Does your hospital ever find itself in a similar position? Would you recognize it if you did?

Capital projects are only one category of major decisions for hospitals, and they may not even be made every year. Their infrequency can be a barrier to excellence at managing that decision process. Also, the infrequency only increases the importance of getting it right when an opportunity does arise. Capital projects can expose weaknesses in a hospital or system decision process, more so than other major decisions, and mistakes can cost millions of dollars.

Decision makers may want to consider their pace of decision. I find situations where hospital building committees wander aimlessly for several years on whether or not to do a capital project, where to locate it, how big it should be…then for some reason get anxious, and over two random weeks manage to make short-sighted decisions that preclude very viable, but unexplored, options. Like the political analogy above, their burn rate on time was incredibly high for a long time. This is fine provided it meets the expectation of an excellent outcome (decision) in the end. But making sudden choices out of boredom or embarrassment that lead to a poor outcome is not beneficial and only burns more time later.

The pace of process leading to a decision should be comfortable and adequately thorough without being too hasty or too deliberate. Previous posts have made reference to the Expected Value of Perfect Information (EVPI).  Although based in decision theory, this concept’s core nugget is that there is an unknown value assigned to knowing all the facts which can lead to an ideal decision. However, it may be cost-prohibitive to “spend” the resources to acquire perfect information to make a decision certain. Strangely, for a hospital architects, program managers, builders, consultants, real estate, ROI, etc. all seem to be assigned dollar values (and hotly debated) before time spent is even considered.

Time is the most precious resource a hospital has. More beds, more doc’s, more patients, more land, more money would be nice but those all carry inherent complications. More beds (capacity) require more staff (expense). Even money can be had from other sources. No one can acquire more time. Still, time is too undervalued in a hospital’s decision process. Time is most valuable not only because it is a finite resource, but because a hospital can convert it into big-time revenue. Even one day is extremely valuable.  Ask your OR scheduler, or ED nurse, or MRI tech what a day means to them financially.

One of the most dangerous things a hospital can do with a capital project is speed up a decision process. This is a no-no for reasons other than it violates Newton’s First Law of Motion. Slowing down a pace to ensure a good decision is acceptable behavior; however, accelerating pace is never wise. A healthcare architect and mentor of mine was fond of saying in project progress meetings “We’re not taking five minutes to decide something that took five months to design”. In other words, the best decision will be arrived at through the typical decision process, not a hasty one; otherwise, something important will be missed.  And those misses are what cost hospital extra money. Those burn.

Salvaging a few days or even weeks is very achievable. For instance, the RFP process’s value has already been questioned given the time required to determine a project partner. Team selection could save months. Or a hospital could hire a design-builder that can eliminate a couple months (or more) with their efficient process.  Or a hospital could simply have decision makers lined up throughout the project process when necessary, like having users available for user meetings the first time the meetings are scheduled—no excuses. This saves at least a week each time.  All of these actions preserve valuable time.

For any decision, hospitals may want to improve how decisions are made internally. As noted earlier, capital projects are especially vulnerable.  By saving precious time, hospitals can turn a position of weakness into a position of strength as a project is completed, and decrease the chance of being burned, with or without notice.

Hadid is a name I know.  The project is a secondary school in England, and it won the Stirling Prize in 2011, which is the most prestigious architecture prize in the UK given out to the architect who has most furthered architectural evolution in the past year.  In other words, the project is deemed progressive.

Evelyn Grace Academy has some aspects hospitals might borrow from. The site is tight and well utilized, with a very smart “S” curve building design that knits the entire site together. In addition, the site is used on multiple levels, with passage ways over and under the building. The building offers a lot of natural light, balcony and patio areas, and walkways. Color-wise, the school is understated on the exterior and interior, with natural concrete and metal panels to match the concrete color. Interior has exposed concrete and splashes of color for lockers and other points of emphasis. Hadid is known as an expert in concrete design and detailing, and this project is no exception.

If I were to suggest the progressive aspects of the building, I would say the offset curve of the building that makes it seem like the upper part is sliding out over the lower.  This provides a significant overhang shelter for weather without being precarious and threatening. The angle used in the building’s exterior metal panels (maybe a 75 degree angle) is acute without pinching, and gives the building a sense of motion. And the angle is not a one-and-done; it is consistent, especially on the interior structure, and even the curtainwall mullions are angled in some parts (which was probably a pain to install and costs more but adds a great deal). Ceilings and lighting are clean and well-done, but areas that do not need high finish (gym) are left natural and exposed, so the money can be spent on the parts that matter.

