Article 71. 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 Best Practices 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 (Best Practices) 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.
Monday, July 28, 2014
Saturday, July 19, 2014
Article 70. 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 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. For an Example of this method see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness and Article 69. Using Enterprise Best Practices at the VA.
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.
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 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. For an Example of this method see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness and Article 69. Using Enterprise Best Practices at the VA.
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.
Saturday, July 12, 2014
Article 69. Using Enterprise Best Practices at the VA
My General Reform Model begins step one with the implementation of a modified Enterprise Lean implementation which may be better explained as Enterprise Best Practices or the determination of Best Practices for ALL VA Health Care processes at a VA Medical Facility. I refer to Best Practices as getting the “Highest Effectiveness possible”. This is followed by the determination of the “most efficient method” of doing the processes. Established Best Practices will be reviewed to verify the actual implementation in current practices in each Function.
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 (Nurces) 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. For an Example of this method see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness.
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 doctors with attending nurses are already in place. Top management of the VA Medical Facility may be selected by the Secretary of Veterans Affairs.
This step addresses the problem of the Bureaucratic management head on. It spreads decision making powers among top management as well as at the bottom of the organization. The Lean Teams which become Functional Teams are empowered to find the most effective way of doing their jobs with the most efficiency. Note that when the bureaucratic organization is converted to a Team Management organization most supervisors at the bottom of the organization are placed back into the Functional Teams which elects their own leaders. Obviously Bullying and Incompetent supervisors will not be elected as Team Leaders. The reasons why they are not elected will be investigated by the implementers of the reforms on a case by case basis. However every effort will be made to find appropriate jobs for redundant supervisors. Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management.
My General Reform Model begins step one with the implementation of a modified Enterprise Lean implementation which may be better explained as Enterprise Best Practices or the determination of Best Practices for ALL VA Health Care processes at a VA Medical Facility. I refer to Best Practices as getting the “Highest Effectiveness possible”. This is followed by the determination of the “most efficient method” of doing the processes. Established Best Practices will be reviewed to verify the actual implementation in current practices in each Function.
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 (Nurces) 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. For an Example of this method see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness.
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 doctors with attending nurses are already in place. Top management of the VA Medical Facility may be selected by the Secretary of Veterans Affairs.
This step addresses the problem of the Bureaucratic management head on. It spreads decision making powers among top management as well as at the bottom of the organization. The Lean Teams which become Functional Teams are empowered to find the most effective way of doing their jobs with the most efficiency. Note that when the bureaucratic organization is converted to a Team Management organization most supervisors at the bottom of the organization are placed back into the Functional Teams which elects their own leaders. Obviously Bullying and Incompetent supervisors will not be elected as Team Leaders. The reasons why they are not elected will be investigated by the implementers of the reforms on a case by case basis. However every effort will be made to find appropriate jobs for redundant supervisors. Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management.
Thursday, July 10, 2014
Article 68. Why VA Management Has Failed
The Department of Veterans Affairs Health Care division has had bureaucratic management problems going back decades. Why is it that the VA simply has not been able to correct its problems. Some problems exist in nearly every Government Bureaucracy but in the VA the problems seam to be worse.
Bureaucratic Managers especially those that are Directors of large medical facilities such as the VA are under tremendous pressure to show leadership especially leadership that purports to be efficient saving the Department of Veterans Affairs money. The Director in turn receives a significant bonus just for appearing to be doing something needed by the Department. The pressures of increased numbers of patients in recent years and an agency with a limited budget caused the Directors of most of the VA Medical facilities to falsify patient schedules. If current VA funding had gone to hire the doctors and staff needed there would have been no funds available for Management bonuses.
Here is why I believe the VA bureaucratic Management has failed:
The management tools for proper management simply do not exist in bureaucratic government. The reason for this is that knowing the cost of a simple process with enough precision to apply the tools of management does not exist. Most companies in private industry know what it costs to manufacture an item or the cost of providing a service. Budgets in private industry to a large extent reflect actual costs while in Government Bureaucracies most budgets are negotiated based on the previous years expenditures and no one knows what the real costs should be.
Not knowing what each process in the Facility should cost means that VA Directors and Managers are unable to know which operations are operating efficiently and which need to be scrutinized and made more efficient. The inability to make this important distinction causes inept managers to apply pressure on all processes scolding and congealing employees to be more efficient. At the lower levels of the agency this leads to bullying of employees and the natural obstinacy of employees.
Sharon Helman suspended director of the VA’s Phoenix Medical Facility is an example of a Director that will do almost anything to make her directorship appear to Veterans Affairs in Washington DC that she is doing an excellent job and deserves the lucrative bonuses that she has received. Unable to actually make her directorship efficient through actual cost data she resorted to a number of tricks to reduce budget. The firing of managers and leaving the post open, the closing of parts of the hospital shutting off services to Vets etc. all were done to make Director Helman appear to be reducing costs while actually causing extreme chaos in the facility. The following article by Sheila Hager highlights the problems.
#WALLA WALLA — A director placed on administrative leave last week at a Phoenix Veterans Affairs medical center had a troubled run here, as well.
#Sharon Helman served as director of the Jonathan M. Wainwright Memorial VA Medical Center after coming from a VA in Roseberg, Ore in January 2007. In June 2008, she transferred to Spokane’s VA medical center.
#Veterans Affairs Secretary Eric K. Shinseki announced on May 1 he had placed Helman, Associate Director Lance Robinson and a third unidentified employee on administrative leave “until further notice,” stemming from a wide-reaching scandal brought on by whistle-blowers accusing the Phoenix VA of keeping a secret waiting list to hide delays in treatment, according to a Los Angeles Times story.
#Helman said she respected Shineski’s decision and was “fully supportive of any decision that ensures we have a thorough review by the Office of the Inspector General.”
#By the end of her tenure in Walla Walla eight years ago, Helman had drawn the ire of VA employees and veterans, according to a Union-Bulletin story.
#In summer of 2008 a group gathered to meet with Sen. Patty Murray’s staff and John Lee, then director of Washington state Department of Veteran Affairs. The discussion, held at the National Guard Armory in Walla Walla, centered on employee morale and quality of medical services during Helman’s tenure.
#Former employee James Bernasconi was vice president of local chapter of the American Federation of Government Employees union at the time. He had recently retired from a 33 year career as a budget analyst for the Walla Walla VA.
#The atmosphere and morale at the medical center was toxic, Bernasconi said at the meeting, covered by the Union-Bulletin.
#In 2007, the mental-health unit at the local VA was considered by some in management to be one of the best in the nation. A year later many believed it to be slated for closure, he explained.
#Bernasconi said it began with the arrival of Helman.
#“They brought Sharon Helman in to quiet the community,” he said. “She had no management skills, but she quieted things down.”
#Under Helman’s reorganization in July 2007, department chiefs were taken out of their positions and departments were left to “intentionally fail,” Bernasconi said in 2008.
#Others at the meeting spoke of the rapid shut down of the Community Living Center, the VA’s nursing home unit, that July. The maneuver took three days and put at least one patient in crisis, those at the meeting said.
#“It seems like a brilliant plan,” said veteran Russ Acord said then. “Blow it up from the inside and blame it on the staff.”
#Acord said he blamed Dennis “Max” Lewis, then Veterans Affairs regional network director, and Helman for “pulling this VA apart as quickly as possible, but they are simply following orders and being paid well to do so.”
#One former employee at the meeting who did not want to be identified in the newspaper told Murray’s staff that managers with long, commendable work histories were fired under Helman as scapegoats, while others fled the situation by quitting. Staff members displaced from other areas had been slotted into spots they weren’t qualified for, she said.
#Sheila Hagar can be reached at sheilahagar@wwub.com or 526-8322.
Comment by Lawrence Rosier Principal Consultant
This is over the top incompetent Management without a clue as to how to actually make an organization more efficient. Please peruse the following articles:
Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness
Article 58. Reinventing the VA
Article 61. Why the Federal Government is Unlikely to fix the VA
Article 64. Bureaucratic “Stone Walling”, Whistle Blowers and a Fix for the problem
Article 65. Why the General Reform Model Works
Article 66. 'Bonus Culture' at VA Scrutinized by House Committee
The Department of Veterans Affairs Health Care division has had bureaucratic management problems going back decades. Why is it that the VA simply has not been able to correct its problems. Some problems exist in nearly every Government Bureaucracy but in the VA the problems seam to be worse.
