Article 121. Enterprise Lean a Universal Tool and the Daily Plan

Enterprise Lean a Universal Tool and the Daily Plan

Lawrence Rosier Consulting
12143 Cedar Grove Rd. Rolla, Missouri 65401
573 426 2997

My two Part Reform  can bring significant improvement in nearly all working environments: Industry, Health Care, Research Labs, State and Federal Governments.   This Article concentrates on Enterprise Lean as the First Part of the reform.  The second part of the reform the development of the Daily Plan follows.

Enterprise Lean implements Lean Teams (developed by Toyota) to make continuous improvements to work processes and can be implemented almost entirely by existing  personnel. The Second Part develops a highly efficient Daily Plan for each repeating process using the Lean Team and a consultant.  

Part 1. Implementation of Enterprise Lean

The Concept of Enterprise Lean is a universal cure for what ever ails an organization.  The difference is in the rules set for the organization of the teams as you will see in the following examples:
1. Industry uses the Teams mostly on assembly lines for products.  The Teams solve production problems related to their work. Lean Teams can also work in the office.

2. Government Bureaucracies such as the massive Veterans Administration can be brought under Top Management control using Lean Teams.  The US Veterans Administration is known to be a highly toxic bureaucratic organization that the government has not been able to control. 

The implementation of Lean Teams by Office of  Inspector General (OIG)  Analysts provides a direct connection of the Lean Team to the Top Management OIG personnel.  This provides a back door connection to the VA management for solving problems at the work place (such as bullying and theft).  Lean Teams organized in this manner virtually eliminates many of the problems related to bureaucracies. This approach requires that the Teams select their leaders through secret ballot.  See Articles 92, 106 and 119.

3. Health Care can be greatly improved using Lean Teams because of the complicated environment of Patients and Procedures the teams can develop unique methods of solving problems.  The organization of the lean teams can be more flexible such as senior team members may be selected as the team leader.   See Articles 42 and 120.

4. Lean teams also work with professionals such as Research labs and other Scientific organizations.  Here again the Team organization is more flexible in the selection of the Team Leader.

Part 2. The Development of the Daily Plan

Most state government organizations: Washington State, Minnesota and Iowa only implement the Enterprise Lean portion of my Two Part Reform and as such overlook $millions in savings from the reorganization of repeating operations into Daily Plans.  ALL repeating operations can be reorganized into Daily Plans.

Lean Teams  provide the means for continuous improvement in all operations and are the best way to for them to be involved in the design of the Daily Plan for repeating operations.

The basic concept is to separate an entity's workforce into two main areas: Repeating operations and non-repeating operations.  Repeating operations are reorganized to get maximum efficiency which I call the Daily Plan. Non-Repeating operations hold the expertise for solving routine and non-routine operation problems.  They also provide backup services for the Repeating operations making sure that nothing interferes with their daily operations.

The best way to do this is to provide Consulting assistance to the Lean Teams of the Repeating operations.  The Lean Team provides the knowledge of how the current process works and working with the consultant the most efficient method can be made into the Daily Plan.  The expertise of the consultant is in being able to balance the work loads of the Team members so that no team Member waits on another to do his job. The Consultant breaks down the jobs and reapportions the jobs to each employee making them equal in time getting the highest efficiency possible.  The average savings is estimated to be a significant 60% of the existing unplanned work.  See Articles 110, 119 and 120.

Article 120. Approach to a Two Part Health Care Reform

Approach to a Two Part Health Care Reform

Lawrence Rosier Consulting
12143 Cedar Grove Rd. Rolla, Missouri 65401
573 426 2997

My two Part Health Care Reform of hospitals can bring significant improvement in operations as well as an average of 60% savings in Routine Procedures.  The First Part of the reform implements Lean Teams (developed by Toyota) to make continuous improvements to Procedures and can be implemented almost entirely by existing Hospital personnel. The Second Part develops a highly efficient Daily Plan for each routine Procedure (requires a consultant).  Once the Daily Plan is developed it can be used in other hospitals. I have included a List of suggested Routine Procedures that can be used in Outpatient Clinics attached to a Hospital.

Part 1. Implementation of Lean Teams:

Consultant starts by working with clients Training Personnel to do the following:
1. Develop enterprise wide introduction plan
    Presentations to selected groups
2.  Determine the number of Facilitators needed
    Each Facilitator meets with about 10 Lean Teams
    Helping them get started: election of Team Leader (by secret
    Ballot) and how to work together to implement improvements. 

Part 2. Development of the Daily Plan

Consultant works with Lean Teams whose processes repeat on a daily basis in Health Care.