Hospitals are difficult to design in a sleek aesthetic because they are usually taller than they are wide, though not slim enough to be a true skyscraper. Hospitals have a lot going against them in their quest for beauty.  They are proportionally quite blocky.  They grow by accretion so they cannot be designed holistically very well.  They require constant access from many sides, so there is no true facade. And programmatically, there is not often much opportunity to engage nature and the exterior (though I hope this will change in the coming decades). Europe and Scandinavia are the world leaders in hospital aesthetics at the moment because they have challenged many assumptions in healthcare design canon.

And hospitals need not look expensive or sleek per se, though they should inspire confidence in wellness, and uplift the patients’ and visitors’ spirits. Unfortunately too few do. Some hospitals and systems are known for consistently good design—Banner Health comes to mind—while others let the enormity of a project get the best of the design—Ohio State University‘s Cancer, Critical Care, et. al expansion (now Wexner) comes to mind.

I think being progressive has value, especially in healthcare environments, because hospitals send the message that quality of space matters, new ideas are valued, and hospitals want to improve and escort us into the future of medicine by way of their facilities. Healthcare design is at an exciting time now as more evidence-based design is embedded into new projects and technology and information management continue to evolve. I would encourage an award similar to the Stirling Prize for progressive healthcare design.

When I pressed her on the details of that relationship, I found the current firm is the third iteration of the original firm that built the hospital. The hospital’s current architecture firm happens to be a large, international, multi-office practice that is several hours away in a very large city. The original architect of the hospital is deceased (not surprising), though their current project architect does have over ten years working knowledge with the hospital.

As much as I appreciate loyalty, I questioned the stance because it almost appeared to be loyalty of a de facto type, a given. Assuming the same architect who has always done your work should continue to do your work appears to be a safe move, but can be a dangerous assumption. Legacy relationships have come under fire while companies from local to Fortune 500 have been tossing out the old and stale legacy providers in exchange for more sophisticated, nimble service providers.

As consolidation continues to occur in the design, engineering and construction industries (and we need it), firms will get larger. The same is happening in healthcare. Large is not bad; large is actually preferred for financial strength, access to resources, and depth of talent to name a few. What is bad about large for a hospital’s designer or builder is culture and service can change when a consolidation occurs.

I have spoken with hospitals who noticed that when their incumbent architecture firm was bought or merged with a multi-state firm, quality changed, responsiveness lagged, client knowledge suffered, prices crept up. There are some key life events, to borrow an insurance industry term, in a firm’s life cycle that leave the firm vulnerable:

• Leadership Change – A new President, CEO or Chief Operations Officer can change policies and how business is done on a big scale. A new Director of Healthcare can affect how services and responsibilities are handled on the project level.
• Ownership Change – Going from private to public or employee-owned, or even domestic to internationally-owned can affect work—especially if the parent is a conglomerate and the design, engineering and construction are a small part of the menu of company offerings. Also, new investors mean the potential for new managerial input and influence.
• Merger / Acquisition - Dramatic differences can occur when a local or small / medium-sized firm is acquired by a national or international, multi-office mega-firm.
• Departure of Key Personnel – Project directors leave the company. Healthcare principals retire. Project architects get promoted. Any key client contact or relationship manager loss can signal the defection of their client(s) as well because they have the most knowledge of the client’s hospital.

This is not an indictment of large firms, but of culture change that can negatively affect client services. Consolidation does not always have to be to the detriment of the existing client base, and it shouldn’t.  In fact, these are good times to look at the existing service relationship and how well it is serving your hospital or system. Negotiation-wise, it is a good time to confirm or ask for some deliverables you may have always wanted to improve. Firms will want to keep their existing clients happy, especially in an acquisition because value of the acquired firm is often tied to its existing client base.

Similarly, it can make a lot of sense for hospital administrators to look outside of their usual talent pools for expertise. Hospitals, like other large companies, need new perspectives that established relationships cannot deliver at times. Many industries hire outside consultants specifically for fresh ideas, and to avoid what organizational behavior experts call group think, or the tendency for employees of a company to adopt similar biases due to company culture that hinder management, execution and growth.