Bureaucratic Managers especially those that are Directors of large medical facilities such as the VA are under tremendous pressure to show leadership especially leadership that purports to be efficient saving the Department of Veterans Affairs money. The Director in turn receives a significant bonus just for appearing to be doing something needed by the Department. The pressures of increased numbers of patients in recent years and an agency with a limited budget caused the Directors of most of the VA Medical facilities to falsify patient schedules. If current VA funding had gone to hire the doctors and staff needed there would have been no funds available for Management bonuses.
Here is why I believe the VA bureaucratic Management has failed:
The management tools for proper management simply do not exist in bureaucratic government. The reason for this is that knowing the cost of a simple process with enough precision to apply the tools of management does not exist. Most companies in private industry know what it costs to manufacture an item or the cost of providing a service. Budgets in private industry to a large extent reflect actual costs while in Government Bureaucracies most budgets are negotiated based on the previous years expenditures and no one knows what the real costs should be.
Not knowing what each process in the Facility should cost means that VA Directors and Managers are unable to know which operations are operating efficiently and which need to be scrutinized and made more efficient. The inability to make this important distinction causes inept managers to apply pressure on all processes scolding and congealing employees to be more efficient. At the lower levels of the agency this leads to bullying of employees and the natural obstinacy of employees.
Sharon Helman suspended director of the VA’s Phoenix Medical Facility is an example of a Director that will do almost anything to make her directorship appear to Veterans Affairs in Washington DC that she is doing an excellent job and deserves the lucrative bonuses that she has received. Unable to actually make her directorship efficient through actual cost data she resorted to a number of tricks to reduce budget. The firing of managers and leaving the post open, the closing of parts of the hospital shutting off services to Vets etc. all were done to make Director Helman appear to be reducing costs while actually causing extreme chaos in the facility. The following article by Sheila Hager highlights the problems.
Suspended Phoenix VA director had problems in Walla Walla
By Sheila Hagar Thursday, May 22, 2014 UnionBulletin.com#WALLA WALLA — A director placed on administrative leave last week at a Phoenix Veterans Affairs medical center had a troubled run here, as well.
#Sharon Helman served as director of the Jonathan M. Wainwright Memorial VA Medical Center after coming from a VA in Roseberg, Ore in January 2007. In June 2008, she transferred to Spokane’s VA medical center.
#Veterans Affairs Secretary Eric K. Shinseki announced on May 1 he had placed Helman, Associate Director Lance Robinson and a third unidentified employee on administrative leave “until further notice,” stemming from a wide-reaching scandal brought on by whistle-blowers accusing the Phoenix VA of keeping a secret waiting list to hide delays in treatment, according to a Los Angeles Times story.
#Helman said she respected Shineski’s decision and was “fully supportive of any decision that ensures we have a thorough review by the Office of the Inspector General.”
#By the end of her tenure in Walla Walla eight years ago, Helman had drawn the ire of VA employees and veterans, according to a Union-Bulletin story.
#In summer of 2008 a group gathered to meet with Sen. Patty Murray’s staff and John Lee, then director of Washington state Department of Veteran Affairs. The discussion, held at the National Guard Armory in Walla Walla, centered on employee morale and quality of medical services during Helman’s tenure.
#Former employee James Bernasconi was vice president of local chapter of the American Federation of Government Employees union at the time. He had recently retired from a 33 year career as a budget analyst for the Walla Walla VA.
#The atmosphere and morale at the medical center was toxic, Bernasconi said at the meeting, covered by the Union-Bulletin.
#In 2007, the mental-health unit at the local VA was considered by some in management to be one of the best in the nation. A year later many believed it to be slated for closure, he explained.
#Bernasconi said it began with the arrival of Helman.
#“They brought Sharon Helman in to quiet the community,” he said. “She had no management skills, but she quieted things down.”
#Under Helman’s reorganization in July 2007, department chiefs were taken out of their positions and departments were left to “intentionally fail,” Bernasconi said in 2008.
#Others at the meeting spoke of the rapid shut down of the Community Living Center, the VA’s nursing home unit, that July. The maneuver took three days and put at least one patient in crisis, those at the meeting said.
#“It seems like a brilliant plan,” said veteran Russ Acord said then. “Blow it up from the inside and blame it on the staff.”
#Acord said he blamed Dennis “Max” Lewis, then Veterans Affairs regional network director, and Helman for “pulling this VA apart as quickly as possible, but they are simply following orders and being paid well to do so.”
#One former employee at the meeting who did not want to be identified in the newspaper told Murray’s staff that managers with long, commendable work histories were fired under Helman as scapegoats, while others fled the situation by quitting. Staff members displaced from other areas had been slotted into spots they weren’t qualified for, she said.
#Sheila Hagar can be reached at sheilahagar@wwub.com or 526-8322.
Comment by Lawrence Rosier Principal Consultant
This is over the top incompetent Management without a clue as to how to actually make an organization more efficient. Please peruse the following articles:
Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness
Article 58. Reinventing the VA
Article 61. Why the Federal Government is Unlikely to fix the VA
Article 64. Bureaucratic “Stone Walling”, Whistle Blowers and a Fix for the problem
Article 65. Why the General Reform Model Works
Article 66. 'Bonus Culture' at VA Scrutinized by House Committee
Wednesday, June 25, 2014
Article 67. Public Attention to VA Problems is Starting to Wane
We have all seen this happen before, public attention is what drives congress and the VA to answer to whistle blowers. The attention lasts for only a few months until some other new catastrophe over shadows the problem such as the recent invasion of Iraq by Muslem extremists. The offending Bureaucracy in this case the VA at first pretends to investigate and finds nothing. In response to Dr. Foote’s first Letter in 2013 about the Scheduling problems at the Phoenix VA Medical facility, the VA had the matter investigated by its OIG and found nothing. It wasn’t until the story broke on Dr. Foote’s second Letter in February 2014 that public attention through the media was focused on the VA’s problems. Meanwhile the VA sent its OIG out again to investigate and the full story began to emerge. As the findings get worse the media attention grows to a peak. This is followed by press releases by the VA that no one has actually been harmed by the VA scheduling problems. This a false claim to sooth the public into thinking that the VA’s problems are being solved and the government is actually doing something. Now the story is waning in the press it is becoming old news and the media moves on to the latest story the Iraq invasion.
The problem is with the VA’s bureaucratic management which operates its Medical Facilities as little medieval fiefdoms. Only reports of good news ever reaches the Secretary of Veterans Affairs and he never investigates rumors of wrong doing lessening the chance of actually finding a substantial problem. What is happening is that in a few more months the VA will claim that it has addressed its problems and the newly appointed Secretary of Veterans Affairs will claim that he will never allow the VA’s problems to occur again. All is forgiven and the VA continues business as usual.
Veteran organizations have been waiting on the sideline to see what the Federal Government actually does. It will find that the Federal Government has done little except to implement new laws allowing for the removal of corrupt VA management a mere slap on the wrists for wide spread mismanagement. This does not imply that all of the VA’s Management need to be replaced many are excellent managers but simply the Bureaucratic environment entraps all of the VA's managers. This is why the systemic Bureaucratic VA management will not reform themselves leaving but one option the reform must come from outside the organization.
Therefore my proposal to the Senate Veterans Affairs and the House Veterans Affairs Committees for a Consulting Agreement. This proposal can only be accepted by the VA Committees by enacting legislation. Because the Federal Government does not accept proposals from the public by its vendor laws. Listed Vendors cannot make originating proposals to the Federal Government they can only make proposals to calls for proposals from government agencies. Simply put an agency is most unlikely to call for proposals from outside Consultants to reform itself.
Since Sweeping Reforms is unlikely to be implemented by the VA itself I recommend that VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. The result could be that the VA becomes the best managed organization in the Federal Government or the alternative "business as usual". See articles 61, 64, 65, and 66.
We have all seen this happen before, public attention is what drives congress and the VA to answer to whistle blowers. The attention lasts for only a few months until some other new catastrophe over shadows the problem such as the recent invasion of Iraq by Muslem extremists. The offending Bureaucracy in this case the VA at first pretends to investigate and finds nothing. In response to Dr. Foote’s first Letter in 2013 about the Scheduling problems at the Phoenix VA Medical facility, the VA had the matter investigated by its OIG and found nothing. It wasn’t until the story broke on Dr. Foote’s second Letter in February 2014 that public attention through the media was focused on the VA’s problems. Meanwhile the VA sent its OIG out again to investigate and the full story began to emerge. As the findings get worse the media attention grows to a peak. This is followed by press releases by the VA that no one has actually been harmed by the VA scheduling problems. This a false claim to sooth the public into thinking that the VA’s problems are being solved and the government is actually doing something. Now the story is waning in the press it is becoming old news and the media moves on to the latest story the Iraq invasion.
