Article 106. US Governments New Budgeting and Management System

US Governments New Budgeting and Management System

Top Down Budgeting Practices
Congressional budget committees at times makes across the board cuts to Federal programs without the knowledge of where cuts can be made and have the least effect on services. Although commendable for its boldness this is a wild and irresponsible attempt at cutting the budget without knowing consequences but it is also a common approach made by the US Government.  The key message is that Congress does not know where or how large of cuts to make and still maintain government services.

Once the New Government Management System has been implemented budgeting personnel will know what Departments and Agencies are over staffed and how many personnel are needed to maintain government services. This is where precision cuts have an advantage over across the board cuts. Across the board cuts harms areas where government services are under staffed and has little to no effect on other over staffed areas of the bureaucracy.

Recommended New Bottoms-Up Budgeting and Management System

Implementation of Enterprise Lean Teams
Starting with the implementation of Enterprise Lean Teams throughout the government. This reform brings a positive cultural change to the organization.  Bottom level functional Lean Team employees become members of Lean Teams and are motivated by empowering them to improve their jobs through innovation. By bringing innovation and continuous improvement to the government’s processes the government will save $billions through increased efficiency both now and in the future. This reform amounts to a win-win situation for government employees as well as the tax payers through employee empowerment and by ending bureaucratic waste.  See Article 104. Enterprise Lean and the New Government Management System.

The key activity I require by my Lean Teams that they develop a Daily Plan, a graphic depiction of the processes that they do on a daily basis.  This depiction may be in the form of a wall chart where each operation performed by members of the Team are depicted graphically in the sequence that the work is done. The accuracy of the wall chart depends on an accurate time for each process.   When the wall chart has been reviewed and no other improvements are known photos of the wall are made and passed to other teams doing the same operations in other government locations.  The final wall chart is not carved in stone but available for continuous improvement.  This activity gets the highest possible efficiency from the function.

Implementation of The New government Management system
The New Government Management organization will be within the Office of Inspector General organization which I recommend be separated from the Government Departments and reports directly to the Office of Management and Budget. 

The new Government Management System is used to set staffing levels and a bottoms-up budget using the Lean Team study data.

First  OIG (Office of Inspector General) Analysts will be trained as Facilitators setting-up and organizing each Lean Team.  The number of VA Lean Teams will depend on the number of functions within each hospital.  An OIG Analyst will be able to Facilitate about 20 Lean Teams. After setting-up the Lean Team the OIG Analyst will monitor and assist in the development of the wall chart. The OIG Analyst will become the manager of his Lean Teams.

The OIG Analyst will be trained to manage about 20 Lean areas:
1. He will work closely with each Lean Team in making improvements including the installation of additional equipment.
2. He will develop and monitor a schedule for each Lean Team based on patient backlogs.
3. He will make a monthly progress report for each Lean Team.
4. He will create a bottoms-up manpower budget for each Lean Team.
5. He will create a annual bottoms-up budget for his functional Lean Teams.
The annual functional bottoms-up budgets are summed establishing an actual min cost at the highest efficiency for the Department all other costs are negotiable.

An Advantage of this Approach
The advantage of this approach is that all actual manpower and operations costs are known creating a minimum known budget.  This means that only addition added budget items need to be negotiated and not the entire Agency Budget.  It also means that with a steady backlog little scheduling and management is needed.  The function nearly runs itself like the health care routine Procedure Clinics.

Where tasks are variable the Lean Teams will be more involved with scheduling and management of daily activities.

Article 105. Explaining How We can Afford Health Care

Explaining How We can Afford Health Care

While Congress and the media are wringing their hands on where the money is going to come from for Health Care.  There is no reason why we can not have affordable healthcare. The following is a simple explanation of how we can pay for Health Care.

The Problem begins with Congress
Congress focuses on one problem at a time: Health Care, Tax reform, balancing the budget etc.  The reason is these are very complicated issues but when they do this they miss the big picture and all of these issues are related because you have to have a way of paying for them. These issues are seen as being mutually exclusive, you cannot have Health Care and tax cuts and balance the budget. The false thinking is that there is only so much money that the government has without raising taxes. This is a nearsighted false concept.

Congress focuses on passing legislation and not on managing legislation. That is left up to the “Spenders” the Government Departments that get the budget to run their organizations.  This is supposedly monitored by the Office of Inspector General within Each Department.  But since the OIG reports directly to the head of the Department nothing is done until a whistle blower goes public then the OIG is asked to look into the Matter.  The result is that waste is built right into the system. US Government Waste is in the $Billions. Ref: LawrenceRosierConsulting blog article 88.

Congress’s Problem
Passing Legislation is only one half of Congress’s Job the other half is insuring that the legislation actually works and does the job efficiently. In this half Congress has been a complete failure.  The fact is that almost nothing is done to prevent waste and Congressmen don’t seam to care and are seemingly unaware that waste and mismanagement exits.  This is because they see it as someone else’s problem and not their own.

The Solution
Once legislation has been passed by Congress the Congressional Budget Office reviews the bill to see if the funding is close to what they think will be required. But instead of sending the budgeted funding directly to the Department for which it was intended it is sent to the new Government Management organization (OIG Analysts) to determine how it will be efficiently used.  If too much funding has been approved by Congress the excess funding will be returned to the US Treasury and if not enough funding has been provided the Government Management organization will determine how much extra funding is required and how it will be used.

The New Government Management organization will be within the Office of Inspector General organization which I recommend be separated from the Government Departments and reports directly to the Office of Management and Budget.

