Hiring more full-time federal bureaucrats will result in smaller and better government

The United States’ federal government has expanded greatly since the 1960s, with spending having increased by a factor of six in over that time. The number of federal employees, however, has not similarly increased, with present numbers close to those of the Reagan Administration and fewer than were present during Kennedy’s term. John J. DiIulio Jr writes that the federal government has become a Leviathan by Proxy, which gives billions of dollars and thousands of contracts to state and local governments, contractors, and non-profits. He argues that recent government problems such as the 2005 reaction to Hurricane Katrina and 2013′s Obamacare rollout show that the federal civil service is overloaded not bloated. In order to make government smaller and better, he calls for the hiring of one million more federal civil servants by 2035 and the introduction of better performance management practices

The Silent Epidemic: Perspectives of High School Dropouts

Presents findings from a survey that examines why some students do not complete their high school education, and what academic and personal supports would have helped them stay in school. Includes recommendations for improving graduation rates

Achievement Trap: How America Is Failing Millions of High-Achieving Students From Lower-Income Families

Assesses the elementary school, high school, college, and graduate school experiences of students who score in the top 25 percent on national standardized tests and whose family incomes are below the national median

Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis.

BackgroundMany studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.ObjectiveTo examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.DesignHCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.SettingInpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.ParticipantsPhysicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.OutcomesEmergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.ResultsWe interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.ConclusionsOur model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications

Evaluating a Modular Decision Support Application For Colorectal Cancer Screening

BACKGROUND: There is a need for health information technology evaluation that goes beyond randomized controlled trials to include consideration of usability, cognition, feedback from representative users, and impact on efficiency, data quality, and clinical workflow. This article presents an evaluation illustrating one approach to this need using the Decision-Centered Design framework. OBJECTIVE: To evaluate, through a Decision-Centered Design framework, the ability of the Screening and Surveillance App to support primary care clinicians in tracking and managing colorectal cancer testing. METHODS: We leveraged two evaluation formats, online and in-person, to obtain feedback from a range primary care clinicians and obtain comparative data. Both the online and in-person evaluations used mock patient data to simulate challenging patient scenarios. Primary care clinicians responded to a series of colorectal cancer-related questions about each patient and made recommendations for screening. We collected data on performance, perceived workload, and usability. Key elements of Decision-Centered Design include evaluation in the context of realistic, challenging scenarios and measures designed to explore impact on cognitive performance. RESULTS: Comparison of means revealed increases in accuracy, efficiency, and usability and decreases in perceived mental effort and workload when using the Screening and Surveillance App. CONCLUSION: The results speak to the benefits of using the Decision-Centered Design approach in the analysis, design, and evaluation of Health Information Technology. Furthermore, the Screening and Surveillance App shows promise for filling decision support gaps in current electronic health records

Point-of-care testing for disasters: needs assessment, strategic planning, and future design.

Objective evidence-based national surveys serve as a first step in identifying suitable point-of-care device designs, effective test clusters, and environmental operating conditions. Preliminary survey results show the need for point-of-care testing (POCT) devices using test clusters that specifically detect pathogens found in disaster scenarios. Hurricane Katrina, the tsunami in southeast Asia, and the current influenza pandemic (H1N1, "swine flu") vividly illustrate lack of national and global preparedness. Gap analysis of current POCT devices versus survey results reveals how POCT needs can be fulfilled. Future thinking will help avoid the worst consequences of disasters on the horizon, such as extensively drug-resistant tuberculosis and pandemic influenzas. A global effort must be made to improve POC technologies to rapidly diagnose and treat patients to improve triaging, on-site decision making, and, ultimately, economic and medical outcomes

The Local Role in Homeland Security

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73848/1/j.1540-5893.2005.00236.x.pd