The problem is with the VA’s bureaucratic management which operates its Medical Facilities as little medieval fiefdoms. Only reports of good news ever reaches the Secretary of Veterans Affairs and he never investigates rumors of wrong doing lessening the chance of actually finding a substantial problem. What is happening is that in a few more months the VA will claim that it has addressed its problems and the newly appointed Secretary of Veterans Affairs will claim that he will never allow the VA’s problems to occur again. All is forgiven and the VA continues business as usual.
Veteran organizations have been waiting on the sideline to see what the Federal Government actually does. It will find that the Federal Government has done little except to implement new laws allowing for the removal of corrupt VA management a mere slap on the wrists for wide spread mismanagement. This does not imply that all of the VA’s Management need to be replaced many are excellent managers but simply the Bureaucratic environment entraps all of the VA's managers. This is why the systemic Bureaucratic VA management will not reform themselves leaving but one option the reform must come from outside the organization.
Therefore my proposal to the Senate Veterans Affairs and the House Veterans Affairs Committees for a Consulting Agreement. This proposal can only be accepted by the VA Committees by enacting legislation. Because the Federal Government does not accept proposals from the public by its vendor laws. Listed Vendors cannot make originating proposals to the Federal Government they can only make proposals to calls for proposals from government agencies. Simply put an agency is most unlikely to call for proposals from outside Consultants to reform itself.
Since Sweeping Reforms is unlikely to be implemented by the VA itself I recommend that VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. The result could be that the VA becomes the best managed organization in the Federal Government or the alternative "business as usual". See articles 61, 64, 65, and 66.
Saturday, June 21, 2014
Article 66. 'Bonus Culture' at VA Scrutinized by House Committee
Now we have further proof that the VA needs sweeping reform. Since Sweeping Reform is unlikely to be implemented by the VA itself I recommend that VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. The result could be that the VA becomes the best managed organization in the Federal Government or the alternative "business as usual".
Lawrence Rosier Principal Consultant
From: 'Outlandish bonus culture' at VA scrutinized by House committee
By Joshua Rhett Miller FoxNews.com House Committee on Veterans’ Affairs Chairman Jeff Miller, R-Fla., led the grilling of Gina Farrisee, the VA’s assistant secretary for human resources and administration, zeroing in on a bonus system that saw about $10 million awarded to executives at the Phoenix VA Health Care System alone over a three-year period. In total, the VA gives out an estimated $400 million per year in performance bonuses.
“Knowing what we know now, about the fraudulent actions being taken at facilities all across this country that have harmed our veterans, do you think that the department’s assessment that 100 percent of senior managers at VA have been fully successful in the past four years is in line with reality?” Miller asked.
Despite revelations that veterans died languishing on waiting lists and some of the lists were even hidden, at least 65 percent of its senior executive workforce received the bonuses, said Miller.
“As the committee’s investigation into the department continues, and new allegations and cover-ups are exposed, it is important that we examine how the department has arrived at the point where it is today,” Miller said in prepared remarks. “Sadly, it’s a point which has eroded veterans’ trust and America’s confidence in VA’s execution of its mission. Part of the mistrust centers on a belief that VA employees are motivated by financial incentives alone, and I can see why.”
"Part of the mistrust centers on a belief that VA employees are motivated by financial incentives alone, and I can see why."- Rep. Jeff Miller, chairman, House Committee on Veterans’ AffairsFarrisee acknowledged the need to hold VA employees and supervisors accountable, particularly regarding performance, but defended the pay bonuses.
“We must recruit and retain the best talent, many of whom require special skills in health care, information technology, management and benefits delivery,” Farrisee testified. “In particular, VA requires talented senior executives to manage the complex set of facilities and programs that VA is responsible to administer.
“Performance plans are the foundation of accountability not only for senior executives but for the entire workforce,” Farrisee’s prepared remarks continued. “Senior leadership engagement in managing executive performance plans, including counseling and mid-year assessments, also serves as the model for the general schedule workforce.”
Farrisee, who joined the agency in September, admitted to Miller that not a single member of its senior executive service – a pool of 470 individuals – received less than a fully satisfactory or successful rating. She acknowledged that the VA's recently exposed problems don't jibe with an agency rewarding employees for stellar work.
Comment by Lawrence Rosier
I disagree with Farrisee's statement:
“We must recruit and retain the best talent, many of whom require special skills in health care, information technology, management and benefits delivery,” Farrisee testified.
The primary talent which these managers have is in calculating their bonuses. The critical skills they lack is the management tools for determining exactly where staffing is needed to meet the 14 day appointment guide line. They also lack the capability to determine the maximum through put of patients necessary for balancing the healthcare work loads. These tools make a Health Care facility effective and efficient thus saving the tax payers real money. This is what bonuses are given for in private industry.
Friday, June 20, 2014
Article 65. Why the General Reform Model Works
The General Reform Model was developed by Lawrence Rosier to solve Bureaucratic systemic management problems exactly like those found in VA Medical Facilities.
1. VA problems are an out growth of Bureaucratic management problems.
Symptoms are:
A. Enormous power concentrated at the top of the organization.
B. Self serving interests of top management are greater than the need to fulfill the organizations Mission to serve Veterans Health Care.
C. OIG discovered excessive bullying and sexual harassment tolerated by upper management.
2. A second problem is found in the toxic culture created by the bureaucratic Management affecting all employees at the VA Medical Facilities.
3. A third problem is the failure of the organization to focus on its Mission “Serving Veterans in their need for Health Care” by focusing on getting the highest Effectiveness possible with efficiency.
This step addresses problems 2. creates a transparent work environment where employees are encouraged to come forward when problems need to be addressed and 3. focuses employees on the Mission of the organization.
Step 2. OIG Analysts collect the Lean Team data: the time to do the improved process, who is working on the process, the equipment needed for the process. This data is collected in a spreadsheet and a database. The results of the data when the entire organization is totaled allows for Right Sizing the organization (reducing over staffed areas and identifying under staffed areas needed to meet Appointment Schedules). The totaled data also provides an accurate budget for all work processes other than Management and overhead. For the first time in government we have accurate tools for the management of variable work enabling the balancing of work loads.
Right-Sizing staffs the entire organization. With this process we know exactly where staffing increases are needed to meet appointment goals. Every effort to retrain employees from overstaffed areas and move them to where they are needed will be done.
Step 3. The conversion of the Bureaucratic organization to a Team Managed organization is really a quite 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 secret ballot. How ever many Professional Teams such as doctors with attending nurses are already in place. Top management of the VA Medical Facility may be selected by the Secretary of Veterans Affairs.
This step addresses the problem of the Bureaucratic management head on. It spreads decision making powers among top management as well as at the bottom of the organization. The Lean Teams which become Functional Teams are empowered to find the most effective way of doing their jobs with the most efficiency. Note that when the bureaucratic organization is converted to a Team Management organization most supervisors at the bottom of the organization are placed back into the Functional Teams which elects their own leaders. Obviously Bullying and Incompetent supervisors will not be elected as Team Leaders. The reasons why they are not elected will be investigated by the implementers of the reforms on a case by case basis. However every effort will be made to find appropriate jobs for redundant supervisors. Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management.
The General Reform Model was developed by Lawrence Rosier to solve Bureaucratic systemic management problems exactly like those found in VA Medical Facilities.
Why the general Reform Model works to solve VA problems
First we want to reiterate actual findings of the OIG at the Phoenix VA Medical facilities. See Article 57. Veterans Health Administration Interim Report1. VA problems are an out growth of Bureaucratic management problems.
Symptoms are:
A. Enormous power concentrated at the top of the organization.
B. Self serving interests of top management are greater than the need to fulfill the organizations Mission to serve Veterans Health Care.
C. OIG discovered excessive bullying and sexual harassment tolerated by upper management.
2. A second problem is found in the toxic culture created by the bureaucratic Management affecting all employees at the VA Medical Facilities.
3. A third problem is the failure of the organization to focus on its Mission “Serving Veterans in their need for Health Care” by focusing on getting the highest Effectiveness possible with efficiency.
The General Reform Model addresses all of the above problems in a step by step approach
Step 1. Implementation of Enterprise Lean (developed by Toyota) uses employee Lean Teams to address the problem of converting a negative toxic cultural work environment into a positive environment and focuses employee attention on improving the systems and processes they are working on. The results get the highest effectiveness and efficiency possible with continuous improvement.This step addresses problems 2. creates a transparent work environment where employees are encouraged to come forward when problems need to be addressed and 3. focuses employees on the Mission of the organization.