The Office of Inspector General's main job is to investigate misuse of Federal Funds this an after the fact investigative organization of waste and mismanagement meaning the investigation occurs after the funds have already been wasted.  With the new Government Management organization the investigative function of the OIG will be greatly reduced allowing OIG Analysts to become available to manage the governments business.

Where the Money for Health Care Comes From
By now you should be realizing that the money for Health Care is found in the elimination of waste both in our Healthcare system and in the Federal Government.   But even more savings becomes available with the implementation of efficient Health Care and Government Management Systems.  While Congress and the media are wringing its hands on the question of where the money is going to come from for Health Care.  The answer is simply stop the waste in government and make the Government and Health Care operate efficiently and no new taxes are needed.

Changes needed to Make US Health Care Work
The Major changes that are needed to make the US health care system efficient and affordable.
But first mistakes were made by Democratic lawmakers in the design and passage of Obamacare.
1. They brought in all the major players to get their input: Private Health Care Providers, Health Insurance Companies etc.  Sounds good but tells us that the lawmakers did not understand why our Health Care costs so much.  Our Private Healthcare System is based largely on defrauding the government to pay for the high cost of health care. Our Fraud based Health Care costs double that of government based European Health Care.  It even costs twice as much as our government based Veterans healthcare system. Ref: LawrenceRosierConsulting Blog Articles: 101.

2. Health Insurance Companies did not explain why the insurance of catastrophic Health Care would drive up the cost of premiums.  This was the major failure of Obamacare Catastrophic health insurance can become costly due to the unpredictably of the need for long term high cost medical services. When Catastrophic Health Care is combined with regular Health Care premiums are driven up due to the high cost of the Catastrophic Health Care making Health Insurance unaffordable.  This became an insurmountable problem when citizens were forced to buy health insurance.

3. They were not focused on bringing down the high cost of healthcare only in passing health care for all.  Once Obamacare was passed we are left without a way of paying for it.

Trump Administration
The Trump Administration did not realize the way that Congress normally operates, focusing narrowly on passing legislation in individual areas.  This GOP Congress has seen few risk takers, they have focused on proposing quick fixes to Obamacare and failed to see that it could be funded by eliminating waste and implementing management reforms to get efficiency.  This puts the responsibility for solving major government problems and introducing innovations in government with the President and his staff. 

If the GOP Congressmen had focused on eliminating waste and had implemented efficient government Management reforms first then a more accurate accounting of saving that could be gotten from this approach would have shown that Health Care may be affordable after all.  This opportunity was missed because Congress has never admitted that it is responsible for the waste and inefficiency of the US government.  The President can correct this problem by implementing recommended reforms in the Veterans Administration as a pilot reform for further implementation throughout the Federal government.  Ref: LawrenceRosierConsulting blog articles 104, 101, 96 and 88.

Congress can enact legislation for separating the Departmental Offices of Inspector General in a single watchdog organization with management responsibility for the recommended new Government Management system. Ref:  LawrenceRosierConsulting blog articles 104, 96 and 88.

Repeal and Replace Obamacare with this Recommended System
The recommended near term approach is to let the people pay what they can afford for their Health Care. Above that the government will provide catastrophic Heath Care to all Americans in a new Catastrophic Health Care System.  Health Care recipients should pay each year for their own health care from private providers up to a specified amount determined by income at several levels.  No one is required to buy health insurance.  Paying all the health care costs for everything that people want is not possible and should not be provided by the Government. As an option private Health Insurance Companies can compete in providing the minimum coverage up to the catastrophic level if wanted by individuals and companies (as was done in the past). Health Insurance is not provided in the governments Catastrophic system.  The Federal Government should not provide healthcare to non-citizens, however State Governments may chose to provide this service.

The key to this system is the elimination of Private Health Insurance and Private Hospitals from the Catastrophic Health Care System. Health Insurance for catastrophic health does not work because profits necessarily drive up insurance rates and co-pays.  Private Hospitals have resorted to massive fraud to survive. Congress has not been able to prevent the waste and corruption found in our health care system. Americans simply can not afford or be expected to pay for a health care system that is the most wasteful and expensive in the world.  The current health care waste from fraud and abuse has been passed on to the public and not enough has been done to make the day to day health care processes themselves efficient.  But now we have the Reforms to be implemented in the VA which makes health care efficient and effective.
This makes possible the Government catastrophic affordable alternative to the current private health care system. LawrenceRosierConsulting Blog Articles: 103,101,97,98

Transition Alternatives
The VA Healthcare system must have reforms fully implemented in all of its facilities and be treated as a separate system providing Vets the health care they need.  The VA system changes according to needs of the Vets with age and with injury types.  Therefore there is a need to go outside the system for healthcare it cannot provide.  This alternative will be the Catastrophic Health Care System that mostly serves those receiving Medicaid.  The cost of the Catastrophic Health Care System may be shared with the State Government.

In the future the US Government may pursue the development of a complete government Health Care system for Medicare as an alternative to the current private health care delivery system that is mainly driven by fraud.  US Health Care reforms can move to a government run system over the next 10 years similar to Europe but with better management controls.  More than $1trillion can be saved by eliminating waste paying for Medicaid, Medicare. LawrenceRosierConsulting Blog Articles: 103, 100, 96.

Catastrophic Health Care should easily Pass both sides of the aisle in Congress. Who is to argue with Health Care paid for by the elimination of waste and a new Government Management system for efficiency.

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

Article 104. Enterprise Lean and the New Government Management System

Enterprise Lean and the New Government Management System

Before we discuss the VA reforms it is important that we recognize that the VA Health Care System with all its faults is half the cost of our Fraud Based Private Health care system.  There is no conceivable way to bring our Private Health care system under proper management control.   My recommendation is that the entire corrupt system be scraped and replaced an efficient government run system such as the reformed VA system.