Daily Plan for Healthcare:
1. Make a list of all possible Routine Procedures.
2. Determine the number of Patients treated at this hospital location for each routine Procedure.
3. Estimate the number of Patients treated in the metro area for each routine Procedure. This determines the number of patients available or backlog.
4. Select first Procedure based on Highest number of Patients and the shortest time for a Surgeon to do the Procedure. Example: With Procedures requiring an hour of surgery time only 7 patients a day can be done.  While for Procedures requiring only a few minutes as many as 20  can be done per Day.  See Example Cataract Surgery with 90% Savings. Lawrence Rosier Consulting Blog Article 110.

The Consultant begins the design of the Daily Plan working with the selected Procedure Lean Team To do the following:
1. Make a cell phone video of the current operation of the selected procedure. 
2. The Number of Patients per day is determined by the length of time for the Surgeon to do the Procedure.
3. Balance the Patient Prep and Recovery time by nurses to the surgeon’s time allowing the Surgeon to do one surgery after another for the day. Review Cell phone video make sure that work load is distributed evenly among nurses so that no one is waiting on others to complete their jobs.
4. Document the Daily Plan.  After completion the Daily Plan can be implemented by other Lean Teams in other hospital locations.

Application to Metropolitan Hospitals

A state’s metro areas offers the biggest savings in Medicaid and in Medicare with a higher number of Patients the routine procedure Clinics can operate on a continuous daily basis.  If the number of patients in the backlog of a clinic is more than the clinic can manage a second duplicated clinic can be added to reduce the Patient backlog.

Application to Hospitals in Smaller Towns

Where Patient Backlog is not enough to support each Routine Clinic:
A Lean Team may have to develop as many as three routine Procedure Daily Plans and switch between them to maintain Patient backlog.  The Lean Team can do a particular routine Procedure for two weeks then switch to another Procedure for a week and then to the third Procedure.

State wide Health Care in Rural Areas

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

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

Possible List of Routine Patient Testing and Procedures

Appendectomy
Cholecystectomy  (surgery to remove the gallbladder)
Dilation and Curettage (also called D & C) is a minor operation in which the cervix is dilated (expanded) so that the cervical canal and uterine lining can be scraped.
Hemorrhoidectomy (surgical removal of hemorrhoids)
Hysterectomy  (surgical removal of a woman's uterus)
Hysteroscopy (surgical procedure used to help diagnose and treat many uterine disorders)
Inguinal hernia repairs (protrusions of part of the intestine into the muscles of the groin.)
Prostatectomy (surgical removal of all or part of the prostate gland)
Tonsillectomy (surgical removal of one or both tonsils)


Common Surgical Procedures
According to the American Medical Association and the American College of Surgeons, some of the most common surgical operations performed in the United States include the above.
Excluded from this list is all cancer procedures considered to be too life threatening.
Excluded Heart surgery, Coronary artery bypass (bypass surgery) considered to be too life threatening.

Also excluded are procedures that vary significantly in time with different patients. Such as Releasing of peritoneal adhessions. (The peritoneum is a two-layered membrane that lines the wall of the abdominal cavity and covers abdominal organs. Sometimes, organs begin to adhere to the peritoneum, requiring surgery to detach them)

Article 119. Simple two Part Reform can Achieve Massive Improvement in the VA

Simple two Part reform can Achieve Massive Improvement in the Veterans Administration.  The two part reform can be implemented almost entirely by existing VA personnel. The reform increases Management control, solves most of the VA's personnel problems and adds efficiency in Part Two saving $billions. I am available to answer any questions you may have about the reform call: LawrenceRosierConsulting (573) 426 2997.

Part 1. Continuous Improvement Teams

A simple two part reform can achieve a massive improvement in the Veterans Administration.  The first part is the implementation of Continuous Improvement Teams (CI Teams) throughout the VA in its hospitals and its offices.

History: CI Teams originally known as Lean Teams (aka Enterprise Lean) were first implemented by Toyota and adopted by nearly all Automotive MFG companies.  Now it has been implemented in Washington State, Minnesota and Iowa state Governments. It has also been implemented at the Cleveland Clinic.

Reason: The Veterans Administration is a large bureaucracy that is not easily managed by the Secretary of the VA especially for appointments from outside the VA by Presidents.  By implementing CI Teams throughout the VA the Mission for Continuous Improvement is given priority and a physical presence within the organization. Each team has a direct connection to VA's DC office where difficult problems can be solved.  Each Team is comprised of a working group both in hospital procedures and in VA offices. Team Leaders are elected by secret ballot and meet once a week or once a month to review and implement improvements to their work processes.

Part 2. The Daily Plan

The Second part of the reform implements what I call a Daily Plan by each CI Team whose basic processes do not change and are the same from day to day.  The CI Team with the help of a trained consultant creates a standard Daily Plan which can be duplicated in all VA areas where the same process is being done.

Development: Nearly all hospital Procedures undergo Planning and identification of which individual is going to do what job during the procedure.  The Daily Plan Standardizes this process and organizes it such a way that balances out each job such that jobs begin and end at the same time.  Thus no employee has to wait on another employee to finish his job. To achieve this the employee who has too much work will give some of his work to another employee that has less work and balance the operation.  The result is a very highly efficient operation that when operated continuously with a higher volume of patients in a hospital environment can increase the average efficiency by 60%.

