“We can renegotiate contracts, standardize products, secure better pricing, but if utilization is misaligned, the “bucket” will continue to leak.”
You may recognize the song lyrics, “There’s a hole in the bucket, dear Liza, dear Liza. There’s a hole in the bucket, dear Liza a hole!” At first glance, it’s just a comical looped song that will get stuck in your head, but at its core this song isn’t about a bucket at all, it’s about human frustration.
The characters go back and forth trying to solve a simple problem, but no matter what they do, each suggestion leads to another problem until it becomes clear that no matter how much effort goes into the solution, the bucket will never work unless the hole is fixed.
The big picture of this song serves as a reminder that when you are stuck in a cycle, the problem isn’t necessarily the tools, it’s the system or the perspective that you’re trapped in.
The hole in a bucket song is a perfect metaphor to one of healthcare’s most persistent challenges, cost optimization without utilization management. We can renegotiate contracts, standardize products, secure better pricing, but if utilization is misaligned, the “bucket” will continue to leak. Value analysis is uniquely positioned to help find the hole, fix the hole, and maintain the bucket.
The Hole in the Bucket
In healthcare, cost optimization is often equated to lower prices. While pricing matters, it’s only one piece of the puzzle. Organizations frequently celebrate the savings on paper, only to find that the overall total spend continues to rise. Why does that happen? Because utilization was never addressed, it’s the hole in the bucket!
In the song, the hardest part isn’t about fixing the bucket, it is more about recognizing that the hole exists in the first place. Even the best priced contracts lose their impact when products are used inconsistently, overused, or applied outside of the evidence-based practice recommendations.
Utilization is not always obvious. It often hides in the day-to-day activities, patterns, habits, and behaviors driven by convenience. Until those behaviors are addressed, true cost optimization remains out of reach. Like pouring water into the bucket with the hole, resources are continuously added, but never fully retained.
Utilization gaps commonly appear as practice variation, unnecessary high use, or products used without clear clinical indication. When utilization data is incorporated within the clinical context, the location of the hole in the bucket becomes clear. Value analysis teams sit at the intersection of clinical practice, supply chain, finance, and quality, which positions them to clearly identify these utilization gaps.
The Fix
Once the hole is identified, the natural instinct is to replace the bucket. In healthcare, that instinct often shows up by searching for the next best product. As the song reminds us, changing tools doesn’t solve the behavioral problem.
An effective utilization-focused value analysis team shifts the conversation from products to practice. They would ask, “Why are we using the product this way?” instead of, “What should we buy now?” This shift provides the structure needed to fix the hole rather than repeatedly refilling the bucket.
Reframing this question requires meaningful utilization data, intentional clinical engagement, and willingness to examine process, education, and workflow. This approach creates a forum where data, evidence, and experience come together to drive change. When discussions are grounded in patient care and supported by the data, the dialogue becomes collaborative rather than defensive.
Utilization-focused value analysis aligns practice with evidence, reduces variation, supports appropriate product selection, enables standardization, and monitors sustainability over time. This is not about using less but using the right tools, in the right way, for the right patient. Just as with every value analysis decision, the patient remains the reason the bucket matters at all. If utilization changes compromise patient outcomes, the solution has failed. Fixing the hole ultimately ensures that what we pour into the system truly reaches the patient. When done well, patients then receive the care they need without the added risk, waste, or inefficiency.
Making the Repair Last
In the song, the characters, Henry and Liza, never quite solve the problem. They stay locked in a cycle of temporary fixes. Each attempt addresses the symptoms rather than the root cause, the hole. In healthcare, we don’t have that luxury. Sustainable cost optimization requires ongoing attention to utilization, not the one-time interventions that Henry keeps trying throughout the song. Without sustained maintenance and review, even well thought out initiatives slowly revert to old habits, and soon a leak has sprung and the hole reappears.
Fixing utilization is not a single event, it is a process. Creating a culture that includes routine utilization reviews, transparent reporting, clinician engagement, and leadership support defines success in utilization-focused value analysis teams. These elements reinforce accountability while maintaining trust and collaboration across disciplines.
Utilization is a learned behavior. When there are clear expectations, reliable data, and clinical rationales, best practice becomes the norm, not the exception. Over time, the behavior sticks, the bucket holds, not because it was replaced, but because it was intentionally repaired, reinforced, and maintained.
Conclusion
Cost optimization without utilization management is like carrying water in a bucket with a hole in it. No matter how well intentioned the effort, the outcome will always fall short. All the tricks in the book can be looked at, pricing strategies, contract negotiations, and standardization efforts, but without utilization management, resources will continue to leak.
When utilization is addressed, cost optimization becomes sustainable, meaningful, and more patient centered. Value analysis teams give the structure and discipline to first identify where the leaking resources are and then the collaborative framework to fix it.
Before we pour more water into the bucket, or negotiate another contract, it’s worth asking the question, “Is the bucket actually sound, or is there still a hole to fix?” Addressing that question first may be the most impactful cost optimization strategy of all.
Article by:
Sarah Hobbs, MSN, RN, CCRN, CVAHP, LSSGB, Clinical Program Director at Blue.Point Supply Chain Solutions; Clinical Value Analysis Program Manager at OHSU
Sarah Hobbs is a clinical and operational leader with more than 20 years of experience across value analysis, critical care nursing, and evidence-based practice. As CVAHP, CCRN, and Lean Six Sigma Green Belt, she blends deep clinical expertise with data-driven strategy to improve quality, reduce variation, and advance value-based decision making.
After more than a decade in high-acuity ICU, Sarah moved into value analysis leadership roles at University Medical Center and later to Lehigh Valley Health Network, leading systemwide evaluations, standardization efforts, and cost-containment initiatives. She is known for translating clinical evidence into actionable insights and building strong partnerships with clinicians, supply chain teams, and executives.
Currently, Sarah serves as Clinical Program Director at Blue.Point Supply Chain Solutions, supporting healthcare organizations nationwide through utilization reviews, client onboarding, education, and new category development, with a continued focus on innovation and clinician engagement. She also serves as the Clinical Value Analysis Program Manager at OHSU.
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