The following is a simple explanation of how the Veteran Affairs reforms of Enterprise Lean and the new government management system will work.  This will be the very first finitely controlled government management system employed in US Government history. This approach fits all government operations that are repeatable on a regular basis such as in Veterans Health Care.  Other attempts to manage government are from a macro point of view and are valid in cases where world events force new management decisions. But even in the macro decision area operations are of a repeated nature and can be managed efficiently using the Enterprise Lean approach.

Enterprise Lean
Enterprise Lean developed by Toyota is currently being used in: Washington State, Iowa and Minnesota governments to make continuous improvements in government processes. It has also been successfully implemented in the Cleveland Clinic well known for its health care.  The process consists of working teams that meet regularly to review and discuss how the work they are doing can be improved upon.

The key activity I require by my Lean Teams that they development a graphic depiction of the processes that they do on a daily basis.  This depiction, a Daily Plan may be in the form of a wall chart where each operation performed by members of the Team are depicted graphically in the sequence that the work is done. The accuracy of the wall chart depends on an accurate time for each process.   When the wall chart has been reviewed and no other improvements are known photos of the wall are made and passed to other teams doing the same operations in other VA Hospitals.  The final wall chart is not carved in stone but available for continuous improvement.

Implementation of Enterprise Lean and the New Management system at the VA
The intent is to grow the implementation of VA reforms starting with the kickoff training provided by the Principal Consultant for current employees of the VA.

The VA has an Office of Inspector General (OIG) with OIG Analysts which investigate waste and fraud within the VA hospital system.  It is believed that problems of this nature will decrease with the Lean Teams who elect their members by secret ballot and are protected whistle blowers.  First OIG Analysts will be trained as Facilitators setting-up and organizing each Lean Team.  The number of VA Lean Teams will depend on the number of functions within each hospital.  An OIG Analyst will be able to Facilitate about 20 Lean Teams. After setting-up the Lean Team the OIG Analyst will monitor and assist in the development of the wall chart. The OIG Analyst will become the manager of his Lean Teams.

The OIG Analyst will be trained to manage about 20 Lean areas:
1. He will work closely with each Lean Team in making improvements including the installation of additional equipment.
2. He will develop and monitor a schedule for each Lean Team based on patient backlogs.
3. He will make a monthly progress report for each Lean Team.
4. He will create a bottoms-up manpower budget for each Lean Team.
5. He will create a annual budget for his Lean Teams.

An Advantage of this Approach
The advantage of this approach is that all actual manpower and operations costs are known creating a minimum known budget.  This means that only addition added budget items need to be negotiated and not the entire Department Budget. 

Additional management Improvements can be made to decrease the cost of operations.  I have experience in creating an effective Management Team that reduces Bureaucratic redundancy by allowing the Elected Team Leaders to become the bottom level supervisors.  Because they are doing what low level supervisors normally do.

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

Article 103. Proposed Implementation Plan for National Health Care System

Proposed Implementation Plan for National Health Care System

The plan is to implement the National Health Care System (NHCS) in stages as it gradually becomes the nations primary health care system.  The plan also separates rural health care from urban health care to accommodate the needs of the nation.

We will combine the VA health care system with a new Catastrophic Health Care system (a government run system) consisting largely of Medicaid and with Medicare in the second stage.  Remember if you have an efficient effective VA program then no private health care company can compete with it because private companies must make healthcare run more efficient than government healthcare. If they can’t do this then there are no profits. If there are no profits in the healthcare system private systems will just drive up the cost of healthcare to get profits. Our Healthcare costs double that of European government health care and they are not efficient.

I call our current Health Care system a fraud based system because it is largely funded by fraud compared with a Government Health Care system monitored by Lean Teams. The best example of this type system is the Cleveland Clinic which has implemented Enterprise Lean Teams.  See Article 101.

Stage 1.  The Startup Stage
As a government run system the current VA health care system may be worse than that of European health care but they both have the same problems: massive bureaucracy, low efficiency, high patient backlogs and uncontrolled costs.   My approach fixes nearly all of the VA’s health care problems.  Europe does not have this approach yet.  If we can fix the VA problems  then this approach will work for a complete US government run healthcare system. Stage one is to implement this new efficient approach using Enterprise Lean with a new government management system through out the VA System.  See Article 104 and 96.

The government will begin to acquire hospitals under financial stress at little to no cost.  I emphasize that the government is not in the business of buying hospital facilities.  The reason is that the operation of government hospitals will be significantly less than that of private hospitals who will not be able to compete with the efficient government hospitals.

Medicaid patients will share VA facilities and the acquired private hospitals.  They will be slowly moved from private hospitals to the Catastrophic Health Care system. VA patients will be served before Medicaid Patients.

Stage 2. Medicaid and Medicare Patients moved to Catastrophic Care Facilities
In addition to the continuing acquisition of private Hospitals new Eye clinics will be acquired or built in urban cites of over one hundred thousand population to perform mass Cataract Surgery.  This a significant cost saving of over ten times the current approach.

As this stage progresses Medicaid patients will be served first followed by Medicare Patients in the Catastrophic facilities.

Stage 3. Accommodation of Patients without Health care Insurance
Regular Health Care Patients without Health Insurance will be allowed to use the Catastrophic Health Care Facilities as they become available.  These Patients will be required to pay for their own health care but at a cost of about 20% less than in the private sector.   This is a key element of the National Health Care System (NHCS).

Stage 4.  The National Health Care System will be Available to all Americans
The expanded Catastrophic Health Care system (called NHCS) will be available to all Americans. Health Insurance Companies will gradually require that patients move to the less expensive NHCS.