Summary: This simple implementation throughout the VA will attain maximum efficiency.

Suggestions for implementing Reforms in the VA

 

Overview of Approach to Reforming Veterans Affairs.

The standard Government and Industry approach which I have developed can be used for implementing Reforms in the VA.  This approach first implements Continuous Improvement Teams (Enterprise Lean) facilitated by OIG Analysts.  As a part of Enterprise Lean's basic function of continuous improvement, Daily Plans are produced by the CI Teams doing repeated processes..  This activity is aided by OIG Analysts acting as Facilitators.

Reorganizing for the Implementation of Reforms

This approach taps into special expertise of the VA OIG organization retraining OIG Analysts to be the primary implementers of the VA reform process.  Using Government Personnel (OIG Analysts) instead of Outside Consultants, enhances the expertise of the OIG organization and will save $millions.  This approach will leave an ongoing OIG organization to maintain government management efficiency. Ref: Article 88. Lawrence Rosier Consulting Blog.

Pilot implementation 
Veterans Affairs Hospitals were selected as a likely pilot for starting the implementations of reforms. This will give a boost in helping Veterans needing healthcare and speedup Patient care through implementation of special patient throughput techniques.  Ref: Article 100. Lawrence Rosier Consulting Blog.

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

The Phases of the Reform Process

Implementation of Continuous Improvement Teams
The first phase is the implementation of Continuous improvement Teams. I suggest that OIG Analysts be trained as facilitators to guide each CI Team through the election of a leader process.

Implementation of the Daily Plan

OIG analysts will work with the CI Teams to get the highest efficiency and effectiveness possible in the Daily Plan.  OIG Analysts can use the data developed from the Daily Plans to develop bottoms-up budgets which identify the actual costs of all needed systems.  This is also the data needed to manage the organization’s work load and in the determination of staffing needed. Ref: Article 96. Lawrence Rosier Consulting Blog

A suggested simple approach is orient OIG Analysts as facilitators and immediately implement the selected VA hospital into CI Teams. The facilitators will then lead each team into building its Daily Plan.

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 OIG Analysts acting as Facilitators, should have their Daily Plans completed.  I suggest that some Functional Lean Teams with significant savings present their improved method to upper management.   The OIG Analyst will study the new method to document savings

Activities of the Reform Consultant

The Consultant will play a key role in being sure that the employee CI Teams are properly trained.  The Consultant will insure that the activities of OIG Analysts will be able to facilitate the implementation of CI Teams and will also aid in the development of daily plans.


Attaining a Balanced Work Flow

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.

The Maximum Patient Throughput Method

The first activity is to determine the actual backlog of patients waiting for each specific hospital Procedure and select the most critical needed.

Individual employee Lean Teams (including Nurses) meet to determine the most effective way to do their Procedure in a Daily Plan.  The objective is to find the most effective and efficient way of doing the Procedure in a balanced work load environment. The Daily Plan is built around the Doctor or surgeon’s time in doing the Procedure for each patient.  This time determines how many patients can be done in a day.  The design of the Daily Plan may be repeated with another Doctor or surgeon to bring down the backlog.  

The Daily Plan arranges 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.  Support operations personnel are used to fill in when Team members are on vacation or absent.

Accurate Cost Data

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

Three levels of Throughput- Current, Capable and Required 

When we examine Patient 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 bring down high Patient backlog levels.  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.

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 VA Reporting 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. Ref: Articles 54 & 55 Lawrence Rosier Consulting Blog.

References:

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

Article 118. Investigation highlights potential dangers of Surgery Centers

CBS "Investigation highlights potential dangers of surgery centers in the U.S." CBS News March 2, 2018.

A joint investigation by USA Today Network and Kaiser Health News highlights the dangerous conditions that have apparently led to many deaths in facilities known as surgery centers across the U.S. The report takes an in-depth look at operations performed at these non-hospital facilities and found more than 260 patients have died after surgery center procedures since 2013.  

The deaths occurred largely because the procedure wasn't done at a hospital, but at one of more than 5,600 surgery centers across the U.S. There are now more surgery centers, which focus on routine, same-day operations, than hospitals. The industry says this can make for cheaper, faster and more convenient service than in a hospital, but when something goes wrong during surgery, the hospital may be the safer option.

 It appears that others mostly individual Doctors have discovered, as I have, that General Hospitals are low patient volume/ high cost and that when routine procedures are moved to individual Surgery Centers the procedures become high patient volume/ low cost.  The problem found by this Investigation was that medical standards were not maintained and many of the Surgery Centers only objective was to make as much money as possible.

What’s happening here is: Insurance Companies, Medicare and Medicaid reimburse at the General Hospital rate leaving Surgery Centers to receive huge bonuses for each patient processed.