Loyalty is not dead, nor should it be. Blind allegiance, on the other hand, ought to be questioned. Hospitals should look at each project engagement on a case-by-case basis. Unbeknownst to all, sometimes the best way for your current architect to remain an institution at your institution is by not embarassing themself on something outside their baliwick—and allowing a different team to preserve the rep of your current one.

A couple paragraphs into the story was the first quote of the article, by Henry Chao, an architect and principal at HOK, regarding keeping building costs under control:  “The best way to control costs is to reduce waste.  Waste comes from medical error. Your best bet is to create the best care in the first go-round.”

I agree with two of Mr. Chao’s three sentences, but the one I disagree with I disagree with so much it really negates my support in his overall point. His statement that “waste comes from medical error” is not remotely true. Medical error can create unnecessary cost (among other things). Medical errors are also potentially dangerous, ineffective care, which can be construed as a type of waste. But medical error does not generate waste.  Waste is a byproduct of an inefficient system, and medical error is a byproduct of an inefficient treatment system.  Medical error is a result, not a cause.

Let me channel Lean thinking here to recap the 7 Wastes, which are specific to processes, like design and construction, or like the treatment processes at work in a hospital:

1. Overproduction
2. Motion
3. Inventory
4. Transportation
5. Waiting
6. Defects
7. Overprocessing
8. Underutilized People (unofficially #8, but not included in Lean orthodoxy)

The presence of any of these items suggests waste, and therefore opportunity for cost savings.  David Chambers provides a good summary for those who want to brush up on Lean, which is focused on reducing waste.

Number six above, Defects, is where medical error falls in. Medical error is a defective outcome, which is the antithesis of efficiency and a Lean process. Defects require a “redo” or “rework” to receive an acceptable and useful outcome, and are a type of waste.

Mr. Chao could have been misquoted for the article, but now that Mr. Chao’s erroneous statement is clarified, I agree whole-heartedly with his belief cost control is best done through the elimination of waste. In speaking with a Lean expert for healthcare clients, the consultant related there is so much waste in hospital processes he routinely accomplishes “30% savings without even trying”. The savings through Lean is particularly valuable because it is efficiency savings that immediately registers with the hospital via:

• Productivity (more work in less time)
• Quality (less duplication of work; less need to redo)
• Staffing (same work by less people)
• Facility (more throughput in same space – for an existing hospital, or same throughput in less space – for a new hospital design)

These concrete savings also help more subjective measurements important to hospitals, like patient safety and satisfaction, and crucial risk management issues like infection control—all of which affect revenue.

The reduction of medical waste is a laudable and forward-thinking goal for an architect, and something we definitely can positively affect on some level. However, identifying waste and understanding cause and effect in a system is crucial to design success. Let’s rely on established Lean analysis to help eliminate waste and provide more affordable, robust, and lasting design for crisis response centers and other facilities of healthcare excellence.

Rework is one of the most insidious causes of price increase on a job because it costs the job time both in doing the task a second time, but also in delaying the schedule of work to follow.  In addition, more manhours (actual and supervisory) and materials are needed. And the aggravation factor also cannot be ignored. No one likes to redo work, from the jobsite laborer to the office CAD tech. It destroys morale.

Rework primarily occurs because information such as design intent or specific detailing direction was not adequately communicated, and work was allowed to proceed without the required information. Integrated design-build avoids rework through industry-leading communication. This is done with actual meetings and tools like BIM, which help coordinate field work correctly the first time. Accurate detailing in a BIM model allows subcontractors to know exactly where and how something is to be done. Giving someone a real perspective view of a corridor plenum on a hand-held computer versus a hard-copy plan is far superior in avoiding rework. One thing Haskell works hard at is pre-coordination meetings of major trades before they get started. Decisions are confirmed as final. Expectations are set early, so when the craftsmen are cut loose they only do things once. These are empowering tools.

Sometimes rework is required because the quality is simply below standard. Construction productivity gets a bad reputation because a lot of people think of government road contracts where one person is jack-hammering, one person is holding a “SLOW” sign, and six people are standing around drinking coffee. It is true:  construction productivity is one of the biggest factors affecting construction cost. If productivity could increase, manpower could be cut by a large percentage, work would get done sooner, and projects would cost a lot less.

Like the average office worker, outside of the tools used, much can be tied to motivation. Most people are motivated to do good work, and do it once. That’s where avoiding rework comes in. With rework out of the way, the focus is on doing good work.