Step 2. OIG Analysts collect the Lean Team data: the time to do the improved process, who is working on the process, the equipment needed for the process. This data is collected in a spreadsheet and a database. The results of the data when the entire organization is totaled allows for Right Sizing the organization (reducing over staffed areas and identifying under staffed areas needed to meet Appointment Schedules). The totaled data also provides an accurate budget for all work processes other than Management and overhead. For the first time in government we have accurate tools for the management of variable work enabling the balancing of work loads.
Right-Sizing staffs the entire organization. With this process we know exactly where staffing increases are needed to meet appointment goals. Every effort to retrain employees from overstaffed areas and move them to where they are needed will be done.
Step 3. The conversion of the Bureaucratic organization to a Team Managed organization is really a quite 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 secret ballot. How ever many Professional Teams such as doctors with attending nurses are already in place. Top management of the VA Medical Facility may be selected by the Secretary of Veterans Affairs.
This step addresses the problem of the Bureaucratic management head on. It spreads decision making powers among top management as well as at the bottom of the organization. The Lean Teams which become Functional Teams are empowered to find the most effective way of doing their jobs with the most efficiency. Note that when the bureaucratic organization is converted to a Team Management organization most supervisors at the bottom of the organization are placed back into the Functional Teams which elects their own leaders. Obviously Bullying and Incompetent supervisors will not be elected as Team Leaders. The reasons why they are not elected will be investigated by the implementers of the reforms on a case by case basis. However every effort will be made to find appropriate jobs for redundant supervisors. Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management.
Sunday, June 15, 2014
Article 64. Bureaucratic “Stone Walling”, Whistle Blowers and a Fix for the problem
Over the years of the Obama Administration Representative Jeff Miller from Florida has written numerous letters to the President some outlining complaints from Veterans relating to the lack of VA healthcare. The letters no doubt ended up in the hands of the Secretary of Veterans Affairs Eric Shinseki. Mr. Shinseki may have contacted the offending Heads of the VA Medical Facilities. Obviously nothing was done ending in classic “stone walling” of government Bureaucratic leaders. Mr. Shinseki Could have initiated an investigation by the VA’s own Office of Inspector General OIG which could have yielded the similar results to the current findings a year earlier but didn’t. But the OIG had already investigated the problem in 2013 and found nothing, at the request of Dr. Sam Foote the current 2014 VA Scandal Whistle Blower.
Dr. Sam Foote the physician who revealed that patients had died while awaiting appointments at the Phoenix VA Health Care System described how he became a whistleblower.
After his original 2013 complaint (to the VA OIG)was apparently disregarded, Dr. Sam Foote wrote a follow-up letter in February 2014 to the VA Office of the Inspector General demanding that his revelations be acted upon, The Arizona Republic reported.
"Patients are still dying. How can that be three months after I first notified you of the problem?" Foote wrote.
The IG's office had in fact begun looking into his allegations in December 2013 but Foote didn't see the situation improving.
In February 2014, Foote wrote a second time to the inspector general, sending copies to Arizona Sen. John McCain, Arizona Rep. Ann Kirkpatrick, and U.S. Attorney John Leonardo.
Only McCain's office got back to him, though Foote did not think it was the kind of response that would bring results. Only when he made contact with Eric Hannel, staff director for a subcommittee of the House Veterans Affairs Committee, did he feel his complaint would be adequately addressed. That's when congressional investigators reporting to Rep. Jeff Miller, R-Fla., launched their inquiry.
From: VA Physician Describes How He Became a Whistleblower
By Elliot Jager From NewsMax Monday, 02 Jun 2014 08:42 AM
The Bureaucratic “Stone Walling” of the VA permeates the entire organization including the vary part of the organization tasked for investigating wrongdoing the VA’s Office of Inspector General. The OIG responding to the 2013 letter from Dr. Sam Foote, failed to find the appointment scheduling problems of Veterans Dieing before they could get an appointment with the Phoenix VA Medical Facility.
The Fix For the VA Management Problem
There is little chance that the sweeping reforms needed to fix the VA will be initiated from within the VA itself because of its systemic management problems. Therefore I recommend that sweeping VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. These major reforms to the VA will not be implemented unless the Veterans Affairs Committees take the lead. See my Article 56. Congressional Veterans Affairs to Tap the GAO to Fix the VA.
The Inspector General Problem
This highlights my observation that all Inspector general offices are not independent but are a part of the Government Bureaucracy to which they are attached and participate in Bureaucratic “Stone Walling”.
Over the years US Government Bureaucracies have developed means for protecting themselves while appearing to be doing the right thing to the public. Currently all major Departments of the Federal Government have their own Inspector General offices to conduct audits and make reports and recommendations to their specific Department Heads. There are 73 federal offices of inspectors general, a significant increase since the statutory creation of the initial 12 offices by the Inspector General Act of 1978. The offices employ special agents (criminal investigators, often armed) and auditors. In addition, federal offices of inspectors general employ forensic auditors, or "audigators," evaluators, inspectors, administrative investigators, and a variety of other specialists. Their activities include the detection and prevention of fraud, waste, abuse, and mismanagement of the government programs and operations within their parent organizations. But these are “Self Investigating Organizations” the primary reason that investigations leading to budget cuts seldom occur. See my Article 52. Establishment of a Government Wide United States Inspector Generals Office.
A problem arises from conflict of interest between a Department's Inspector Generals office and the Department head it reports to, where waste of government funds are concerned and especially where reduced budgets are the result of the Inspector General's recommendations. There appears to be no single organization in the US Federal Government with a free hand for fixing government waste problems leading to reduced budgets and smaller government.
Therefore I am making the following recommendation for the establishment of a United States Inspectors General Office with all Departmental Inspectors Generals reporting directly to and funded by this office and not to their current Department offices. I further recommend that the Government Accountability Office (GAO) be the Home for this organization. The US Inspector General would report directly to the Comptroller General of the GAO. All Department Inspector Generals offices will remain in their current locations within each US Government Department.
The Logic for the US Inspector General reporting directly to the Comptroller General of the GAO is found through the special independent relationship of the GAO to Congress and with oversight of the GAO. This extends Congressional oversight over the Proposed US Inspector Generals Office. The enhanced powers of the GAO provides for a single organization with the express powers for finding and eliminating Government wrongdoing and Government Waste. A much needed investigative tool for Congress.
The need for Congress to have investigative powers should be obvious. For example, consider the case of the NSA, listening to millions of American citizen phone calls and claiming falsely in US Senate hearings that they were not doing this. With Congressional investigative powers through the GAO’s proposed US Office of Inspector General Congress could have claims made by Whistle Blowers investigated anonymously. This could have avoided the massive disclosure of US secrets by Edward Snowden.
A major benefit to the American Taxpayer
The GAO is the most likely independent Agency for eliminating the waste in government. Because since 2010 the GAO has been tasked with identifying duplicated government services such as the 345 page document in March 2013 identifying significant duplicated services in our government. The number of duplicated services makes it impossible for Congress to enact enough laws to fix only but a few of the problems. Therefore the GAO with my recommendation for a US Office of Inspector General within the GAO must be empowered by Congress to fix waste problems not just identify the waste. See my Article 50. The Wounded Warrior Government Waste Elimination Project and Article 51. Legislation for Elimination of Government Waste Leading to Major Reform of the Federal Government
Over the years of the Obama Administration Representative Jeff Miller from Florida has written numerous letters to the President some outlining complaints from Veterans relating to the lack of VA healthcare. The letters no doubt ended up in the hands of the Secretary of Veterans Affairs Eric Shinseki. Mr. Shinseki may have contacted the offending Heads of the VA Medical Facilities. Obviously nothing was done ending in classic “stone walling” of government Bureaucratic leaders. Mr. Shinseki Could have initiated an investigation by the VA’s own Office of Inspector General OIG which could have yielded the similar results to the current findings a year earlier but didn’t. But the OIG had already investigated the problem in 2013 and found nothing, at the request of Dr. Sam Foote the current 2014 VA Scandal Whistle Blower.
Dr. Sam Foote the physician who revealed that patients had died while awaiting appointments at the Phoenix VA Health Care System described how he became a whistleblower.
After his original 2013 complaint (to the VA OIG)was apparently disregarded, Dr. Sam Foote wrote a follow-up letter in February 2014 to the VA Office of the Inspector General demanding that his revelations be acted upon, The Arizona Republic reported.
"Patients are still dying. How can that be three months after I first notified you of the problem?" Foote wrote.
The IG's office had in fact begun looking into his allegations in December 2013 but Foote didn't see the situation improving.