I recommend that all General Hospitals in metro areas reorganize creating routine specialized Surgery Centers (I have identified about 15) within the Hospital grounds with access to the Hospitals ER. 

This will reduce the cost of Health Care for: insurance Companies, Medicare and Medicaid. Unfortunately in rural areas where patient volume is low General hospitals will continue to provide services but at the current high rate. 

A related problem is that in metro areas with the conversion to internal independent routine Surgery Centers within each Hospital fewer Hospitals will be needed.

Article 117. The Amazon, JPMorgan Chase, Berkshire Hathaway Consortium

The Amazon, JPMorgan Chase, Berkshire Hathaway Consortium

Three corporate giants: Amazon, Berkshire Hathaway and JP Morgan Chase have announced that they would form an independent health care company for their employees in the United States. This announcement signaled a possible massive change in the Nations Health Care causing Health Care stocks to plummet in the stock market. 

Our US fraud based private for-profit Health Care costs double that of Europe’s Government Health Care systems.  The Affordable Health Care Act provided health care for all but did almost nothing to reduce costs.  US Health Care is anything but affordable.

The Health Care Lobby in Congress has prevented reform in the nation’s health care.  A few years ago Lobbyists successfully got Congress to allow TV advertisements for Prescription Drugs now more money is spent by some drug companies on TV advertisements than on research boosting the cost of drugs.

State Governments are overwhelmed with healthcare overruns especially in Medicaid.  Now with US health care in near total disarray Corporate Giants are stepping in to provide health care for their employees and retirees.  They may then form alliances with State Governments to provide much needed change in health care.

My Health Care Suggestions have been adopted by the Consortium
General hospitals do nearly all Procedures with low patient volume and at high cost. The hospital design I am proposing is exactly the opposite: wholly independent routine Procedures are done in specialized Clinics with high patient volume at the lowest cost.  The Corporate Consortium can take advantage of this approach to reduce Health care costs for routine Procedures by as much as 60%.  Cataract surgery has been shown to reduce costs by 90%. Ref. Article 110.

Routine Procedure Clinic are completely independent and have their own staff and facilities.  Should the patient Volume be higher than that of the design the procedure can be redesigned or it can be duplicated with added staff and facilities. I have Identified about 15 possible clinics. Ref: Article 111.


Lean Teams develop Daily Plans
Enterprise Lean Teams developed by Toyota is currently being used in: Washington State, Iowa and Minnesota governments to make continuous improvements in State Government Functions. It has also been successfully implemented in the Cleveland Clinic well known for its health care.  The process consists of working teams that meet regularly to review and discuss how the work they are doing can be improved upon. Employees were found to become excited about their jobs with their involvement providing continuous innovative solutions to work problems.

For each Lean Team I have added the task of developing a Daily Plan for their Procedure.  Daily Plans are not easily constructed and will need help from trained professionals.

The Routine Procedure Clinics work Best with the following Criteria:

• Repeatable Processes (relatively routine, process does not vary)

• Sufficient Backlog for Continuous Operation  

• Daily Plan efficiently designed by each Lean Team

• Balanced Operations (no one waits for others to do their jobs)

In the future States may pursue the development of a State Health Care Delivery system as an alternative to the current private health care delivery system that is mainly driven by fraud.  The new system will require those who can, will pay for their own health care or provide their own insurance. The hope is that Corporate involvement in US Health Care reforms will migrate to a State government run non-profit system over the next 10 years similar to Europe but with better management controls.   $billions can be saved by eliminating waste in our Health care system.

The State of Missouri is following this recommendation when fully implemented will save the state $2 billion annually. 

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

Article 116. Example of a Birthing Clinic

Example of a Birthing Clinic

This an example of a Birthing Clinic designed for efficiency it is a departure from other routine procedure clinics in that the patient is not free to chose when a baby is to be delivered in the Natural Birthing unit but in a Cesarean birth the time of the delivery can be planned.
The clinic is partitioned into the following completely separate Units:
1. Prenatal Care Unit (where patients and fetus are assessed before birth).
2. Natural Birthing Delivery Unit (most births).
3. Cesarean Delivery Unit
4. Natal Care Unit
5. Urgent Care Unit (for Fetal Delivery assistance and emergencies)

The prenatal Care Unit is where the delivery method is assessed Natural birth or Cesarean.  Special fetal problems are noted to be dealt with at birth.

The Natural Birth Delivery Unit has extra pre-staged delivery rooms for mothers awaiting birth.  Mothers awaiting delivery become a part of a triage where those requiring immediate delivery are delivered first. The Number of pre-staged delivery rooms is determined from historical data. The Natural delivery Unit will at times have extra unused facilities and staff but will be more efficient than most General Hospital births.

The Cesarean delivery Unit is largely a completely separate unit but Cesarean deliveries can be halted if doctors in the Natural Birth Unit become over-run. With an efficient Daily Plan Cesarean births can be done with considerable savings.