In the field, work is often repetitive. Conditions are not always favorable, which is why a lot of construction outfits are gravitating toward prefabrication (mass assembly off-site in controlled conditions and brought to site for quick installation) as much as possible. Excluding prefab, productivity comes down to getting the most from the men and women doing the building on the jobsite.

As Barry LePatner relates in his book Broked Buildings, Busted Budgets, piecework is a powerful and underutilized tool for increasing productivity. With piecework, a laborer is paid by the number of (acceptable) pieces put into place. A mason might, therefore, get paid by the block or course or wall. For repetitive work, this works well. Some installations and tasks are more difficult and less repetitive. They require a different method:  hourly pay. Where judgment is involved, the worker should decide the best method for completing a task satisfactorily. This motivates workers and promotes independence. And appropriate supervision and training are also integral to quality and avoiding rework, as well as motivating workers for increased productivity.

Perhaps the most emphatic point on construction productivity comes from LePatner again:  ‘If the construction industry was competitive, workers would be paid by the hour with managerial direction, or they would be given autonomy and paid by the piece.’ Here is the implicit message:  for motivation, productivity and high quality work, a construction worker needs to be given guidance on how something should be done. In exchange, the worker is compensated by the hour because the freedom to complete a task has not been given. However, where freedom to complete a task is given, pay-per-piece is appropriate because it provides an incentive to come up with a quality way to produce the most work and the worker is paid accordingly.

Either way (by-the-hour or by-the-piece) motivation, compensation, supervision and communication all help avoid what no one wants—waste due to rework—and integrated design-build provides an effective system to minimize rework.

The issue causing the rub between designers and building owners is inaccuracy in the energy model, and occupants appear to be the scapegoat because their behavior is hard to predict. Green Source notes that the burden is on the design community to “more effectively communicate the role of operations and occupants in building performance”. This should be obvious to both designer and owner.

I think any reasonable owner cannot expect high energy performance without compliance on the user side since energy use is integral to everyday building use, and people inside a building affect energy use.  People give off heat; they consume water; they require light, heating and cooling for comfort; people use equipment and machinery to do their jobs, and that equipment requires electricity and puts off heat. Building users also open windows, fiddle with thermostats, bring in space heaters, and waste water and electricity from time to time.

Likewise, I think any reasonable designer cannot expect building users to act in an ideal way. In modeling energy use, designers must ask a lot of questions about expected building use and anticipated user behavior.  Designers must input realistic numbers based on industry benchmarks for building type, size, occupants, historical data from the client, or base input on defensible assumptions. Builders do this all the time when they produce estimates. Any builder knows it is easier to put in a place-holder value with a reasonable explanation than to come back later and say they didn’t know, excluded it, or blame the owner:  ’they didn’t give me such-and-such information’. Much like formulating a personal budget, an individual cannot allocate money based on what they wish or hope will happen, or conditions in an ideal situation, and hope to succeed, but how money actually gets spent each month. The same is true for energy:  model on reality. Improvements can come at a later time, not in a model.

Given the recent advent of lawsuits by owners against designers and builders for not meeting LEED energy design targets, it seems important for owners and the design team to do two things throughout the project, and especially in regard to the energy model:  communicate and align expectations. LEED is addressing this issue by auditing buildings to verify they perform as designed, especially in regard to energy.

On a project basis, it simply makes the most sense to include all hospital parties with a stake in, or passion about, the energy performance, including Plant Operations, Facilities, IT, Planning, Clinical Services, Design & Construction, COO, CFO, even CEO, along with the Architect, Engineers, Construction team and relevant consultants like Commissioning Agents and even Food Service Design. With hundreds of thousands of dollars in energy costs a month for many hospitals, and well into seven figures for large facilities, this coordination is a huge step for a high-performing hospital—and on a smaller scale may simply ensure the doors stay open.

Think of all the things built into our lives because our plans don’t go as expected:  slush funds, buffers, contingencies, airbags, redundancies, safety factors. If everything planned turned out well, we would have no need for them. But they don’t.

Let’s face it:  if all healthcare projects were destined for perfection, it would not matter who a hospital hired to do the work because the outcome would be guaranteed—success every time. Any team would be as effective as the next. But projects don’t always go well. Some industry experts say one-in-five projects ends up with a busted schedule, budget or lawsuit. Others suggest possibly 50% of healthcare projects have at least one unexpected, expensive and contentious issue.

