementation of a new Centralized Relational Database Management System (RDMS) similar to that implemented in Washington State. The RDMS is developed completely separate from the current obsolete Agency computer systems. No funds were wasted on trying to patch the old systems. When the New Centralized Data Center and its systems were up and running the plug was pulled on the old systems.
The State of Virginia wasted nearly a $billion on the VITA Contract with Northrop Grumman. State leaders funding VITA were naïve computer illiterate politicians who entered into a long term contract with Northrop Grumman to develop an Email system and revise their current State systems. They could have had an email system from Google for next to nothing. Most current systems can not be economically brought up to date. Northrop Grumman as a contractor worked on the state’s systems for years with what I am told was only a partial success.
Why didn’t Virginia’s VITA organization come up with the above state recommended solution? The answer is nearly all of the state’s IT personnel associated with the state’s VITA organization have training or some kind of connection to IBM. So what’s the problem with IBM? Simply this, IBM is in business to sell a proprietary system that shuts out competitors and forces the customers to use its proprietary software. The RDMS is an open software system where an IBM computer could be replaced by a competitor’s computer. Computers can then be purchased simply for their competitive computing power and not just because it will work with the software. At least some of the VITA members must have known about the RDMS solution because it has been around for more than twenty years but it is simply not good business for IBM or its friends. For all practical purposes VITA may as well have been on the IBM payroll.
The GSA’s Current Relationship with Its OIG Subsidiary
The GSA’s OIG subsidiary has the power to make recommendations to the GSA’s management and the GSA can chose to follow those recommendations as in the case of 18F’s problems or not to follow recommendations. The OIG as a subsidiary of the GSA Department has little power to implement solutions to problems it identifies.
The GSA’s Recommended Relationship with Its OIG Subsidiary
This is a key part of the recommended US Government reforms. It solves the problem that Departmental OIGs are not independent organizations and are under control of department heads. In the new independent OIG organization OIGs will remain in their present departmental physical locations but will be a part of a single OIG organization reporting directly to the OMB.
This reform will require Congressional approval for the creation of a US Office of Inspector General (USOIG) organization. It will report to the Office of Management and Budget (OMB) headed by the new position of US Inspector General appointed by the President. Each Departmental OIG organization (about 17) will report directly to the US Inspector General.
The first and primary responsibility of the new Inspector General is to lead the implantation of Federal Government Reforms. Requiring specialized training for OIG personnel in Right-sizing and Facilitator for the implementation of Enterprise lean. Current investigative activities may be put on hold until the implementation of reforms have been completed.
After Reforms have been implemented OIG Analysts will return to their normal investigative activities with strengthened oversight powers to manage staffing budgets as well.
From Fedscoop
https://www.fedscoop.com/18f-gsa-ig-report-october-2016/
David A. Shive is the Chief Information Officer for the U.S. General Services Administration.
Shive oversees GSA IT - formerly known as the Office of the Chief Information Officer (OCIO) - and information technology operations and budget, ensuring its alignment with agency and administration strategic objectives and priorities. Shive began his career at Lockheed Martin Corporation in management and consulting roles overseeing large, customer-centric, IT organizations serving state and local, federal and international government customers.
GSA IG: 18F’s financial projections need a rework
The General Services Administration’s 18F has seen a cumulative net loss of more than $31 million between fiscal year 2014 and the third quarter of fiscal year 2016, a report released Monday from the agency’s inspector general has found.
The inability to recover costs came from “18F’s inaccurate financial projections, increased staffing levels, and the amount of staff time spent on non-billable activities,” the report reads.
The evaluation started in December 2015, according to a release on the report, “after several senior GSA officials expressed concerns about the management of 18F to the OIG.”
Lawmakers have in the past expressed concerns about 18F’s little-defined role in the federal IT space and called for greater organizational transparency.
[Read more: Lawmakers crave transparency from USDS, 18F digital teams]
The report details how 18F operated at an increasing deficit, where staffing continued to balloon at the organization despite gaining smaller revenues than anticipated.
“18F senior managers have established a pattern of overestimating revenue projections,” according to the release.