Some Private Hospitals may still be available for those who want them.

The NHCS Rural Health Care System
Small Clinics should be built in towns of about 10 thousand and about 25 miles apart.  The Clinics will be of the following design: They will be built adjacent to a fire station with ambulances. They will be 24-7 Emergency Clinics with a few over night beds and a helicopter port.  Some designs may have more beds.  Besides doctors and nurses this system depends on volunteers from within the community.

Besides an Emergency function the clinics can serve as place for state wide traveling Cataract Surgery teams to do Cataract Surgery.   The clinics can also service a traveling Dialysis Van for patients in remote rural areas.

Article 102. About the Author Lawrence Rosier

About The Author Lawrence Rosier  August 5, 2017

Lawrence Rosier 12143 Cedar Grove Rd.
Rolla, Missouri 65401 
573-578-4716      LawrenceRosier4@gmail.com

In 2004 I became interested in solving government problems and set up a popular Government Reform blog attaining up to 2000 hits per day.  The current Blog was begun in 2013 (although with fewer hits) after the first one was abruptly cancelled when the provider went out of business.  In 2013 and 2014 I had perfected my approach to government reform and I made a number of proposals to fix  Veterans Affairs health care and management problems but all were rejected by the Obama Administration. This postponed my attempt as an independent Consultant in Government Reform. Now with the Trump Administration new opportunities may be available.

Since I have became semi-retired I developed an interested finding an Energy Solution.  In 2009 with the worlds reliance on fossil fuels automobiles and electric power generation I wanted to find a technology that could provide breakthroughs in power generation. My research uncovered several hoaxes and some real possibilities.

I focused on the Nicola Tesla/Steven Mark/Edwin Gray/ Don Smith Inventions. I researched this technology thoroughly and found that it was not a hoax.   Recently I have followed Don Smith and his invention using a Tesla Coil to generate 160 kilowatts of continuous electrical power while not connected to the grid.  The unit was small enough to fit on a kitchen table.  Don’s 48 inventions were mostly in foreign countries for individual clients who have welcomed the “New” Electric Technology. See my Abstract: “New” Electric Technology by Lawrence Rosier on my blog: Perpetualelectric.blogspot.com  Articles 10, 13, 14, and 15.

Engineering and Consulting Experience
After Graduation form the University of Missouri in 1961 as an Industrial Engineer I was hired by  McDonnell Aircraft Co.  I did time-studies and balancing the Final Assembly line of the F4 Phantom for 3 years.  Then as a mechanical Engineer I designed a mechanism for allowing pilots to eject on the ground after the disastrous Forestall Aircraft Carrier fire in Vietnam. In 1969 in Washington State I served on the staff of: George Parker, Manager of Special Projects, Boeing Co. working with a team that certified the 747 commercial aircraft.  I was later a Management Consultant with Alexander Proudfoot and Scheduling Corp. both firms located in Chicago. In my first two weeks on location with Proudfoot I was able to save the client, Clark Equipment of Battle Creak MI, $10 million after discovering that their Production Control Dept. was 50% overstaffed.  I was also the Manager of Manufacturing Engineering for Multiplex Company in St. Louis.  In 1983 I served on Hal Yost’s staff, President of McDonnell Douglas Missile Systems Co. and later on Vice President of Manufacturing George Masurat‘s staff.

My most significant achievement was my proposal and acceptance by Sanford McDonnell CEO of McDonnell Douglas Corp. of a modification to the company’s Quality of Work Life (QWL) implementation (the forerunner of Enterprise Lean). The modification replaced the existing Bureaucratic organization with a Team Management organization consisting of Steering Management Teams and Functional Management Teams for the entire McDonnell Douglas Missile Systems Co. This Team Management style was enthusiastically received by employees and inspired employee innovation. It was used successfully for over ten years until the sale of the Company to Boeing in the 1990’s.

Education
Education included degrees in Industrial Engineering and Secondary Education graduating with a 4.0 GPA.   I was a graduate instructor at the University of Washington Experimental Education Unit where I studied Behavioral Modification.

Family
Lawrence was born August 30, 1938 in McCook, Nebraska.  my family moved to Mound City, Missouri in 1940.  My wife Sharon a former school teacher and I have no children and I am in excellent heath for my age.  I am from a well respected religious family and one of the largest private farm land owners in Missouri. My family installed 19 wind generators several years ago. 

Lawrence Rosier is an Independent Consultant registered in the State of Missouri as "Lawrence Rosier Consulting".

Lawrence Rosier’s Ebooks on Government Reform can be purchased through Amazon.com

Article 101. Why is the US Health Care System the Costliest in the World

 Why is the US Health Care System the Costliest in the World?
Government run European Health Care systems are much less costly but can be made more efficient with Enterprise Lean.

I call our Health Care system a fraud based system because it is largely funded by fraud compared with a Government Health Care system monitored by Lean Teams. The best example of this type system is the Cleveland Clinic which has implemented Enterprise Lean Teams. I can explain this by reviewing the routine questions that arise when an Enterprise Lean Team examines their processes.

Question No.
1. Is this process really necessary for the patient? 
In a Lean Team based system the question can be focused on the Patient.

In a fraud based system the answer is nearly always yes to add funding needed to pay for hospital operations.

2. Is this the most efficient way of doing the process?
In a Lean Team system the question brings different ideas to the discussion for examination ending in the determination of the best solution.

In a fraud based system the answer is how can we increase the cost to get more funding for hospital operations. This is where we find items such as a roll of gauze costing an exorbitant amount such as $25 and unnecessary tests being conducted for the patient.