In February 2014, Foote wrote a second time to the inspector general, sending copies to Arizona Sen. John McCain, Arizona Rep. Ann Kirkpatrick, and U.S. Attorney John Leonardo.
Only McCain's office got back to him, though Foote did not think it was the kind of response that would bring results. Only when he made contact with Eric Hannel, staff director for a subcommittee of the House Veterans Affairs Committee, did he feel his complaint would be adequately addressed. That's when congressional investigators reporting to Rep. Jeff Miller, R-Fla., launched their inquiry.
From: VA Physician Describes How He Became a Whistleblower
By Elliot Jager From NewsMax Monday, 02 Jun 2014 08:42 AM
The Bureaucratic “Stone Walling” of the VA permeates the entire organization including the vary part of the organization tasked for investigating wrongdoing the VA’s Office of Inspector General. The OIG responding to the 2013 letter from Dr. Sam Foote, failed to find the appointment scheduling problems of Veterans Dieing before they could get an appointment with the Phoenix VA Medical Facility.
The Fix For the VA Management Problem
There is little chance that the sweeping reforms needed to fix the VA will be initiated from within the VA itself because of its systemic management problems. Therefore I recommend that sweeping VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. These major reforms to the VA will not be implemented unless the Veterans Affairs Committees take the lead. See my Article 56. Congressional Veterans Affairs to Tap the GAO to Fix the VA.
The Inspector General Problem
This highlights my observation that all Inspector general offices are not independent but are a part of the Government Bureaucracy to which they are attached and participate in Bureaucratic “Stone Walling”.
Over the years US Government Bureaucracies have developed means for protecting themselves while appearing to be doing the right thing to the public. Currently all major Departments of the Federal Government have their own Inspector General offices to conduct audits and make reports and recommendations to their specific Department Heads. There are 73 federal offices of inspectors general, a significant increase since the statutory creation of the initial 12 offices by the Inspector General Act of 1978. The offices employ special agents (criminal investigators, often armed) and auditors. In addition, federal offices of inspectors general employ forensic auditors, or "audigators," evaluators, inspectors, administrative investigators, and a variety of other specialists. Their activities include the detection and prevention of fraud, waste, abuse, and mismanagement of the government programs and operations within their parent organizations. But these are “Self Investigating Organizations” the primary reason that investigations leading to budget cuts seldom occur. See my Article 52. Establishment of a Government Wide United States Inspector Generals Office.
A problem arises from conflict of interest between a Department's Inspector Generals office and the Department head it reports to, where waste of government funds are concerned and especially where reduced budgets are the result of the Inspector General's recommendations. There appears to be no single organization in the US Federal Government with a free hand for fixing government waste problems leading to reduced budgets and smaller government.
Therefore I am making the following recommendation for the establishment of a United States Inspectors General Office with all Departmental Inspectors Generals reporting directly to and funded by this office and not to their current Department offices. I further recommend that the Government Accountability Office (GAO) be the Home for this organization. The US Inspector General would report directly to the Comptroller General of the GAO. All Department Inspector Generals offices will remain in their current locations within each US Government Department.
The Logic for the US Inspector General reporting directly to the Comptroller General of the GAO is found through the special independent relationship of the GAO to Congress and with oversight of the GAO. This extends Congressional oversight over the Proposed US Inspector Generals Office. The enhanced powers of the GAO provides for a single organization with the express powers for finding and eliminating Government wrongdoing and Government Waste. A much needed investigative tool for Congress.
The need for Congress to have investigative powers should be obvious. For example, consider the case of the NSA, listening to millions of American citizen phone calls and claiming falsely in US Senate hearings that they were not doing this. With Congressional investigative powers through the GAO’s proposed US Office of Inspector General Congress could have claims made by Whistle Blowers investigated anonymously. This could have avoided the massive disclosure of US secrets by Edward Snowden.
A major benefit to the American Taxpayer
The GAO is the most likely independent Agency for eliminating the waste in government. Because since 2010 the GAO has been tasked with identifying duplicated government services such as the 345 page document in March 2013 identifying significant duplicated services in our government. The number of duplicated services makes it impossible for Congress to enact enough laws to fix only but a few of the problems. Therefore the GAO with my recommendation for a US Office of Inspector General within the GAO must be empowered by Congress to fix waste problems not just identify the waste. See my Article 50. The Wounded Warrior Government Waste Elimination Project and Article 51. Legislation for Elimination of Government Waste Leading to Major Reform of the Federal Government
Thursday, June 12, 2014
Article 63. Open letter to Senate & House VA Committees
June12, 2014
To: Senator Bernie Sanders Senate Veterans Affairs Committee and Representative Jeff Miller House Veterans Affairs Committee
From: Lawrence Rosier Principal Consultant
Subject: Implementation of Reforms in the VA organization
With the recent disclosures from the VA Office of the Inspector General there is evidence of a clear failure of the VA in its mission to serve Veterans in their health care needs. This has been labeled as systemic throughout the VA Health Care bureaucracy. I suspect that this is an unfair label because parts of the system are doing an excellent job in serving Veterans.
In my experience I have found that when sweeping reform is necessary in an organization both public and private. The reforms must be implemented from outside the organization. Reforms implemented from inside can only be cosmetic in nature due to the massive objection of Management. This is especially the case for the VA where “Management” failure is the primary problem. This means that a new Secretary of the Veterans Affairs will have limited success in implementing change and will fail in any attempt to implement sweeping reforms from within the VA. For more on this visit my website Article 61. Why the Federal Government is Unlikely to fix the VA.
I recommend the implementation of my General Reform Model which uses proven successful tools from business to achieve the following.
Step 1. Implementation of Enterprise Lean (developed by Toyota) uses employee Lean Teams to address the problem of converting a negative cultural work environment into a positive environment and focuses employee attention on improving the systems and processes they are working on. The results get the highest effectiveness and efficiency possible with continuous improvement.
Step 2. OAG Analysts collect the Lean Team data: the time to do the improved process, who is working on the process, the equipment need for the process. This data is collected in a spreadsheet and a database. The results of the data when the entire organization is totaled allows for Right Sizing the organization (reducing over staffed areas and identifying under staffed areas needed to meet Appointment Schedules. The totaled data also provides an accurate budget for all work processes other than Management and overhead. For the first time in government we have accurate tools for the management of variable work enabling the balancing of work loads.
Step 3. The conversion of the Bureaucratic organization to a Team Managed organization is really a quite 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 doctors with attending nurses are already in place. Top management of the VA Medical Facility would be selected by the Secretary of Veterans Affairs.
Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management. With this process we know exactly where staffing increases are needed to meet appointment goals. Every effort to retrain employees from overstaffed areas to where they are needed will be done.
Funding to implement the general reform model is minimum because most of the work is done by current employees. The entire implementation is under the direct supervision of myself as an independent Consultant. Training support will be required from professional Enterprise Lean trainers.
The Fix For the VA Management Problem
There is little chance that the sweeping reforms needed to fix the VA will be initiated from within the VA itself because of its systemic management problems. Therefore I recommend that sweeping VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. These major reforms to the VA will not be implemented unless the Veterans Affairs Committees take the lead. See my Article 56. Congressional Veterans Affairs to Tap the GAO to Fix the VA.
I propose that a pilot implementation be made at the Phoenix VA Medical Facility where OIG Analysts will receive on-the-job training in the Implementation of my General Reform Model. The OIG Analysts will have the capability to implement the General Reform Model in other VA Medical Facilities. For more details of the Proposal visit my website: Article 62. Fixing the VA Now with New Disclosures.
The urgency of meeting the health care needs of our Veterans and the VA’s lack of expertise in the area of accurately determining work loads and staffing requirements has the high probability of continued failure of the VA in serving our Veterans.
Since the Federal Government does not recognize proposed Consulting Agreements such as mine legislation will be necessary to make this proposal a reality.
Lawrence Rosier Principal Consultant 573 364 8789 cell 573 578 4716
12143 Cedar Grove Rd. Rolla, Missouri 65401 email: LawrenceRosier4@gmail.com
Educational website: LawrenceRosierConsulting.blogspot.com
June12, 2014
To: Senator Bernie Sanders Senate Veterans Affairs Committee and Representative Jeff Miller House Veterans Affairs Committee
From: Lawrence Rosier Principal Consultant
Subject: Implementation of Reforms in the VA organization
With the recent disclosures from the VA Office of the Inspector General there is evidence of a clear failure of the VA in its mission to serve Veterans in their health care needs. This has been labeled as systemic throughout the VA Health Care bureaucracy. I suspect that this is an unfair label because parts of the system are doing an excellent job in serving Veterans.