An example: Projected annual revenue for fiscal year 2014 was $4.76 million, but the year closed with a grand total of zero revenue billed or collected, according to the report.
The report also found 18F’s billing process was not always accurate and resulted in “a series of inaccurate charges to their clients.”
“If billing discrepancies are left unresolved, GSA could be held accountable for augmenting appropriations for other federal agencies,” the release says.
Breaking even
The report found internal discussions among senior management “that raise doubts about their intent to break even.”
“To be frank, there are some of us that don’t give rip about the losses,” said 18F’s director of operations in February when 18F management was discussing three breakeven scenarios.
And in response, the report notes Regional Administrator for GSA’s Region 9, Andrew McMahon said, “Sure, in the end, I could care less. ASF loses money all over the place. That’s the decision we should reiterate with Denise [GSA Administrator Roth], do you care about losing +$2.5M in order to bring in 100 more great hired [sic] into government?”
The report also details in particular an internal struggle on one approach potentially breaking even more quickly: freezing hiring.
From April 2014 to March 2016, the 18F staff expanded from 33 to 201 full time employees.
Federal Acquisitions Service Commissioner Thomas Sharpe advised Administrator Denise Turner Roth and the former Technology Transformation Service Commissioner at least three times to pause hiring, but the IG found through internal records that 18F management and the administrator’s office did not support it.
Roth wrote to Sharpe in January 2016, “Demand for 18F services continues to be strong, the utilization rate is increasing, and there is other activity in place that justifies staying the course on hiring at this time,” according to the report.
The report says former Executive Director Aaron Snow said “18F continued to hire to meet demand for projects because they did not have the staff in place to accept all project requests. Also, he wanted to ensure 18F had enough staff to mitigate the impact of occasional staff turnover.”
The OIG also found that staff spent little time working on projects billed to federal agencies — less than half of their time.
The report notes 18F’s timekeeping system showed that nonbillable time was spent on activities such as “outreach promoting 18F projects and accomplishments, developing an 18F brand and developing an internal timekeeping system.”
What’s next?
GSA management agreed with the report’s seven recommendations and told the OIG they had intentions to take action.
The report’s seven recommendations were for GSA leadership to:
o Establish a viable plan to ensure full cost recovery of Acquisition Services Fund monies expended by 18F;
o Ensure that internal 18F projects have appropriate supervisory review;
o Implement controls over 18F’s reimbursable agreement process to ensure that work is not performed outside of a fully executed agreement;
o Ensure that GSA CIO reviews and approves, in writing, all 18F IT-related work performed for GSA internal organizations;
o Implement a comprehensive review of 18F’s past work to ensure accuracy of all billings;
o Establish reliable internal controls to ensure that 18F’s future billings are accurate; and
o Ensure that 18F’s billing records are retained in accordance with GSA records management standards.
In response, 18F’s Dave Zvenyach writes in a blog post that the office has taken numerous steps to correct the issues brought up in the report: “We take these issues seriously and have taken significant steps to strengthen 18F’s operations.”
The blog post states the office has instituted dashboards for real-time management of financial performance and staff utilization, conducted a reconciliation of past agreements to ensure accurate billing and “standardized the relationship between 18F and the CIO by, among other things, having a CIO lead who reviews all internal technology projects for 18F.”
“Our mission requires us to be relentlessly focused on helping our agency partners, and that means we need to ensure that we continuously improve on our controls and processes to meet that mission,” the blog post reads.
Snow recently told FedScoop 18F’s long-term impact is about more than money — particularly in things that are “intangible.”
“The measure of 18F’s value is not just the dollars saved on the projects we’re working on right now with an agency any more than the measure of its value is the number of dollars it makes or loses,” he said then. “The measure of its value is how much we help agencies evolve how they think about the delivery of digital services in government across all of their work.”
“And I don’t think anybody has done a fantastic job yet of measuring the success of the intangibles that we are ultimately after,” he added.
At the time, Snow also said 18F is going to be around for a long time, in spite of a changing administration.
“It seems clear there is support for what we do from all sides, all points on the political spectrum,” he said then. “I don’t think that a change in administration substantially changes what we do, how we do it or the scale of impact we can have.”