3. What are the skill levels needed to do this Process?
In a Lean Team based system the Team will examine what the nurses and support staff are actually doing and assign the proper skill levels required.

In a fraud based system the answer is how can we get by with the skill levels we have without adding cost. There is no oversight to insure that standards are properly maintained.

4. Is Proper billing for medical services being done?
In a Lean Team based system the Medical Services Team will insure proper billing methods.

In a fraud based system patients and Insurance companies are sometimes double billed  through a variety of methods such as combining all the individual bills into one large bill followed by billing each of the bills issued separately.

This provides some insight as to what is happening in our health care system and why I recommend that that a properly managed government run health care system with the profit motive removed can be much less costly. See Articles 97. and 98.  See also Reform of the Veteran Affairs hospitals Article 96.

Ref: Article 93. "Example of Massive Medicare Fraud".  Hospitals throughout the US in 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.

Article 100. Growing Government Reform from the VA Pilot to the Entire Federal Government

Growing Government Reform from the VA Pilot to the Entire Federal Government
Based on Article 99 Reform of the US Government in General and Article 96 the reform of the pilot VA.

The Republican Party has this present unique window of opportunity to bring spending under control and prevent the need to continually raise the debt limit making the US Government financially sound again.  My Reform proposals give an overview of how the Trump Administration can bring innovation and reform to the US federal Government saving the tax payers $trillions. The strategy is to Grow Government Reform with the VA Pilot and then spread the reforms throughout the Entire Federal Government.

The Reform process in the current Trump administration has already begun with the new Budget using the approach of first simplifying government using new tools such as the Effectiveness Test to determine how well an item meets the expected results of its originators. Waste from duplication of government efforts by multiple Agencies is yet to be addressed.  The process of reform continues with the prototype implementation of Veterans Affairs Hospitals making them efficient through Continuous Improvement.

The Recommended Startup Plan focuses on the implementation of Reforms in the Veteran’s Administration Under the direction of the White House Office of American Innovation lead by Jared Kushner to begin within the first six months of the Trump Administration.  This article explains how a single person the Principle Consultant can make this implementation happen without hundreds of consultants swarming all over the government costing $millions and leaving the government after a few years in turmoil.  So how can one person effectively reform the US Federal Government. The answer is he can’t without strong Congressional and Presidential support.  But it can be done by growing an organization such as the OIG within the Federal Government to become the implementers of the reforms followed by becoming the managers of government. The basic reform process is called Enterprise Lean developed years ago by Toyota and has now been successfully implemented in Minnesota and Iowa State governments.

I propose that a single Principle Consultant such as myself can begin a training program for OIG Analysts first in being Facilitators for setting up Enterprise Lean Teams in each function of the DC Veterans Hospital.  Each OIG Analyst will organize several Lean Teams, helping them to elect their leaders and follow on with the building of wall charts(from the 1980s). Now a 60 in. flat screen TV with a modified spreadsheet will serve the same purpose.  The Wall Screen allows each Lean Team member to view the entirety of their functional work flows and provide input to improving the function's processes.  When the Wall Screen is completed the result is placed into actual use in the hospital's function and after testing a thumb drive of the screen is shared with all VA Hospital's OIG analysts and their Lean Teams.  The documented wall screen is not the final method but can be updated by any Lean Team and the improvement be shared with other Lean Teams.

The second part of the OIG training will be in the work measurement of each of the processes that are a part of the function and necessary in building the wall Screen.

A third part of the OIG training will be in the collection of the measured data into a database representing the total hours for the function.  As the functions develop their work hours for all the members of the Lean Teams the Departmental database will be collected into what I call a bottoms-up manpower budget.  This will be used to determine right-sizing of the function based on patient backlog.  From this the OIG Analysts will be schooled in the scheduling needed to meet patient backlogs.  We now have the data to manage the Federal Government for the very first time in history.

Critics will argue that this will lead to making VA hospitals employees work harder.  But what we have done is simply removed the wait times for employees waiting on other employees, allowing employees to work smarter rather than harder. Working smarter allows for Continuous Improvement in the Lean Teams function.  With 90% of VA personnel meeting once a week in Lean Teams Continuous Improvement can result in thousands of what appear to be small fixes such as the: removing red tape or Improvements in patient care to major cost reductions.

Article 99. Massive Tax Savings through Government Reform

Massive Tax Savings through Government Reform
By Lawrence Rosier Principal Consultant

The answer to the problem of rising Federal debt and the necessity of raising the debt ceiling is the implementation of the recommended management and efficiency reforms in the Federal Government. Upon implementation of reforms within a year the federal debt will start to decrease and it is no longer necessary to raise the debt ceiling. This article describes the process for achieving a balanced budget and a significant tax reduction through the implementation of government reforms.

The Office of Veterans Affairs (VA) because of its problems in serving Veterans it is the logical choice for a prototype.  Article 96. Highlights the details for the reform of specific problems found in the VA by taking the general approach we can surmise how the Federal Government can be reformed in similar functioning areas.  The result over time in using the reform process with management controls and the Continuous Improvement technique will result in a possible savings of as much as 50% or more.

Before Making Government Efficient
Before  making government efficient we must build a new kind of Federal Budget that eliminates waste.  In building this budget we must identify and remove items that do not meet an “Effectiveness test” (how well an item serves its intended use). See Article 49. LawrenceRosierConsulting Blog.

Another group of Items are those that are duplicated. There are thousands of these items which need to consolidated into a single organization or to a manageable few organizations using my Consolidation Model.  An example is: while most people think that there are only three or four Intelligence agencies there are actually seventeen contributing to government waste. See article 48. LawrenceRosierConsulting Blog.