In my experience I have found that when sweeping reform is necessary in an organization both public and private. The reforms must be implemented from outside the organization. Reforms implemented from inside can only be cosmetic in nature due to the massive objection of Management. This is especially the case for the VA where “Management” failure is the primary problem. This means that a new Secretary of the Veterans Affairs will have limited success in implementing change and will fail in any attempt to implement sweeping reforms from within the VA. For more on this visit my website Article 61. Why the Federal Government is Unlikely to fix the VA.
I recommend the implementation of my General Reform Model which uses proven successful tools from business to achieve the following.
Step 1. Implementation of Enterprise Lean (developed by Toyota) uses employee Lean Teams to address the problem of converting a negative cultural work environment into a positive environment and focuses employee attention on improving the systems and processes they are working on. The results get the highest effectiveness and efficiency possible with continuous improvement.
Step 2. OAG Analysts collect the Lean Team data: the time to do the improved process, who is working on the process, the equipment need for the process. This data is collected in a spreadsheet and a database. The results of the data when the entire organization is totaled allows for Right Sizing the organization (reducing over staffed areas and identifying under staffed areas needed to meet Appointment Schedules. The totaled data also provides an accurate budget for all work processes other than Management and overhead. For the first time in government we have accurate tools for the management of variable work enabling the balancing of work loads.
Step 3. The conversion of the Bureaucratic organization to a Team Managed organization is really a quite 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 doctors with attending nurses are already in place. Top management of the VA Medical Facility would be selected by the Secretary of Veterans Affairs.
Note that most if not all of the current toxic bureaucratic problems simply disappear with Team Management. With this process we know exactly where staffing increases are needed to meet appointment goals. Every effort to retrain employees from overstaffed areas to where they are needed will be done.
Funding to implement the general reform model is minimum because most of the work is done by current employees. The entire implementation is under the direct supervision of myself as an independent Consultant. Training support will be required from professional Enterprise Lean trainers.
The Fix For the VA Management Problem
There is little chance that the sweeping reforms needed to fix the VA will be initiated from within the VA itself because of its systemic management problems. Therefore I recommend that sweeping VA reforms be implemented by a Congressionally Chartered Veterans Affairs Reform Committee. This Committee should have the power to bring in outside Consultants to implement the needed reforms. These major reforms to the VA will not be implemented unless the Veterans Affairs Committees take the lead. See my Article 56. Congressional Veterans Affairs to Tap the GAO to Fix the VA.
I propose that a pilot implementation be made at the Phoenix VA Medical Facility where OIG Analysts will receive on-the-job training in the Implementation of my General Reform Model. The OIG Analysts will have the capability to implement the General Reform Model in other VA Medical Facilities. For more details of the Proposal visit my website: Article 62. Fixing the VA Now with New Disclosures.
The urgency of meeting the health care needs of our Veterans and the VA’s lack of expertise in the area of accurately determining work loads and staffing requirements has the high probability of continued failure of the VA in serving our Veterans.
Since the Federal Government does not recognize proposed Consulting Agreements such as mine legislation will be necessary to make this proposal a reality.
Lawrence Rosier Principal Consultant 573 364 8789 cell 573 578 4716
12143 Cedar Grove Rd. Rolla, Missouri 65401 email: LawrenceRosier4@gmail.com
Educational website: LawrenceRosierConsulting.blogspot.com
Tuesday, June 10, 2014
Article 62. Fixing the VA Now with New Disclosures
Highlights of the VA Audit Findings Released June 9, 2014
Now with results of audits taken in 731 VA Medical facilities by the Inspector Generals Office throughout the VA the following discoveries were made:
1. 57,000 Veterans waiting 90 days or more for first appointments
2. 64,000 Never had appointments scheduled after registering and requesting medical care
3. Thirteen percent of Schedulers say supervisors asked them to falsify appointment schedules
4. The 14 Day target wait times “not attainable”
From PBS NEWS Hour Gwen Ifill Interview with Ralph Ibson and Dr. Sam Foote.
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.
For example at the Phoenix VA Medical Facility I recommended a mass screening of the 1700 new patients entered into the system with patient 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.
3. VA leaders who have compromised the VA scheduling system should be removed or disciplined before mass hiring of needed staff is initiated.
4. The OIG Analysts and others in the VA can now make estimates of where staffing is needed and begin the hiring process.
5. If a VA Medical facility can not meet staffing requirements for Patient Appointment standards then the following immediate steps to correct the problem may be put in place.
(a). Retrain nursing staff from other over staffed areas if possible to fill some of the requirements. This is beyond the current capability of OIG auditors.
(b). Hirer nursing and doctors as quickly as possible.
(c). Allow Vets with critical needs such as cancer patients to go to private Medical facilities at government expense.
Those areas identified as needing increased staffing at the Phoenix Medical Facility will be addressed first. This is a preliminary start by finding through employee Lean Teams as quickly as possible where exactly increased staffing is needed and the level of staffing that should to be hired to meet appointment standards. The data for increased staffing at the Phoenix Medical Facility can be replicated in all VA facilities.
The Approach:
A. Identify all systems processes affected by increased patient loads from the mass screening and establish an employee Lean Team for each set of processes. Empower Lean Teams (Preceding the long term Enterprise Lean implementation) to come up with the most effective and efficient approach for doing the process. This approach will also identifies the needed equipment and machines to be purchased by the Phoenix VA. In doing this approach the Team will have also determined the time for doing the entire set of processes and the staffing required.
As Principal Consultant I will take the lead in this endeavor with the help of OIG Analysts. Informal training in Lean is provided by myself and the trained OIG Analysts for the employee Lean Teams. To understand how the process works to get the maximum patient throughput see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness.
B. The time for doing the processes developed by the employee Lean Teams will be added to the time for each and every system affected by patient impact in a particular area within the Phoenix VA medical Facility. The required staffing can not only be determined for the Phoenix Medical Facility but the data can be used in all VA medical facilities to arrive at staffing requirements calculated to meet any patient appointment standard.
Implementation of the General Reform Model at all VA Facilities
Part 1. Implement Enterprise Lean in all VA Medical Facilities
I recommend the mass implementation of Enterprise Lean in every VA Medical Facility in the US. The reason for doing this is that it brings a culture change in the VA employee environment converting the current negative toxic bureaucratic environment to a positive productive environment and focuses employee attention on serving Veterans health needs with effectiveness and efficiency. Enterprise Lean is proven industry method developed by Toyota and is the initial step in my General Reform Model.
The General Reform Model: Empowers VA Employees through Lean Teams(Enterprise Lean); determines the actual cost and staffing required to meet appointment standards; changes the current Bureaucratic management to a Team Managed organization; and identifies incompetent management.
This is a low cost solution available now which can yield results in the Phoenix VA Medical Facility within three months with full implementation within six months to a year. The process develops the management data that can be replicated in all VA Medical Facilities.
Implementation of Reforms at the Phoenix VA Medical Facility
The VA Inspector General will also have oversight of this part of the Agreement. The Principal Consultant Lawrence Rosier will manage and have complete control of the implementation of the General Reform Model at the Phoenix Medical Facility separate from investigations conducted by the OIG. He will also train and supervise VA Analysts provided by the Inspector General‘s office according to this Agreement. The Principal Consultant will be able at his discretion to identify and remove incompetent management and reduce redundant management and staff where required at the Phoenix Medical Facility. He will recommend retraining of redundant employees to fill needed positions where possible. The OIG representative at the Phoenix Medical Facility shall have the authority and responsibility to hire new personnel to fill vacancies identified by the Lean Data work Load.
Selection of VA Analysts for Training at the Phoenix Facility
The Principal Consultant will participate with the Inspector General in the selection of VA Analysts to receive training in Lean. Policies and procedures for the analysts will be developed jointly by the VA and the Principal Consultant. Specialized training in Lean for all VA Analysts by a certified Lean instructor is recommended at VA expense.
Training in Specific Technologies Provided by the Principal Consultant:
The development of a Pedagogy for class room instruction of VA Analysts in special technologies by the Principal Consultant. VA Analysts selected for this Agreement will receive an overview of the reform models with classroom training in the following supporting skills and on the job training during the implementation of the reform models.