Friday, February 24, 2017
Article 94. Flexibility of US Government Reform Design
The US Government Reforms Recommended at this website has a great deal of flexibility in its implementation (See Article 84). The speed of implementation depends on the number of Outside Consultants who are permanently hired to manage the training and implementation of reforms in the OIG Departments. I have recommended that about 17 of these specially trained employees be hired to start across the board reforms in 17 OIG offices. This will allow 17 reform implementations to be done simultaneously. I have also recommended that these17 OIG offices report to a single new US office of Inspector General (This title may be modified) reporting to the OMB for coordination of reform implementations and subsequent budget and efficiency management after reforms have been implemented.
An alternative to hiring 17 professional Right-sizers (consultants) to head OIG departments and to train OIG Analysts is the following: Hire a professional Right-sizer to Head the new OIG organization (the USOIG) and have him train his current 17 OIG Department heads in the process of Right-sizing. This will slow the implementation of reforms by only a few weeks but will bring unity to a diverse organization. The new OIG organization will delay its current responsibility for investigations until after Right-sizing and Enterprise lean have been implemented. When the reforms have been completed OIG Analysts will return to their current duties of investigations and will manage the bottoms-up manpower budgets of the department.
I recommend against a pilot implementation which can delay reforms for at least six months. But the number of OIG offices to be reformed can vary from 17. The selection of the OIG offices is left up to the Trump Administration in planning for the reforms. One criteria that may be helpful is that the size of the OIG offices be approximately the same which will allow the implementations to end at the same time but this is not required. OIG offices whose primary work is repetitive is best for work measurement and budget management. OIGs whose work is repetitive but varies in length can be managed successfully using statistical processes. However OIGs Like Homeland Security who respond to treats from outside are better left for the department to manage through planning.
U.S. Offices of Inspector General (from Wikipedia)
Presidentially appointed inspectors general
* Recommended that each be combined under new USOIG (reporting to the OMB) for implementation of Reforms and subsequent management of budgets and efficiency in addition to current OIG duties.
Agency for International Development (AID-OIG)
*United States Department of Agriculture (USDA-OIG) inline
Central Intelligence Agency (CIA-OIG)
*United States Department of Commerce (DOC-OIG)
Corporation for National and Community Service (CNCS-OIG)
*Office of the Inspector General, Department of Defense (DOD-OIG)
*United States Department of Education (ED-OIG)
*United States Department of Energy (DOE-OIG)
*Environmental Protection Agency (EPA-OIG)
Export-Import Bank of the United States (EIB-OIG)
Federal Deposit Insurance Corporation (FDIC-OIG)
*General Services Administration (GSA-OIG)
*United States Department of Health and Human Services (HHS-OIG)
Department of Homeland Security Office of Inspector General (DHS-OIG)
*United States Department of Housing and Urban Development (HUD-OIG)
*United States Department of the Interior (DOI-OIG)
United States Department of Justice Office of the Inspector General(DOJ-OIG)
*United States Department of Labor Office of Inspector General (DOL-OIG)
*National Aeronautics and Space Administration (NASA-OIG)
Nuclear Regulatory Commission (NRC-OIG)
*United States Office of Personnel Management (OPM-OIG)
Railroad Retirement Board (RRB-OIG)
Small Business Administration (SBA-OIG) inline
*Social Security Administration (SSA-OIG) inline
United States Department of State — Office of Inspector General (OIG) for the U.S. Department of State and the Broadcasting Board of Governors (BBG) (DOS-OIG) Tennessee Valley Authority (TVA-OIG) inline
*Office of Inspector General for the Department of Transportation (DOT-OIG)
United States Department of the Treasury (Treasury OIG)
*Treasury Inspector General for Tax Administration (TIGTA) of the Department of the Treasury
*United States Department of Veterans Affairs (VA-OIG)
The Reform Process
Using the General Reform Model. See Article 84
1. Simplification
Government activities to be reformed must first undergo a simplification process where: outdated, duplicated and noneffective operations are eliminated. I have developed the Consolidation Model and the Effectiveness Test to aid in this step.