Save the Bureaucrats…from the Politicians

If Paul Verkuil was a stock, I would buy him. And if his wonderful keynote address at the Penn Program on Regulation’s 2015 Annual Regulation Dinner were a petition, I would sign it! Verkuil nails it in Save the Bureaucrats. We are living, as he says, in a “neo-spoils” era, but one created by what he has previously described and decried, in his fabulous 2007 book, as a process of “outsourcing sovereignty.” In his keynote address, Verkuil referenced the “killer chart” on the cover of my own my recent book, Bring Back the Bureaucrats, a chart showing that the federal government spends five times what it spent in 1960, adjusted for inflation, but that the federal workforce is smaller today than it was in 1960. I only wish more politicians thought about the killer truth behind that chart; instead, most either deny, ignore, or distort it. For instance, in a speech delivered earlier this summer, Republican presidential candidate Jeb Bush proclaimed “reducing the size of the bureaucracy by 10 percent within 4 years is a realistic goal, saving tens of billions of dollars, and without adding to unemployment.” Bush is no government bureaucracy-basher, but his proposal, like the more radical plans that many Republican members of Congress have concocted for rolling back big government by shrinking the federal workforce, ignores at least eight sets of facts relevant to understanding why we need to “save the bureaucrats” from the politicians. First, when George W. Bush became president, the executive branch employed about 1.8 million civilians (not counting postal workers), which was about the same number as when John F. Kennedy won the White House. And there were more federal bureaucrats (about 2.2 million) when Ronald Reagan won reelection in 1984 than when Barack Obama won reelection in 2012 (about 2 million). Second, eliminating the entire federal civilian workforce would save about $250 billion a year in wages and benefits, or less than the over$300 billion a year that Washington spends on defense contractors and under half of the more than $600 billion a year that it spends on Medicare beneficiaries. Third, the federal government spends more than$600 billion per year on more than 200 grant programs for state and local governments, a ten-fold increase, in constant dollars, since 1960. The post-1960 federal civilian workforce has remained steady, but the state and local government workforce has roughly tripled to more than 18 million. Many state workers function as de facto federal bureaucrats. The largest single item in most state budgets is the federal-state Medicaid program. More than 90 percent of federal environmental protection programs are administered by state and local agencies that together employ many times the U.S. Environmental Protection Agency’s workforce of below 20,000. Fourth, the federal government also has millions of de facto employees in for-profit firms and nonprofit organizations. For example, the U.S. Department of Defense has roughly 800,000 civilian workers – plus the equivalent of some 710,000 full-time contract employees. Likewise, the U.S. Department of Energy spends about 90 percent of its annual budget on thousands of private contractors, who handle everything from radioactive waste disposal to energy production. The nonprofit sector has grown to encompass about 1.6 million organizations registered with the Internal Revenue Service, plus thousands more tax-exempt groups that are not required to register. The registered nonprofits have more than $2 trillion in annual revenues, with roughly a third of that money – and a large fraction of all jobs in the nonprofit sector – coming from government grants as well as fees for services and goods from government sources. Fifth, read the Congressional Record: state and local governments, businesses, and nonprofit organizations lobby incessantly for federal policies, programs, and regulations that they are paid to administer. The proxies rarely lose, which is a big reason why government never stops growing. Federal employees and their unions are not politically toothless but, compared to Washington’s contract- and grant-funded federal proxies, they have had almost nothing to do with the post-1960 growth in federal spending. Sixth, Jeb Bush is right that many federal bureaucrats are “hired, promoted, and given pay increases often without regard to performance;” but it is also often the federal government’s paid proxies – incompetent, overpaid, or corrupt for-profit contractors and the nonprofit grantees – not federal civil servants, who are behind performance problems on chores as distinct as handling plutonium, approving pesticides, and containing forest fires. There is no empirical evidence that outsourcing saves money, and a small but growing body of evidence shows that it actually costs more than it would to have government workers supply the same services. Seventh, the most catastrophic government performance failures have typically occurred when federal agencies had too few, not too many, full-time workers. For instance, in 2005, we witnessed the Federal Emergency Management Agency’s (FEMA) failed response to Hurricane Katrina, which hit when FEMA had only about 2,100 employees and had recently lost many senior managers. In 2013, we lamented the lame launch of Obamacare health exchanges, which involved scores of contractors and was overseen by the Centers for Medicare and Medicaid Services, an agency with fewer than 5,000 employees. Over the last two years, we’ve been sickened by the scandals at Veterans Affairs hospitals, whose so-called Contracting Officer’s Representatives are too few to properly monitor what its medical centers’ small armies of contractors do. Eighth, many federal agencies are already in dire need of more workers. For instance, by 2025, Social Security beneficiaries will exceed 85 million people, and the Social Security Administration (SSA) will disburse nearly$1.8 trillion a year. But the SSA projects that it could lose a third of its workforce by 2020, when some 7,000 SSA headquarters and 24,000 SSA field employees become eligible for retirement. Unfortunately, in recent years, due to a congressionally mandated hiring freeze, the SSA has been unable to fill positions left open by employee retirements. In sum, as Verkuil suggested, today’s federal civil service is overloaded, not bloated. We have too few federal bureaucrats monitoring too many federal grants and contracts, and handling too many dollars spent hiring others to do the work of the federal government. And we do a terrible job recruiting, training, and rewarding those who do venture into our federal civil service. Terrible! Here is one little Verkuil-inspired challenge to Jeb Bush and other presidency-seekers who favor cutting the flat-for-decades federal workforce as a way to cut costs and shrink government: Do you also favor cutting the federal for-profit contractor workforce, and, if so, by exactly how much and in what specific programs? I expect few politicians would favor cutting the outsourced bureaucracy. Maybe Verkuil and I and others who see things as we do should save our breath. But we won’t. The country can’t afford any longer to neglect its bureaucrats! This essay is the second in a four-part Regulatory Review series, Good Government Requires Good People