The reason for doing this before implementing government reforms is best explained by Peter Drucker  “It is best not to make efficient those things that are going away”.  Key References to Government Efficiency and Reforms are found at the end of Article 96. LawrenceRosierConsulting Blog.

Responsibilities of the Principal Consultant
The Principle Consultant will provide broad support for all aspects of the Federal Reform process of overseeing the training of OIG Analysts to support the Federal Government Reform implementations.  The Principle Consultant will review and make recommendations for ongoing implementation of reforms by all Departmental OIG organizations. This includes the implementation of: Effectiveness Tests, The Consolidation Model, the General Reform Model and the development of new approaches needed to make the Federal Government Efficient. The Principal Consultant will provide specific support for the transfer of all Departments from the Bureaucratic organization to the new Team Management organization.

The General Reform Model
The “General Reform Model” implements Right-Sizing and the development of bottoms-up manpower budgets.  It also implements Enterprise Lean also known as “Continuous Improvement”  using the Lean Teams as a basis to convert the Department’s Bureaucratic organization to a Team Management organization. The Principal Consultant will play a key role in being sure that the Lean teams are properly trained. The Principal Consultant will also insure that the activities of OIG Analysts are trained in Right-Sizing and can determine the correct staffing level through Work Measurement.  Data on the number of occurrences of the function over time, is obtained from a daily log kept by each Lean Team and provides the basis for an accurate functional manpower budget.  OIG Analysts will summarize data in a OMB managed Lean database where all of the Department’s functional data is stored. OIG Analysts will assume the responsibility for the management and reporting of government activities and will be followed closely during the implementation by the Principal Consultant.

It is important to realize that this article represents a simplification of what should happen during the implementation of Reforms the Principal Consultant provides the guidance needed in actuality. 


The Phases of the Implementation of Federal Government Reforms

Phase 1. Committee for Oversight Of Federal Government Reforms
A Governmental Reform Oversight Committee involving representatives from all OIG organizations should be established and be chaired jointly by  The Secretary of the Office Management and Budgets (OMB) and the Principal Consultant. Members of the Committee will include heads of Departmental OIGs who will have the responsibility for the implementation of the Federal Government Reforms in their departments.

Departmental OIG Analysts will act as facilitators supporting the implementation of Enterprise Lean until it has been implemented in its entirety throughout their departments. When the implementation has been completed the OIG Analysts will assume a management function maintaining the new Bottoms-up Budget databases. The Department’s budget databases may be stored in an OMB managed database such as Google’s cloud storage “Google Drive” at limited cost.
 
Phase 2. Training OIG Analysts to Facilitate Enterprise Lean and Data Collection
The Principal Consultant will participate in a train the trainer program beginning with the VA pilot implementation. The knowledge gained in the VA pilot implementation will allow OIGs from the VA to communicate their experience by establishing a training program for OIG Analysts in other departments.

Each Departmental OIG head will also have the responsibility to train their OIG Analysts as Facilitators.  Planning for all Training should done by the OIG Reform Committee meeting with the counsel of the Principal Consultant.  OIG Analysts acting as Lean Facilitators will organize and train each employee functional Lean Team work group which usually meets for one hour on a weekly basis.

The principle duty of each Lean Team will be the development of flow charts depicting the flow of processes which the team is responsible for, also called work load balancing.  I have had the best success in placing these flows on a wall chart such that the entire process is visible to all members of the team.  The goal is to establish the most efficient operations such that no members of the team must wait until others complete their tasks.  In the case of the VA hospital teams when the flow chart has been completed a Template is made of the wall chart and it is made available to other VA hospitals.

The management data resulting from building the wall chart will be used by OIG Analysts to build a bottoms up budget and to schedule operations.  In the case of the VA the data will be used to schedule and reduce patient backlogs.
 
Establishment of Management Lean Teams
There are two major Lean Team groups, high level Management Lean Teams and at-the-work-place Functional Lean Teams. Management Lean Teams are organized and lead by members of management. They are tasked to study individual high level systems problems within the Department and those that interact with other Departments, mostly document flows.

Phase 3. Review of Lean Team Results and Collection of Lean Data
After a period of about three months most Functional Lean Teams, those that were organized and trained by Facilitators, should have their Lean Data collection completed and wall charts completed.  An OIG Facilitator Analyst will document the lean Team's savings findings in a spreadsheet.

Details of the Data Collection and Reform Process
The technical reform process begins after the decision to implement Enterprise Lean and after the functional Lean teams have completed their lean studies. The important data that is necessary for reform is the functional cost data developed by the Functional Lean Teams from their individual functions.

The data may be collected in electronic tablets or Google Chrome books using a spreadsheet program specifically designed for this process.  All tablet spread sheets will be continuously updated using a special Google App (application).   Each Departmental OIG head will provide training of OIG Analysts in the collection of this data and all subsequent reform steps.

Lean Team Data that is collected and allowed to accumulate
The following steps show how the Lean Team Data is collected and allowed to accumulate in the spreadsheet program and how the summarized data is used. 
1. The Lean Data for each function will be documented in the spreadsheet.

2. All labor and expense cost data will be documented and allowed to accumulate as functions are added to the spreadsheet until all functions have been accounted for (bottoms-up manpower budget).

3. The names of the employees working on the function will be documented with any special expertise they are using in performing the function. Each employee’s labor hours expended in doing the function will be documented and allowed to accumulate. This data will be used during the Right-Sizing process.

4. Where there is interaction between several employees during the performance of the function as a part of a work load balancing chart will be a part of the documentation. This work load chart can be used later to balance the function’s work load. (prevents employees from waiting on other employees).