The Natal care unit would have the same capability as a General Hospital.

The Urgent Care Unit is available for to assist in difficult and multiple births (This is a small team with special skills).

A General Hospital may be converted to Birthing Clinic saving considerable investment costs over a new facility.

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

Article 115. Focusing on Reduction of Medicaid Health Care Costs

Focusing on Reduction of Medicaid Health Care Costs

The reduction of State Medicaid health care costs is only a fraction of the total Medicaid costs. Total Medicaid costs for Missouri $9.9 billion of this the conversion of General Hospitals from low patient volume to high patient volume specialized clinics is expected to save only $1billion. 

The Medicaid savings is contingent on:
1. The state if not owning the new Clinics must at least manage the clinics. 
2.  All Medicaid Patients will be required to use the Clinics except in rural areas.
3.  Clinics must be located in populated areas to maintain sustained patient volume.
4.  Medicaid and Medicare Patients may use the Clinics to get the Patient Volume needed.

I have suggested that the State start with just one General Hospital in a metro area.  This is a good way to prove the process but I now want to introduce a second alternative which doubles up on the development of Daily Plans and the necessary facility reorganization. This is done to shorten the time for the State to start gathering savings.

When observing a metro area for implementation of this approach I would look at three or four General Hospitals all centrally located near where most Medicaid patients live.  The Idea is to have a plan for converting these hospitals into specialized Clinics.

The Plan:
1. Implement Continuous Improvement Teams in each General Hospital this will take a month before the teams understand the process.  The CI Teams are required to aid in designing the Daily Plans while working with the Consultant.  The State will provide nursing students to work with the consultant and be trained by him to continue the implementation in other metro areas. The students will act as Facilitators when installing the CI Teams and follow the development of the Daily Plans and the facility reorganization.

2. One year of data will be collected from each hospital showing all procedures done at the hospital.  The number of routine procedures done at each hospital will be used to determine where to best locate the routine Clinics. The assumption is that a combination of in-patient and out-patient procedures will be done in each of the selected hospitals.

3. The Consultant and the CI Team (along with trainees) will develop the Daily Plan for each of the routine areas.

4.  The Consultant will have the hospital facility plans for each hospital sent to his office.  By placing the Daily plans as they are completed over possible hospital locations the process will help to keep the cost of reorganization down with as few changes as possible.  At this point an Architect engaged by the state will complete the reorganization construction plan (adding rooms and extra surgery facilities).

5.  Three or four completely independent Clinics will be located in each of the original hospitals. Each Clinic will have its own waiting room and other facilities.  

6.  Procedures such as Cataract Surgery will need to be done in an Eye Clinic.   A birthing hospital is not included in the Clinic concept because the patients are not free to chose when the Procedure is to be done.  However there is much savings to gained by designing a separate Birthing hospital.

 7.  After the Daily Plans have been completed and trainees are available hospital facilities in other metro areas may be reviewed and reorganization plans made.

This approach will speedup the process for implementing the new Clinics in the entire State.  When the Federal Government recognizes the savings involved nearly all hospitals will be converted to the new Clinic plan.  The change will also be demanded by Health Insurance Companies.

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

Article114. Designing Daily Plans & Hospital Reorganization

Designing Daily Plans & Hospital Reorganization 

How to get started Designing Daily Plans and Hospital reorganizations. This is a quick look at the decisions to be made and how they can be implemented.

Selecting the Routine Procedure to Start With
1. In Article 113. I have listed 15 possible Procedures that appear to fit the category of being routine and relatively safe.  I would select an outpatient Procedure first because it is less expensive when the its time to reorganize the hospital facility.

2. The Enterprise Lean Team (aka Continuous Improvement Team) must be in place and a part of the Procedure team selected and meet at least once a week. More meetings will be required as the design of the Daily Plan progresses.

3.  Introduce the Lean Team (CI Team) to the concept of the Daily Plan and the reorganization of facilities to support the Daily Plan. Objective to change a low patient volume/high cost Procedure into a high patient volume / low cost Procedure.

4.  The selected Procedure is an entirely separate Procedure from all other Procedures in a hospital environment completely staffed with its own facilities. The reason for not having shared facilities is that the Scheduling would destroy the balanced operations of the selected Procedure.

5. The most basic element driving the design is Patient volume.  An entire metropolitan area may be available for certain procedures due to the low cost of the Procedure.  This will drive the design of the daily plan to handle more volume and will also increase the facilities required. Early on a Patient Volume survey should be conducted for each of the procedures in the metro area identifying overall patient volume and those expected to use the new facility.

For lower patient volume two Completely separate Procedures may be designed using the same facility.  The staff would be trained to do two separate Procedures with two separate Daily Plans alternating between them to keep patient volume stable.  