Valuing Democratic Governance

Paul R. Verkuil’s Valuing Bureaucracy: The Case for Professional Government is a tour de force of historical interpretation and empirical analysis. It is also a civics sermon predicated on and punctuated by the author’s unshakeable faith in American democracy. I write to trumpet Verkuil’s history lessons, endorse his analyses—and question his faith. First, however, full disclosure: Valuing Bureaucracy contains frequent and favorable citations to public administration studies by Donald F. Kettl, Paul Light, and yours truly (two home runs and a foul ball, respectively), including one to an op-ed in The Washington Post that I co-authored with Verkuil in 2016. So, consider the source, but Verkuil’s historical renderings are vivid and visionary. Two chapters of the book, entitled “The Growth of Contracting Out in Government” and “The Consequences of Federal Contractor Government,” summarize just about every significant fact, development, and dispute of relevance to federal contracting. The former chapter expertly places the current government outsourcing frenzy in the context of the “growth in contractors in the economy as a whole over the last decade,” a trend that Verkuil suggests reflects a wider “transformation in the employer-employee relationship.” But, as Verkuil emphasizes, in the public sector “contractors now represent not only numbers, but brains—brains that have been outsourced.” To cite just my favorite from among Verkuil’s many compelling examples, just one unit—Booz Allen Hamilton—of one mega-corporation—the Carlyle Group—earns $5.48 billion a year from government agencies and employs nearly 23,000 people, “many of whom have prior government service, and one-half of whom have security clearances.” In agency after agency, Verkuil shows, there are “glaring inadequacies in oversight of the contractor regime” that “can only be overcome by infusing more talent in government itself.” Then these words, which might be the best single-sentence summary of the book’s bedrock thesis: “Rational government is not contractor government, it is professional government managing contractor services.” Verkuil supports his thesis with a variety of case studies. What do a coal ash spill in North Carolina, IBM litigation in Indiana, the administration of climate change regulations in New Jersey, and the privatization of government tasks in Texas all have in common? One part of the answer is monumental performance failure wrought by the use of paid non-public proxies to administer the people’s business, including with respect to tasks that even a radical libertarian might agree are inherently governmental. Another part of the answer lies in what happened after “each of these states shrank its public workforce in a risky gamble for government efficiency.” One subsection of Valuing Bureaucracy—entitled “Workarounds and Professionalism,” which includes Verkuil’s first-person testimonies about the conditions under which workarounds work (or do not work)—deserves to be nominated as the single most nuanced and novel part of the book. In computer science parlance, “workaround” refers to a technique for compensating for or curing a program feature or “bug” that causes a system to falter or fail. In bureaucratic parlance, “workaround” generally refers to ways and means of cutting red tape or overcoming other effectiveness-sapping, performance-killing organizational routines and structures. To achieve anything resembling administrative excellence, many, perhaps most, government organizations need workaround-ready leaders and managers who can circumnavigate “encrusted statutory and regulatory commands” and cope creatively with “what happens when rules are stacked upon one another across administrations over many years.” As Verkuil avers, “nowhere is professional expertise more needed than in cutting through the spider’s web of rules and formalities that delay and trap citizens.” But nowhere, as he illustrates, are contractors less suitable substitutes for seasoned public servants than in identifying, crafting, and executing workarounds that result in government either working better, or costing less, or both. As Verkuil demonstrates via facts, figures, and four superb case studies, that thesis applies not just to the federal contractor regime, but to the contractor regimes that now dominate most states. In his discussion of civil service reform, Verkuil refers to Achieving Regulatory Excellence, the outstanding 2017 volume edited by Cary Coglianese, but he could have cited it no less aptly in discussing the need for professional public servants, not paid contractors, when it comes to making workaround work. As Coglianese noted in that volume’s opening chapter, professional regulators practice “discretion with accountability” and must learn “what aspects of a problem to focus on or what rule violations to target or overlook.” But it is Verkuil’s faith in American democracy that motivates the book, and it is by no means a naïve faith. Verkuil has worked as a top college’s president and as dean of two great law schools. He served a half-decade under President Barack Obama as Chairman of the Administrative Conference of the United States. He is a model pragmatic idealist, and his book Outsourcing Sovereignty remains a landmark treatise in spotlighting the many dangers associated with relying so heavily on contractors to translate public laws and policies into administrative action. In short, Verkuil is a noble civic soul whose final page is a hymn to hope: “I am always hopeful that arguments well-made can persuade, so long as people remain faithful to the cause of democratic governance.” I wish I were half as hopeful. As described in my little 2014 book, Bring Back the Bureaucrats, sadly, what I see is a constitutionally limited government that has morphed into a “Leviathan by Proxy”—a debt-financed, proxy-administered state in which most voters love their member of Congress but hate Congress; demand more government benefits without more taxes; unite in bipartisan disregard for “our Posterity;” divide into polarized partisan and ideological factions; and doubt or deny that public service professionals serve “the cause of democratic governance.” But maybe Verkuil is right to hope. Maybe Valuing Bureaucracy itself will win some hearts and minds. Even in the Trump Administration, Verkuil concludes, “doubters must come to recognize the bureaucracy is their government and disparaging it will neither make it go away nor perform better.” Maybe in the wake of the Federal Emergency Management Agency’s relatively fine performance in responding to hurricanes Harvey and Irma, the story of how that particular agency was reformed and rebuilt post-Hurricane Katrina will be revisited, and the lessons duly generalized. And maybe rhetoric about “draining the swamp,” orders for freezing government payrolls, and the similar symbolic gestures will give way to a more fact-based focus on the need for real civil service reform. …Or maybe not