When I bought our certified pre-owned Honda Pilot two years ago, I felt like a sucker because I paid for the extended warranty. On my drive home I kept mulling over the significant increase in my car payment. Was the higher first cost worth the peace-of-mind? The factory warranty was still in place, and who buys an extended warranty on a Honda? 

This week I picked up the Honda from the dealership after a new transmission. Yes, at 41,000 miles—5,000 miles past when the factory warranty ran out.  If I did not have the extended warranty, it would have been an extremely expensive out-of-pocket fix, or an uphill battle with the manufacturer to prove the transmission was defective prior to purchase. The extended warranty paid for itself four times over.

We buy insurance and extended warranties because we expect the unexpected. We make a calculated judgment that, like jet fuel futures, a small investment can both protect us and provide an advantage over those who are not putting a similar protection in place.

While design-bid-build (DBB) may be the lowest first cost, quality is suspect and performance of the subcontractors is dubious. Unlike DBB, any errors, omissions and field rework come out of the design-builder’s pocket, not the owner’s. And while CM-at-Risk offers some early price protection, price escalations can wreak havoc on a project budget.  Those are passed through to the owner and there is no protection when prices are moving up:  bids can’t come in fast enough and sub’s can’t be signed up soon enough. Unlike CM, value engineering re-design, re-estimating and re-scheduling come out of the design-builder’s pocket, not the owner’s.

Owners need a project delivery system designed for when things don’t go smoothly. Design-build offers that protection. Design-build (DB) is like project insurance.

Mechanically speaking, the hospital needs to figure out how to move more units (patients) through their system (imaging) with their resources (equipment, staff, rooms and time).  A hospital has three options:

1. Overload the System.  Overload is great as a short-term solution, like a factory hiring temp workers or instituting a third shift to meet an order—”mandatory overtime”. For an imaging department, this might mean expanding the schedule times each day, really early to really late seven days a week. Or cheating on some of the buffers that you like to build in— ramp up in the morning, scheduled maintenance, lunchtime—to squeeze a few more scans in. Unfortunately when you overload, eventually something ‘redlines’ and part of the system breaks down because everything is functioning at maximum capability, longer.
2. Increase Capacity.  To increase capacity usually means to build, aka a capital project. For imaging at least, there are short-term capacity options like renting a portable MRI and parking it next to your building. It is a stop-gap solution because it costs money to rent, it is not physically connected to your facility, and quality or reliability may suffer. A new building project is slow, expensive, stressful, and should be a last resort action because of those attributes.
3. Increase Throughput.  To get more patients through a system given a certain block of time, while using the same infrastructure (nothing new), hospitals must improve efficiency. This means studying where the bottleneck (greatest limiting factor) is that prevents more from getting done, and it smooth out the treatment process. Efficiency analysis may reduce the steps to treat a typical patient. If this shortens treatment time even by a few minutes, that time savings is multiplied by the number of patients, and throughput increases:  more people can be treated in the same amount of time without increasing costs for more equipment. 

But how is this really studied and executed accurately?  Simulation.  I have chronicled the growth in simulation, and its ability to assist in both existing operations, and in new facility design. When coupled with Lean and / or Six Sigma analysis, it can be a pretty compelling package.

Simulation means taking existing operations data (travel times, activities at each patient handling, etc.), modeling it in 3D, and animating it for all to see and understand. Much can be learned by both recording what currently happens in a department, what should happen, and what can happen better.  Simulation makes visible many work-related actions that are invisible or hard to observe.  It can help verify a program prior to design or construction, also test potential solutions by modeling real scenarios and how they would work—before they are built or accidentally developed further.

Without simulation, it is incredibly difficult to make decisions because there is no confirming or backup data, only gut feelings and observations. Many market forces are likely to increase demand for services in the near term, and only so many patients can be deflected to satellite facilities. For hospitals not flush with cash, efficiency is the only affordable option to improve care, patient satisfaction and absorb additional demand. Healthcare needs  increased efficiency, and simulation is the tool to help achieve it.

Architecturally, it is debatable when white became the de facto aesthetic of hospitals.  I have long wondered whether we will ever evolve past gleaming white as a signifier of cleanliness. 

White has always been perceived as clean, sterile and safe. Given a recent WSJ article on brown, particularly in paper, as a new aesthetic choice (mostly to signal environmental sensitivity), I am curious whether sustainability is a strong enough ‘movement’ to rival or displace white as an acceptable color of health in our hospitals of the future.  Or should it even?