What’s needed to build a Daily Plan?
1.  Precise times for all the processes done must be known.  To these times a increase of 25% is added as a protection from unintended delays. Remember the objective is to work smarter not harder savings come from the continuous operation of the process not from the speed of the process.

2.  First take the time of the doctor or surgeons process as a base time identifying how many patient operations can be done in one day. Then identify all processes leading up to the surgery and those following the surgery.  For example if a nurse requires twice as much time as the surgery process then two nurses will be required each preparing a different patient in a different room (two Rooms Required). The resulting Daily Plan will balance all the processes allowing no one to wait on another employee.
Patient backlog means that the staff does not wait on patients.  If work times can not be balanced then the extra time a staff person has can be designated as “Preparation Time”.

3.  With a sufficient backlog of patients the Daily Plan becomes a smooth running operation virtually eliminating Management intervention for budgeting and Scheduling.  Supplies are ordered automatically.


 Hospital Reorganization
1.  If a general hospital is to be reorganized planning for Hospital reorganization should not be under taken until all the Procedures using the hospital facility are known and least most of them have their Daily Plans completed.

2.  If several Procedures are using the same hospital facility then the hospital reorganization will encompass all of the Procedures supporting their Daily plans.

3.  If the Procedures can be separated into separate clinic facilities then the reorganization process becomes much simpler.  Ref: Cataract Surgery Clinic proposed in Article 110 and Article 111. Designing a High Patient Volume Low Cost Hospital.

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

Article 113. Five Year Plan for Missouri Health Care System

Five Year Plan for Missouri Health Care System (MHCS) 

Developed by Lawrence Rosier Consulting on November 27, 2017.  Ref: LawrenceRosierConsulting Blog Articles 112, 111, 109, 107.

This plan embodies far reaching strategic thinking that overturns false ideas about Health Care and reduces the cost of Health Care in Missouri significantly. Because of the movement from Private for-profit Health care system to not for-profit Missouri government managed hospitals a five year adjustment period is needed.  This is an important backup plan that brings Missouri into solvency in health care regardless of what the Federal Government does in a National Health Care plan.

Facts about the current health care system, it is a growth industry that appears to have no limits in cost projections.  US Private health care costs double that of European government based health care, neither have the efficient approach embodied in this Plan.  Converting from a Private profit based to a not for-profit or government based health care system is expected to reduce Health care costs by 50% due to the reduction in fraud and other efficiency reasons but with increased efficiency I have estimated a conservative 60% reduction in overall health care costs in the new high volume/low cost specialized health care system.

Medicaid
Medicaid costs in Missouri is 9.9 $billion.  Only about 10% or $1billion of this cost can be reduced by the efficiency in hospital operations presented in this Plan. Much of Medicaid costs are in long term care where some efficiencies may be implemented by Lean Teams.

Medicare
Medicare however presents a much different view because funding by the Federal Government would go directly to the state of Missouri providing the funding needed to convert private hospitals acquired by the State in its conversion to the Missouri Health Care System (MHCS).  An agreement with the Federal government to pay the full amount of Medicare costs to the State until the new efficient system can be developed may be required or the Federal Government might chose funding Missouri’s MHCS.  Ref: the example Cataract Surgery Clinic with a 90% decrease in costs at LawrenceRosierConsulting Blog Articles 110,109. 

Missouri’s Health Care System (MHCS) Open to all Missourians
As the system grows in the last years of this plan the Missouri Health Care System would be available to all Missourians, open to those with or without insurance.   MHCS expected costs to be 20% to 50% less than Private Hospitals.  Insurance companies may provide incentives for those insured to use the new system.

Starting the Reorganization
A not for-profit General hospital is selected in a large city. General Hospitals do nearly all procedures therefore they are low volume/high cost facilities.  Nearly all routine procedures are removed and reorganized into high patient volume/low cost specialized Clinics. The General Hospital now serves vital care and emergency trauma care patients.  How the specialized clinics use the old General hospital space will require a good deal of planning.  But the in-patient special clinic patients will require hospital bed space and will most likely remain in the General Hospital facilities while out-patient procedures will be in new individualized Clinics. 


List of implementation events for the Missouri State board of Health:
1. State Board of Health Selects State Hospital and Clinic Management Team
2. First hospital is selected and acquired in a high Medicaid patient area.
3. Enterprise Lean Teams are organized for the entire Hospital.
4. Lean Teams in Procedures meeting criteria design Daily Plans.
Lean Teams may require help in designing Daily Plans.
5. Hospital facilities are designed & built to meet the needs of each of the selected Procedures.
6. New high patient volume low cost plan is implemented.
7. Once Daily Plans and Facilities have been designed and the process tested mass implementation can be done throughout the State saving an average of $1billion in Medicaid and $6 billion in Medicare & Regular health care costs for the State.
8. States may also agree to share Daily Plans & facility designs.