2. Right-sizing
Professional outside Consultants are permanently hired to manage the training and implementation of Right-sizing done by Departmental OIG Analysts. Right-sizing involves: measuring the work required to do a process and the addition of all the processes to form what I call a bottoms up manpower budget providing the correct staffing needed to do the work.
3. Implementation of Enterprise Lean
Enterprise Lean is implemented by organizing the work force into continuous improvement Teams. The leader of each Team is elected by the team members in most of the organization and may be appointed in the top management teams. OIG Analysts facilitate the process in each Department. This process has been highly successful in improving government operations and in eliminating red tape in the states of Iowa and Minnesota.
4. Implementation of Team Management Replacing Bureaucracy
With several months of operation the Team Management organization will replace the Bureaucratic organization as the preferred management organization.
This approach will make the necessary improvements to 17 DC government departments. With the widespread training of government personnel the remainder of the Federal government outside of Washington will eventually be reformed.
The above Government Reform process leverages the use of government OIG employees and minimizes the use of expensive outside consultants providing major reform at minimum expense. The process was developed over a ten year period by Lawrence Rosier Principal Consultant.
An alternative to hiring 17 professional Right-sizers (consultants) to head OIG departments and to train OIG Analysts is the following: Hire a professional Right-sizer to Head the new OIG organization (the USOIG) and have him train his current 17 OIG Department heads in the process of Right-sizing. This will slow the implementation of reforms by only a few weeks but will bring unity to a diverse organization. The new OIG organization will delay its current responsibility for investigations until after Right-sizing and Enterprise lean have been implemented. When the reforms have been completed OIG Analysts will return to their current duties of investigations and will manage the bottoms-up manpower budgets of the department.
I recommend against a pilot implementation which can delay reforms for at least six months. But the number of OIG offices to be reformed can vary from 17. The selection of the OIG offices is left up to the Trump Administration in planning for the reforms. One criteria that may be helpful is that the size of the OIG offices be approximately the same which will allow the implementations to end at the same time but this is not required. OIG offices whose primary work is repetitive is best for work measurement and budget management. OIGs whose work is repetitive but varies in length can be managed successfully using statistical processes. However OIGs Like Homeland Security who respond to treats from outside are better left for the department to manage through planning.
U.S. Offices of Inspector General (from Wikipedia)
Presidentially appointed inspectors general
* Recommended that each be combined under new USOIG (reporting to the OMB) for implementation of Reforms and subsequent management of budgets and efficiency in addition to current OIG duties.
Agency for International Development (AID-OIG)
*United States Department of Agriculture (USDA-OIG) inline
Central Intelligence Agency (CIA-OIG)
*United States Department of Commerce (DOC-OIG)
Corporation for National and Community Service (CNCS-OIG)
*Office of the Inspector General, Department of Defense (DOD-OIG)
*United States Department of Education (ED-OIG)
*United States Department of Energy (DOE-OIG)
*Environmental Protection Agency (EPA-OIG)
Export-Import Bank of the United States (EIB-OIG)
Federal Deposit Insurance Corporation (FDIC-OIG)
*General Services Administration (GSA-OIG)
*United States Department of Health and Human Services (HHS-OIG)
Department of Homeland Security Office of Inspector General (DHS-OIG)
*United States Department of Housing and Urban Development (HUD-OIG)
*United States Department of the Interior (DOI-OIG)
United States Department of Justice Office of the Inspector General(DOJ-OIG)
*United States Department of Labor Office of Inspector General (DOL-OIG)
*National Aeronautics and Space Administration (NASA-OIG)
Nuclear Regulatory Commission (NRC-OIG)
*United States Office of Personnel Management (OPM-OIG)
Railroad Retirement Board (RRB-OIG)
Small Business Administration (SBA-OIG) inline
*Social Security Administration (SSA-OIG) inline
United States Department of State — Office of Inspector General (OIG) for the U.S. Department of State and the Broadcasting Board of Governors (BBG) (DOS-OIG) Tennessee Valley Authority (TVA-OIG) inline
*Office of Inspector General for the Department of Transportation (DOT-OIG)
United States Department of the Treasury (Treasury OIG)
*Treasury Inspector General for Tax Administration (TIGTA) of the Department of the Treasury
*United States Department of Veterans Affairs (VA-OIG)
Overview of US Government Reform Process As Recommended by Lawrence Rosier Principal Consultant
The process begins by the passage of a Congressional Reform Bill for funding and to clear the way for the orderly implementation of reforms. See Article 88.The Reform Process
Using the General Reform Model. See Article 84
1. Simplification
Government activities to be reformed must first undergo a simplification process where: outdated, duplicated and noneffective operations are eliminated. I have developed the Consolidation Model and the Effectiveness Test to aid in this step.