1. Team Management- by the Principal consultant
2. Enterprise Lean- by the Principal Consultant
3. Variable Function Analysis- by the Principal consultant
4. Time studies (a necessary basic skill)- by the Principal consultant
5. Statistical Sampling- by the Principal consultant
6. Right-Sizing (makes sure all employees have a full time job)- by the Principal consultant
7. Bottoms-up budgeting- by the Principal consultant
8. Staffing- by the Principal consultant
9. Workload Balancing (management of the work flow)- by the Principal consultant
10. Short Interval Scheduling- by the Principal consultant
11. Operation Sequence Charts- by the Principal consultant
12. Productivity Reporting Techniques- by the Principal consultant
13. Effectiveness Evaluation Team training- by the Principal consultant
Goals:
The main Goal is to provide a demonstration of the full implementation of the General Reform Model at the Phoenix VA Hospital fixing Identified problems and getting the highest efficiency and effectiveness possible. The method empowers VA employees in the new organization through Lean Teams involving them in work process decisions and continuous improvement to their jobs.
A second Goal; is to balance the work load primarily through retraining current employees and by hiring needed staffing to meet desired service levels and laying off of redundant employees including management staff.
A third Goal; is the collection of Lean Team management data into a universal database of management standards with the highest effectiveness and efficiency that can be applied in all VA hospitals. The Database is open by approval for continuous improvement.
A fourth Goal; of the implementation is to strengthen the VA Budgeting process by providing transparency of the Functional activities of the new organization to the VA budget leaders enabling them to control budgets through the knowledge of the correct Functional staffing and its budget.
A fifth Goal; the Principal Consultant will be able at his discretion to suggest replacement of incompetent management including adding and reducing staff where required to balance work loads at the Phoenix Medical Facilities. The VA will be responsible for hiring all management and staff.
The General Reform Model at the Phoenix Facility:
The General Reform Model begins with the implementation Enterprise Lean throughout the Phoenix Medical Facility involving nearly all employees tasked to make all functional systems efficient and effective. To get the highest efficiency and effectiveness possible we will use the data developed by the employee Functional Lean Teams. The lean data will be collected and documented by VA Analysts in a spreadsheet program. When all of the data for the entire Agency has been collected it will be used to Right-Size the organization making sure all personnel have a full time job. The employee Lean Team data will also be used for staffing and to develop bottoms-up budgets which identify the actual costs of a systems functions. This is also the data needed to manage an organization’s work by balancing its work load. The lean data will also be used to determine the staffing required to meet patient appointment requirements.
Phase 1. The VA Inspector General's Office will have Oversight of this Agreement for the implementation of the General Reform Model and will provide VA Analysts that have received classroom training to assist in the implementation of the General Reform Model. The VA Analysts will become Facilitators for the implementation of Enterprise Lean as required until it has been implemented in its entirety throughout the Phoenix Medical Facility.
When the implementation of enterprise Lean has been completed the VA Analysts will collect the Lean Data in spreadsheets from all of the Agencies Functions. The Lean data will then be used to Right-Size the Agency (making sure that all employees have a full time Job) followed by staffing and Bottoms-up Budgeting. The VA will maintain the new Bottoms-up Budget databases. The Agency’s budget databases may be stored in cloud storage at little or no cost.
Phase 2. The Training and Organization of Employee Enterprise Lean Teams
The Principal Consultant recommends that an Enterprise Lean Training specialist be brought in from a local University to Kick off the implementation with training seminars for the Agency‘s employees. Lean training should begin immediately by the Agency’s training staff. I suggest that the normal training curriculum for the Agency 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 (VA Analysts) and general employees.
Management Lean Teams
There are two major Lean Team groups, high level Management Lean Teams (which will become Steering Teams) and at-the-work-place employee Functional Lean Teams. Management Lean Teams are organized and lead by members of management. They are tasked to study individual high level systems within the VA and those that interact with other VA facilities mostly document flows. A key element of the High level Lean Teams is their role in management when converting from the bureaucratic organization to the Team Managed organization.
Phase 3. Review of Lean Team Results and Collection of Lean Data
After a period of about two months most Functional Lean Teams, those that were organized and trained by VA Analyst 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. I suggest that some Functional Lean Teams with significant savings present their improved method to management. After the presentation the rolled document is given to a VA Analyst to document the savings from the proposal in a spreadsheet.
Phase 4. Activities of the Principal Consultant
The Principal Consultant will play a key role in being sure that the employee Lean teams are properly trained and in the selection and approach of the high level Lean Teams. The Principal Consultant will insure that the activities of VA Analysts can determine the correct staffing level through Work Measurement and any expenses needed during the process. Some VA Analysts may find the proper staffing for variable processes difficult to determine, the Principal 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 VA Analysts and summarized in a database where all of the Agency’s functional data is stored. The activities of VA Analysts are important and will be followed closely by the Principal Consultant.
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 Value Stream Mapping (VSM) 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 will 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 Principal Consultant will provide on the job training of VA 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. This approach to reform meets all of the VA’s criteria for an Agency: efficient, effective, ethical, equitable and responsive .
1. The VSM (Value Stream Mapping) 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 of the Agency’s functions have been accounted for.
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 the VSM 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.
5. When all of an Agencies 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 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 is 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 we have what I call a Bottoms-up Functional Budget.
8. Next we want to 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. If this is not the case then we have introduced an error more than likely in the number of times that a Function is being performed annually. This should be resolved by reviewing the Lean data in the Agency’s spreadsheet.
9. We can now 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 layoff. 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 now 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 are stored on thumb drives for each Agency 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 VA. This allows availability of the data for all who want to review the actual labor and expense cost of an Agency function including the Agency’s Bottoms-up Budget.
Phase 5. Organization Reform
In the final step of the General Reform Model 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.
This is also the period of time for the reduction of redundant of management and staff. To attain a balanced work load is the primary objective where retraining employees to fill needed vacancies is pursued.
Highlights of the VA Audit Findings Released June 9, 2014
Now with results of audits taken in 731 VA Medical facilities by the Inspector Generals Office throughout the VA the following discoveries were made:
1. 57,000 Veterans waiting 90 days or more for first appointments
2. 64,000 Never had appointments scheduled after registering and requesting medical care
3. Thirteen percent of Schedulers say supervisors asked them to falsify appointment schedules
4. The 14 Day target wait times “not attainable”
From PBS NEWS Hour Gwen Ifill Interview with Ralph Ibson and Dr. Sam Foote.
My Approach to fixing the VA Now
The solution of the VA problems should be seen as a short term solution to immediately serve the Veterans who have waited for appointments and in a long term solution making a final implementation of reforms that changes the culture and makes the entire VA system effective and efficient. This will require Congress to enact Legislation for outside contractors to implement the reforms.The Short Term Approach for all VA Medical Facilities
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.
For example at the Phoenix VA Medical Facility I recommended a mass screening of the 1700 new patients entered into the system with patient 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.
3. VA leaders who have compromised the VA scheduling system should be removed or disciplined before mass hiring of needed staff is initiated.
4. The OIG Analysts and others in the VA can now make estimates of where staffing is needed and begin the hiring process.
5. If a VA Medical facility can not meet staffing requirements for Patient Appointment standards then the following immediate steps to correct the problem may be put in place.
(a). Retrain nursing staff from other over staffed areas if possible to fill some of the requirements. This is beyond the current capability of OIG auditors.
(b). Hirer nursing and doctors as quickly as possible.
(c). Allow Vets with critical needs such as cancer patients to go to private Medical facilities at government expense.
Special Implementation of Lean at Phoenix Facility
The Initial Implementation of employee Lean Teams at the Phoenix Medical Facility is followed by collection of Lean Team data.Those areas identified as needing increased staffing at the Phoenix Medical Facility will be addressed first. This is a preliminary start by finding through employee Lean Teams as quickly as possible where exactly increased staffing is needed and the level of staffing that should to be hired to meet appointment standards. The data for increased staffing at the Phoenix Medical Facility can be replicated in all VA facilities.
The Approach:
A. Identify all systems processes affected by increased patient loads from the mass screening and establish an employee Lean Team for each set of processes. Empower Lean Teams (Preceding the long term Enterprise Lean implementation) to come up with the most effective and efficient approach for doing the process. This approach will also identifies the needed equipment and machines to be purchased by the Phoenix VA. In doing this approach the Team will have also determined the time for doing the entire set of processes and the staffing required.
As Principal Consultant I will take the lead in this endeavor with the help of OIG Analysts. Informal training in Lean is provided by myself and the trained OIG Analysts for the employee Lean Teams. To understand how the process works to get the maximum patient throughput see Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness.
B. The time for doing the processes developed by the employee Lean Teams will be added to the time for each and every system affected by patient impact in a particular area within the Phoenix VA medical Facility. The required staffing can not only be determined for the Phoenix Medical Facility but the data can be used in all VA medical facilities to arrive at staffing requirements calculated to meet any patient appointment standard.