Overview of the Missouri Health Care System (MHCS) Plan

Stage 1.  The Startup Stage Beginning January 2018
The State Government may acquire General Hospitals under financial stress at little to no cost or enter into an agreement with a private not for-profit hospitals.  I emphasize that the government is not in the business of buying hospital facilities.  The reason is that the operation of government hospitals will be significantly less than that of private hospitals who will not be able to compete with the efficient government hospitals.  At least one General Hospital will be acquired in St Louis, Kansas City and Springfield in stage 1. As this stage progresses Medicaid patients will be served first followed by Medicare Patients to make sure of a continuous backlog of patients.

The Hospitals will be reorganized in the following manor:
General hospitals do nearly all Procedures with low patient volume and at high cost. The New hospital design I am proposing is exactly the opposite: wholly independent routine procedures with high patient volume at the lowest cost. Procedures which do not meet the criteria will remain in the General hospital system with Urgent Care. Ref: Article 110.

Stage 2. Medicaid and Medicare Patients continued move to new system
In addition to the continuing acquisition of private Hospitals new Eye clinics will be acquired or built in urban cites of over one hundred thousand population to perform mass Cataract Surgery.  This a significant cost saving of  90% the current approach. Ref: Article 110.

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

Stage 4.  The MHCS will be Available to all Missourians
The expanded MHCS will be available to all Missourians. Health Insurance Companies will gradually require that patients move to the less expensive MHCS.  Private Hospitals will still be available for those who want them.

The MHCS Rural Health Care System
Small Clinics should be built in towns of about 10 thousand and about 25 to 50 miles apart.  The Clinics will be of the following design: They will be built adjacent to a fire station with ambulances. They will be 24-7 Emergency Clinics with a few over night beds and a helicopter port.  Some designs may have more beds.  Besides doctors and nurses this system depends on volunteers from within the community.


Criteria for the Selection of Routine Procedures:

•    Repeatable processes with the time being the same for 
•    all patients (relatively routine)

•    Sufficient Patient Backlog for Continuous operation   

•    Daily Plan efficiently designed by each Lean Team

•    Balanced Operations

Routine Outpatient and Inpatient Procedures

Outpatient Testing and Procedures
1. Radiology/Diagnostic Imaging Including MRI, CT scans, ultrasound, nuclear medicine, mammography and x-ray.
2. Colonoscopy
3. Prenatal care, also known as antenatal care is a type of preventive healthcare, with the goal of providing regular check-ups
4. Cataract surgery Ref: Articles 109,110 Example of a Daily Plan.

Inpatient Testing and Procedures
1. Appendectomy
2. Natal care (Baby Deliveries)
3. Cesarean section (also called a c-section)
4. Cholecystectomy  (surgery to remove the gallbladder)
5. Dilation and Curettage (also called D & C) is a minor operation in which the cervix is dilated (expanded) so that the cervical canal and uterine lining can be scraped.
6. Hemorrhoidectomy (surgical removal of hemorrhoids)
7. Hysterectomy  (surgical removal of a woman's uterus)
8. Hysteroscopy (surgical procedure used to help diagnose and treat many uterine disorders)
9. Inguinal hernia repairs (protrusions of part of the intestine into the muscles of the groin.)
10. Prostatectomy (surgical removal of all or part of the prostate gland)
11. Tonsillectomy (surgical removal of one or both tonsils)

Savings for Routine Procedures
With Cataract surgery at 90% reduction of costs it appears that there are other procedures where savings were estimated at 60% are now estimated at 70% to 80% reduction in costs.  These savings appear to be impossible but this approach has never been considered before.

Common Surgical Procedures
According to the American Medical Association and the American College of Surgeons, some of the most common surgical operations performed in the United States include the above.
Excluded from this list is all cancer procedures considered to be too life threatening.
Excluded Heart surgery, Coronary artery bypass (bypass surgery) considered to be too life threatening.

Also excluded are procedures that vary significantly in time with different patients. Such as Releasing of peritoneal adhesion's. (The peritoneum is a two-layered membrane that lines the wall of the abdominal cavity and covers abdominal organs. Sometimes, organs begin to adhere to the peritoneum, requiring surgery to detach them)

Article:112. Federal Government and State Health Care Suggestions

Federal Government and State Health Care Suggestions

The Health Care recommendations in this Blog are freely given to be used by the Federal government and the States with only the acknowledgement of its origins.

The Federal Government shall Repeal and Replace the Affordable Health Care Act with the following new National Health Care System (NHCS). The Federal Government shall immediately cease payments to Health Insurance companies.  Block Grants may be given to States instead. 

Key Characteristics of the National Health Care System (NHCS)  

• The NHCS covers all Medicaid Patients and eventually all Americans
  

• No one will be required to purchase Health Care Insurance but those who can afford it will be required to pay for their own health care or acquire insurance.

• Catastrophic Health Care will be funded by savings from elimination of waste in the current Healthcare system and in the Federal governments operations.