5. When all of a Departments Functions have been logged into the spread sheet the final labor hours and expense numbers will have been automatically tallied in the spread sheet along with the total hours worked by each employee in the particular function.

6. A key question asked of employees is the estimate for the number of times that the function is done per week this is tallied and recorded in the spread sheet. This number is authenticated by history and other knowledgeable personnel including the enumeration of purchased goods consumed by the function.

7. The total annual accumulated functional hours rated at 100% productivity and must be converted to provide a realistic number at 75% productivity. To make this conversion you will add 25% more time to the total or multiply the total time by 125%. This becomes the labor hours for staffing and budgeting and is what is referred to as a Gross Load among consultants. When all of the Agency’s functional labor hours have been accumulated at 125% and we add in the total annual expenses, Vacations etc. we have what is called a Bottoms-up Functional Budget.

8. Next we will compare the Bottoms-up Budget with the current Top-Down Agency Budget. To do this we remove all management and overhead expenditures from the Agency’s Top-Down Budget to obtain an equal expenditure. Then we compare the Bottoms-up Budget with the Top-Down Budget. The Bottoms-up Budget should be 20% or more less than the Top-Down Budget.  This can be verified by the number of times that a Function is being performed annually. This is determined by reviewing the Lean data in the Agency’s spreadsheet.

9. We can do Right-Sizing using the employee accumulated Lean data from the spreadsheet. As a rule of thumb the employee accumulated hours is separated between those who have accumulated more than 20 hours per week average and those who have accumulated less than 20 hours per week. Those who have accumulated less than 20 hours per week are considered to be redundant and slated for retraining for a new job. Their accumulated hours are spread among those with more than 20 hours per week increasing their hours to at least 37 hours per week. This involves reviewing each function and reassigning tasks to employees according to their capability and availability.

10. We need to review the spreadsheet for those jobs noted as occurring on a random basis. These special jobs need to be separated form those jobs that occur on a continuing basis. An individual employee is specially trained to do the job of Work Planning, forecasting scheduling these jobs on a weekly basis.

11. The spreadsheets can be stored on thumb drives for each Department and protected. The labor data for each function is stored in a Database at 100% to be used for calculating productivity where required. The Database also includes the staffing and bottoms-up budgeting data. I recommend that the data be protected by an independent organization such as the OMB. This allows availability of the data for all who want to review the actual labor and expense cost of a Department’s function including the Bottoms-up Budget.

Phase 4. Organization Reform
In the final step of the General Reform Model the Principal Consultant will support 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 Six Sigma Teams (where used). 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. But if the bureaucracy is allowed to stay in place after only a few years of mismanagement the level of staffing could grow to where it originally was. 

Article 98. Transition to a New Government Catastrophic Health Care System

Transition to a New Government Catastrophic Health Care System
By Lawrence Rosier Consultant
Based on the suggestions in Article 97 and the implementation of VA reforms in Article 96.

My approach is to let the people pay what they can afford and above that have the government provide catastrophic heath care to all Americans.  This is what most Americans want.  Health care recipients should pay each year for their own health care from private providers up to a specified near catastrophic amount determined by income at several levels.  Paying all the health care costs for everything that people want is not possible and should not be provided by the Government. For example abortion should not be paid for as a part of health care.

As an option private Health Insurance Companies can compete in providing the minimum coverage up to the catastrophic level if wanted by individuals and companies. Insurance coverage for Catastrophic Health Care has been proven to have failed under Obamacare and does not work.

The Federal Government should not provide healthcare to non-citizens, however State Governments may chose to provide this service.

The key to this system is the elimination of Private Health Insurance and Private Hospitals from the Catastrophic Health Care System. Health Insurance for catastrophic health does not work because profits necessarily drive up insurance rates and co-pays.  Private Hospitals have resorted to massive fraud to survive. Congress has not been able to prevent the waste and corruption found in our health care system. Americans simply can not afford or be expected to pay for a health care system that is the most wasteful and expensive in the world.  The current health care waste from fraud and abuse has been passed on to the public and not enough has been done to make the day to day health care processes themselves efficient.  But now we have the Reforms to be implemented in the VA which makes health care efficient and effective. This makes possible the Government Catastrophic Health Care system as an affordable alternative to the current fraud based Private Health Care system and over priced Health Insurance system.

Transition Alternatives:
The VA Healthcare system must have reforms fully implemented in all of its facilities and be treated as a separate system providing Vets the health care they need.  The VA system changes according to needs of the Vets with age and with injury types.  Therefore there is a need to go outside the system for healthcare it cannot provide.  This alternative could be the Catastrophic Health Care System that mostly serves those receiving Medicaid.  The cost of the Catastrophic Health Care System may be shared with the State Government.

In the future the US Government may pursue the development of a complete government Health Care system for Medicare as an alternative to the current private health care delivery system that is mainly driven by fraud. Without this approach Medicare will become less and less affordable causing the starting age to be raised and benefits to be cut.

We must separate and remove all healthcare costs that have nothing to do with healthcare.
All drugs, supplies and equipment must be purchased on the world wide market.  This means for example that a drug manufacturer can not sell a pill in the US for $100 and in India for $2.  All drug sales must share in the development costs and the drug will have a single world wide price.


Example of Why the Cost of Health Care can be Reduced 
The CBS 60 minute segment "Out of Darkness" by two eye surgeons Sanduk and Geoffrey Tabin who relate their activities performing cataract surgery in Burma where 100 or more patients were operated on each day compared with 5 in the US.  This is an actual patient increase in efficiency of 2000% and a reduction of cost $2000 in US to $20 in Burma per patient eye.