Regionally, and even in some hospital lobbies, brown rock and earthy tones are acceptable because they are comforting; they remind us of the hearth and home. Originally, brown surfaced in recycled products because the pulp was unbleached (not treated with additional chemicals), which made it more natural; things were brown by default. Now it appears companies are actually adding brown dye to emphasize recycled content. This inevitably leads to questions about legitimacy and “greenwashing”; people are now making things brown because they appear more recycled and “green”. Maybe white is so accepted because it is understood as transparent and hard to fake.

Color has an important role in our visual world, and signaling is one of those jobs. Although brown is the color of many foods, generally brown is a dirty color in hospitals. My question about the future aesthetic of what we understand and accept as clean is less about brown and more about anything other than white.  Will we ever have an alternative to white in hospitals?  And what would it take to take us there?

In light of the upcoming primary election (Florida’s is tomorrow), I reflected on the past few years of politics. So much energy has been put into healthcare reform, even before the fateful March 23, 2010 PPACA legislation was passed. From a layman’s view, I see hospitals fearful, wondering what the economic landscape will be like for them in the next year or five.  Many are paralyzed until the complexity of the legislation is digested still, nearly two years later. Doctors are running for the shelter of hospitals, who are financially overburdened. Medicare and Medicaid reimbursables are being pinched, threats abound on other cuts. The rules of engagement are changing as the fee-for-service model evolves to fee-for-outcome (quality). Rural providers are still wondering whether Uncle Sam will provide for their continued existence as they try to keep up to speed with expensive technology mandates and dwindling patient populations. Insurance costs are expanding, people are tired of paying more, customer service needs a lot of attention in healthcare. Work and expertise is still very siloed within care.

And then to learn that a scam on the magnitude of $70 billion or more (no one even knows the scope of the problem because it has not been adequately studied) has been growing like a weed unchecked for the past two dozen years at least—well, frankly, it is sickening. Yes, the waste is sickening. Yes, it is sickening to know people are getting rich off taxpayers and a government so bloated and inept it cannot track and account for such stealing. However, it is most disturbing on two equally terrific levels:  1) Politicians are not willing to fight this fight.  They would rather let a fire hydrant shoot straight into the air and complain there is no water.  2) The political posturing and hand-wringing of the past decade plus does not need to happen if the corruption is kept in check.  Note well:  I am sad and embarrassed that my state of residence, Florida, appears to harbor the most expert violators.

Amazingly, it does not even need to be stopped completely, just minimized to something in the order of what a normal company would accept.  The article notes credit card companies live with 1% fraud.  Our government accepts 10% for Medicare fraud (!), but it could be as high as 30%—no one knows!  As was stated in the article:

“We’d easily find $200 billion over 10 years. That means you wouldn’t need to cut reimbursement rates for providers. You wouldn’t need to restrict insurance coverage. You wouldn’t have to increase deductibles. Getting hold of this problem is a much healthier way of dealing with the cost control imperative than through indiscriminate cutbacks.”

No healthcare jobs need to be lost, no reimbursables cut, no facility improvements indefinitely delayed.

One of the most comprehensive articles on the ineffectiveness of government to run practically anything was published a few years ago in the Wall Street Journal by John Steele Gordon:  “Why Government Can’t Run a Business”.  Every time I hear the government attempting to extend its…reach into things I am pretty sure it has no need to get involved in, I remember the points from this article.  Here are Mr. Gordon’s seven:

1. Governments are run by politicians, not businessmen.
2. Politicians need headlines.
3. Governments use other people’s money.
4. Government does not tolerate competition.
5. Government enterprises are almost always monopolies and thus do not face competition at all.
6. Successful corporations are run by benevolent despots.
7. Government is regulated by government.

You can easily see which ones have relevance in the healthcare fraud debate.

I am not banging a political drum so much as placing a call to action to stop this waste and make everyone else’s lives better. Occupy Wall Street:  the real issue is our own government’s lack of oversight.

Americans complain so much about government regulation, but when regulation could really help (internally, as in monitoring and tracking fraud) it is nowhere to be found. Why would the government work so hard through the IRS to triple its audit team to catch a few thousand dollars here and there, when the real graft is on a much more pervasive scale, with numbers that actually matter?  Why can’t some presidential candidate run with this platform?  You would get my vote.