• Catastrophic Health Care will not be funded by individuals purchasing Insurance.

• Insurance Companies will return to their practices before the Affordable Care Act.

The Role of the Federal Government, the VA and the States
The Federal Government will implement the NHCS by supporting each state’s acquisition and conversion of hospitals to the NHCS requirements. Ref: Articles 109,110.

The Veterans Affaires Hospitals will be reformed to make them more efficient.  Veterans will also be able to use the new NHCS state hospitals.

Each State will acquire, reform and manage hospital acquisitions for the NHCS.  This will begin in its larger cities where the largest number of Medicaid recipients live. Ref: Articles 107,109,110.


Proposed Implementation Plan for the National Health Care System  

The plan is to implement NHCS (by changing from a private based system to a government based system) in stages as it gradually becomes the nations primary health care system.  The plan also separates rural health care from urban health care to accommodate the needs of the Nation.  We will allow the VA Health Care system to use the NHCS consisting largely of Medicaid and Medicare in the first stage.

Savings
The savings resulting from switching from a Private to a Government System is estimated at 60% of current costs.  Medicaid savings is expected to average $1billion for each state. Due to the increased efficiency of the NHCS staffing and
hospital facilities can be reduced by 20% or more in larger cities.  General Hospitals in rural areas will be less affected because of low patient volume.

If you have an efficient effective Government Run Health Care system then no private health care company can compete with it because private companies must make healthcare run more efficient than government healthcare. If they can’t do this then there are no profits. If there are no profits in the private system they will drive up the cost of healthcare to get profits.  I call our current Health Care system a “fraud based system” because it is largely funded by fraud.  Our Fraud Based Healthcare system costs double that of European Government health care systems and even they are not efficient.  The present fraud based system cannot be fixed and it is best scrapped as the most costly mistake ever made in health care.


Stage 1.  The Startup Stage Beginning January 2018
Each State Government will begin immediately to acquire General Hospitals under financial stress at little to no cost.  I emphasize that the government is not in the business of buying hospital facilities.  The reason is that the operation of government hospitals will be significantly less than that of private hospitals who will not be able to compete with the efficient government hospitals.  At least one General Hospital will be acquired by the state in each major city in stage 1.

The Hospitals will be reorganized in the following manor:
General hospitals do nearly all Procedures with low patient volume and at high cost. The New hospital design I am proposing is exactly the opposite: wholly independent routine procedures with high patient volume at the lowest cost. Procedures which do not meet the following criteria will remain in the General hospital system with Urgent Care. Ref: Article 110.

Criteria for the selection of Procedures:
Repeatable processes with the same time for all patients (relatively routine)
Sufficient Patient Backlog for Continuous operation 
Daily Plan efficiently designed by each Lean Team
Balanced Operations (no one waits on others to do their jobs).

Veterans will share NHCS hospitals with Medicaid and Medicare patients

Lawrence Rosier Principal Consultant is making the following proposal to States:
In the interest of quickly bringing my recommended reforms to as many States as possible allowing them to benefit in massive savings in regular State Government activities, and in Medicaid and Medicare health care.  Saving To each State 60% of current Medicaid hospital costs or an average of $1billion per State.

Each participating State will work through Lawrence Rosier Consulting (to prevent duplicated work) with other states in the development of shared efficiently designed Daily Plans by Lean Teams.  This will allow up to 50 Daily Plans to be developed and implemented in the time it would take for only a few Procedures by an on-site Consultant. After review of each State’s developed Daily Plans for a Procedure by Lawrence Rosier Consultants it is made available for implementation to the subscribing States allowing for immediate savings to become available. This is a continuous process until all hospital Procedures meeting the criteria have been completed. Note that the new hospital operations do not require management scheduling and budgeting personnel.  Ref: Article 109.

Stage 2. Medicaid and Medicare Patients continued move to NHCS
In addition to the continuing acquisition of private Hospitals new Eye clinics will be acquired or built in urban cites of over one hundred thousand population to perform mass Cataract Surgery.  This a significant cost saving of  90% the current approach. Ref: Article 110.

As this stage progresses Medicaid patients will be served first followed by Medicare Patients to make sure of a continuous backlog of patients.

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

Stage 4.  The NHCS will be Available to all Americans
The expanded NHCS will be available to all Americans. Health Insurance Companies will gradually require that patients move to the less expensive NHCS Health care system.
Private Hospitals will still be available for those who want them.

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

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

Concurrent Reform of the VA Health Care System
As a government run system the current VA health care system may be worse than that of European health care but they both have the same problems: massive bureaucracy, low efficiency, high patient backlogs and uncontrolled costs.   My approach fixes nearly all of the VA’s health care problems including its management problems.  This is the same approach that works for a complete US government run healthcare system.  Start by implementing this new efficient approach using Enterprise Lean through out the VA Health Care System.  See Article 104 and 96.