In the future government run Cataract Surgery hospital units can be established in major cities.  As many as 50 eye surgeries can be performed per day reducing the cost per eye from $2000 to $200.  These hospitals can serve Veterans as well as Medicaid and Medicare patients. This will bring down the cost of cataract surgery by a factor of 10X.

The surgery was accomplished by introducing efficiency and the elimination of Red Tape.  Given this example there is no reason that a goal of 50% reduction in health care costs can be attained over time in the US.  This can be attained and tested through the implementation of Enterprise Lean In VA hospitals where 90% of employees meet once a week to make continuous improvement in their processes. With the reform of Continuous Improvement ALL Health Care Costs can be reduced by as much as 50% over time.

If you are one of those who are offended by the assembly line operations in Burma then you should consider the blind patients who walked miles to get to the Clinic for the 5 minute operation that restored their sight. It is possible to have an assembly line of operations and still preserve the dignity of the patient.  This is the price of having efficient health care, the alternative is no universal heath care.

It is important that congress can see what actually can be done.  Continuous improvement suggests that the number of patients processed can be increased in stages from 5 to 15 and then up to 40 patients per day in the US. The Teams biggest challenge will be in getting rid of red tape.

Example of how Cataract Surgery can be Implemented in the US
Cataract Surgery Clinics can be established in every major city of over 100 thousand population.  Each surgeon can perform surgery up to 40 patients per day with minimum expense of about $400 per eye rather than the current $2000 cost.  The Eye clinics would serve Veterans, Medicaid and Medicare patients saving $billions.

Supporting Article
New Yorker's 2012 Cheesecake Factory Article missed-Enterprise Lean, Continuous Improvement as the solution to obtaining improvements to health care that the author was looking for. http://www.newyorker.com/magazine/2012/08/13/big-med …
 
 Advantages of the Catastrophic Health Care System
People without serious health problems will not be required to buy healthcare through a Health Insurance Co. But they must pay for their health care with what they can afford based on income with the remainder covered under the Governments Catastrophic Health Care System.  Families will not be devastated with high healthcare costs forcing them to sell their homes.

Doctors incomes will not be curtailed they can still specialize in diseases of the rich outside the government heath care system.

This approach is supported by Dr ken Davis Mount Sinai Hospital: "Conservatives have got to deal with reforms that affect Health Care costs, House & Senate Health Care bills don’t." PBSNewsHour Monday June 26, 2017

Rural Health Care Solutions
Cataract surgeries may be done by a traveling team of eye surgeons and nurses visiting designated rural Clinics on a periodic basis.  They can perform up to 20 surgeries in a two day visit to a clinic.

A traveling dialysis equipped van can visit rural clinics on a regular basis where patients cannot get to a dialysis equipped hospital.

Article 97. My Approach to Solving VA Healthcare Problems works in the US and Europe

 My Approach to Solving VA Healthcare Problems works in the US and Europe
by  Lawrence Rosier  Government Reform Consultant

My suggestions on Reforming US Government Health Care:
As a government run system VA health care may be worse than that of European health care but they both have the same problems: massive bureaucracy, low efficiency, high patient backlogs and uncontrolled costs.   My approach fixes nearly all of the VA’s health care problems.  Europe does not have this approach yet.  If we can fix the VA problems (and I believe with confidence that we can), then this approach will work for a complete US government run healthcare system without the bureaucracy.

We can combine the VA health care system with a new Catastrophic health care system (a government run system) consisting largely of Medicaid and with Medicare in the future.   Remember if you have an efficient effective VA program then no private health care company can compete with it because private companies must make healthcare run more efficient than government healthcare. If they can’t do this then there are no profits. If there are no profits in the healthcare system private systems will just drive up the cost of healthcare to get profits.  We must separate and remove all healthcare costs that have nothing to do with healthcare.

We are making health care much too complicated.
My approach is to let the people pay what they can afford and above that have the government provide catastrophic heath care to all Americans (the VA currently uses the government as an insurance provider).  This is what most Americans want.  Health care recipients should pay each year for their own health care from private providers up to a specified amount determined by income at several levels.  Paying all the health care costs for everything that people want is not possible and should not be provided by the Federal Government. As an option private Health Insurance Companies can compete in providing the minimum coverage up to the catastrophic level if wanted by individuals and companies.

The current approach in thinking Insurance Companies provide competition and therefore reduce costs for all health care, over that than can be provided by an efficient government health care system is a false approach.  Insurance Companies do not reduce heath care costs. In fact they do the opposite they increase the cost of heath care by adding thousands of Americans working in insurance companies arguing over how much they will pay.  Only better management of medical Systems will make health care more efficient as recommended in the VA reforms.

The current medical system has a massive complicated set of codes that unnecessarily complicate the system to make sure those who deliver services get paid for their services.  In a government run system all personnel are salaried with no need for codes.

This suggestion removes private Health Insurance Companies and thousands of their employees from the government operated catastrophic health care system.  When trying to provide a total insurance approach for all health care private Health Insurance Companies simply do not work (this is the worst part of Obama care).

If this suggestion is implemented it will remove the Private profits from the government operated catastrophic health care system virtually eliminating the massive fraud found in our current health care system. Ref: Article 93. "Example of Massive Medicare Fraud".  Hospitals throughout the US in 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.

Added suggestions: the biggest single cost of RX drugs is in TV advertising simply disallowing this will reduce RX drug costs significantly. Medical facilities should also be able to buy drugs from a world wide competition of drug producers. Again, we must separate and remove all healthcare costs that have nothing to do with healthcare.