2. Right-sizing
Professional outside Consultants are permanently hired to manage the training and implementation of Right-sizing done by Departmental OIG Analysts. Right-sizing involves: measuring the work required to do a process and the addition of all the processes to form what I call a bottoms up manpower budget providing the correct staffing needed to do the work.
3. Implementation of Enterprise Lean
Enterprise Lean is implemented by organizing the work force into continuous improvement Teams. The leader of each Team is elected by the team members in most of the organization and may be appointed in the top management teams. OIG Analysts facilitate the process in each Department. This process has been highly successful in improving government operations and in eliminating red tape in the states of Iowa and Minnesota.
4. Implementation of Team Management Replacing Bureaucracy
With several months of operation the Team Management organization will replace the Bureaucratic organization as the preferred management organization.
This approach will make the necessary improvements to 17 DC government departments. With the widespread training of government personnel the remainder of the Federal government outside of Washington will eventually be reformed.
The above Government Reform process leverages the use of government OIG employees and minimizes the use of expensive outside consultants providing major reform at minimum expense. The process was developed over a ten year period by Lawrence Rosier Principal Consultant.
Friday, February 17, 2017
Article 93. Example of Massive Medicare Fraud
Example of Massive Medicare Fraud
Hospitals throughout the US in a large numbers are using sick and confused mostly elderly patients as cash cows billing Medicare for unnecessary treatments. This mass fraud is used to finance hospital operations and building projects.
Example of how the Fraud works:
An elderly person without a private Doctor seeks healthcare through the hospitals walk-in clinic. The clinic gives convincing advice suggesting the patient needs blood tests and suggests that a hospital doctor becomes the patient’s private doctor. Once the patient selects a private doctor connected to the hospital the Doctor arranges for extensive blood tests and other related tests including X-rays and other expensive observations. The hospital can run-up thousands of dollars of unnecessary tests and exploratory operations all billed to Medicare. This is not an isolated case but common practice. At present there is no mechanism for preventing this type of fraud. The cost of prosecuting those committing this type of fraud is in most cases greater than the cost of the fraud itself.
The Solution:
Require all Medicaid patients to have a private doctor. This Doctor must be certified to be an independent doctor not connected to a clinic or a hospital in any way and subject to verification by Medicare. The private doctor will independently determine what tests and exploratory operations are required for the patients healthcare.
This suggested solution can save $billions in unnecessary Medicare expenses.
Hospitals throughout the US in a large numbers are using sick and confused mostly elderly patients as cash cows billing Medicare for unnecessary treatments. This mass fraud is used to finance hospital operations and building projects.
Example of how the Fraud works:
An elderly person without a private Doctor seeks healthcare through the hospitals walk-in clinic. The clinic gives convincing advice suggesting the patient needs blood tests and suggests that a hospital doctor becomes the patient’s private doctor. Once the patient selects a private doctor connected to the hospital the Doctor arranges for extensive blood tests and other related tests including X-rays and other expensive observations. The hospital can run-up thousands of dollars of unnecessary tests and exploratory operations all billed to Medicare. This is not an isolated case but common practice. At present there is no mechanism for preventing this type of fraud. The cost of prosecuting those committing this type of fraud is in most cases greater than the cost of the fraud itself.
The Solution:
Require all Medicaid patients to have a private doctor. This Doctor must be certified to be an independent doctor not connected to a clinic or a hospital in any way and subject to verification by Medicare. The private doctor will independently determine what tests and exploratory operations are required for the patients healthcare.
This suggested solution can save $billions in unnecessary Medicare expenses.
Tuesday, January 31, 2017
Article 92. Downsizing The Federal Government
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
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
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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