Long Term implementation in all VA Health Care Facilities
The long term approach begins with the full implementation of my General Reform Model in the Phoenix VA Medical Facility. The implementation is primarily a training mission for preparing OIG Analysts to replicate the reforms in the entire VA health care system. It is step by step process beginning with Part 1. the implementation of Enterprise Lean throughout the entire Phoenix Facility and in all other VA Health Care Facilities. After OIG Analysts have been trained at the Phoenix Facility they will be able to implement the remaining Parts of the General Reform Model in all VA Medical Facilities.Implementation of the General Reform Model at all VA Facilities
Part 1. Implement Enterprise Lean in all VA Medical Facilities
I recommend the mass implementation of Enterprise Lean in every VA Medical Facility in the US. The reason for doing this is that it brings a culture change in the VA employee environment converting the current negative toxic bureaucratic environment to a positive productive environment and focuses employee attention on serving Veterans health needs with effectiveness and efficiency. Enterprise Lean is proven industry method developed by Toyota and is the initial step in my General Reform Model.
The General Reform Model: Empowers VA Employees through Lean Teams(Enterprise Lean); determines the actual cost and staffing required to meet appointment standards; changes the current Bureaucratic management to a Team Managed organization; and identifies incompetent management.
This is a low cost solution available now which can yield results in the Phoenix VA Medical Facility within three months with full implementation within six months to a year. The process develops the management data that can be replicated in all VA Medical Facilities.
Implementation of Reforms at the Phoenix VA Medical Facility
The VA Inspector General will also have oversight of this part of the Agreement. The Principal Consultant Lawrence Rosier will manage and have complete control of the implementation of the General Reform Model at the Phoenix Medical Facility separate from investigations conducted by the OIG. He will also train and supervise VA Analysts provided by the Inspector General‘s office according to this Agreement. The Principal Consultant will be able at his discretion to identify and remove incompetent management and reduce redundant management and staff where required at the Phoenix Medical Facility. He will recommend retraining of redundant employees to fill needed positions where possible. The OIG representative at the Phoenix Medical Facility shall have the authority and responsibility to hire new personnel to fill vacancies identified by the Lean Data work Load.
Selection of VA Analysts for Training at the Phoenix Facility
The Principal Consultant will participate with the Inspector General in the selection of VA Analysts to receive training in Lean. Policies and procedures for the analysts will be developed jointly by the VA and the Principal Consultant. Specialized training in Lean for all VA Analysts by a certified Lean instructor is recommended at VA expense.
Training in Specific Technologies Provided by the Principal Consultant:
The development of a Pedagogy for class room instruction of VA Analysts in special technologies by the Principal Consultant. VA Analysts selected for this Agreement will receive an overview of the reform models with classroom training in the following supporting skills and on the job training during the implementation of the reform models.
1. Team Management- by the Principal consultant
2. Enterprise Lean- by the Principal Consultant
3. Variable Function Analysis- by the Principal consultant
4. Time studies (a necessary basic skill)- by the Principal consultant
5. Statistical Sampling- by the Principal consultant
6. Right-Sizing (makes sure all employees have a full time job)- by the Principal consultant
7. Bottoms-up budgeting- by the Principal consultant
8. Staffing- by the Principal consultant
9. Workload Balancing (management of the work flow)- by the Principal consultant
10. Short Interval Scheduling- by the Principal consultant
11. Operation Sequence Charts- by the Principal consultant
12. Productivity Reporting Techniques- by the Principal consultant
13. Effectiveness Evaluation Team training- by the Principal consultant
Goals:
The main Goal is to provide a demonstration of the full implementation of the General Reform Model at the Phoenix VA Hospital fixing Identified problems and getting the highest efficiency and effectiveness possible. The method empowers VA employees in the new organization through Lean Teams involving them in work process decisions and continuous improvement to their jobs.
A second Goal; is to balance the work load primarily through retraining current employees and by hiring needed staffing to meet desired service levels and laying off of redundant employees including management staff.
A third Goal; is the collection of Lean Team management data into a universal database of management standards with the highest effectiveness and efficiency that can be applied in all VA hospitals. The Database is open by approval for continuous improvement.
A fourth Goal; of the implementation is to strengthen the VA Budgeting process by providing transparency of the Functional activities of the new organization to the VA budget leaders enabling them to control budgets through the knowledge of the correct Functional staffing and its budget.
A fifth Goal; the Principal Consultant will be able at his discretion to suggest replacement of incompetent management including adding and reducing staff where required to balance work loads at the Phoenix Medical Facilities. The VA will be responsible for hiring all management and staff.
The General Reform Model at the Phoenix Facility:
The General Reform Model begins with the implementation Enterprise Lean throughout the Phoenix Medical Facility involving nearly all employees tasked to make all functional systems efficient and effective. To get the highest efficiency and effectiveness possible we will use the data developed by the employee Functional Lean Teams. The lean data will be collected and documented by VA Analysts in a spreadsheet program. When all of the data for the entire Agency has been collected it will be used to Right-Size the organization making sure all personnel have a full time job. The employee Lean Team data will also be used for staffing and to develop bottoms-up budgets which identify the actual costs of a systems functions. This is also the data needed to manage an organization’s work by balancing its work load. The lean data will also be used to determine the staffing required to meet patient appointment requirements.
Phase 1. The VA Inspector General's Office will have Oversight of this Agreement for the implementation of the General Reform Model and will provide VA Analysts that have received classroom training to assist in the implementation of the General Reform Model. The VA Analysts will become Facilitators for the implementation of Enterprise Lean as required until it has been implemented in its entirety throughout the Phoenix Medical Facility.
When the implementation of enterprise Lean has been completed the VA Analysts will collect the Lean Data in spreadsheets from all of the Agencies Functions. The Lean data will then be used to Right-Size the Agency (making sure that all employees have a full time Job) followed by staffing and Bottoms-up Budgeting. The VA will maintain the new Bottoms-up Budget databases. The Agency’s budget databases may be stored in cloud storage at little or no cost.
Phase 2. The Training and Organization of Employee Enterprise Lean Teams
The Principal Consultant recommends that an Enterprise Lean Training specialist be brought in from a local University to Kick off the implementation with training seminars for the Agency‘s employees. Lean training should begin immediately by the Agency’s training staff. I suggest that the normal training curriculum for the Agency 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 (VA Analysts) and general employees.
Management Lean Teams
There are two major Lean Team groups, high level Management Lean Teams (which will become Steering Teams) and at-the-work-place employee Functional Lean Teams. Management Lean Teams are organized and lead by members of management. They are tasked to study individual high level systems within the VA and those that interact with other VA facilities mostly document flows. A key element of the High level Lean Teams is their role in management when converting from the bureaucratic organization to the Team Managed organization.
Phase 3. Review of Lean Team Results and Collection of Lean Data
After a period of about two months most Functional Lean Teams, those that were organized and trained by VA Analyst 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. I suggest that some Functional Lean Teams with significant savings present their improved method to management. After the presentation the rolled document is given to a VA Analyst to document the savings from the proposal in a spreadsheet.
Phase 4. Activities of the Principal Consultant
The Principal Consultant will play a key role in being sure that the employee Lean teams are properly trained and in the selection and approach of the high level Lean Teams. The Principal Consultant will insure that the activities of VA Analysts can determine the correct staffing level through Work Measurement and any expenses needed during the process. Some VA Analysts may find the proper staffing for variable processes difficult to determine, the Principal 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 VA Analysts and summarized in a database where all of the Agency’s functional data is stored. The activities of VA Analysts are important and will be followed closely by the Principal Consultant.
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 Value Stream Mapping (VSM) 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 will 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 Principal Consultant will provide on the job training of VA 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. This approach to reform meets all of the VA’s criteria for an Agency: efficient, effective, ethical, equitable and responsive .
1. The VSM (Value Stream Mapping) 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 of the Agency’s functions have been accounted for.
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 the VSM 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.
5. When all of an Agencies 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 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 is 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 we have what I call a Bottoms-up Functional Budget.
8. Next we want to 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. If this is not the case then we have introduced an error more than likely in the number of times that a Function is being performed annually. This should be resolved by reviewing the Lean data in the Agency’s spreadsheet.
9. We can now 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 layoff. 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 now 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 are stored on thumb drives for each Agency 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 VA. This allows availability of the data for all who want to review the actual labor and expense cost of an Agency function including the Agency’s Bottoms-up Budget.
Phase 5. Organization Reform
In the final step of the General Reform Model 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.
This is also the period of time for the reduction of redundant of management and staff. To attain a balanced work load is the primary objective where retraining employees to fill needed vacancies is pursued.
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