April 9, 2011

State Budget Shortfalls – update

Mint.com has an interesting info graphic looking at recent and projected state budget shortfalls. Though the title is a bit alarmist what this shows is that the situation is improving in most states when compared with data from 2010. Have shortfalls peaked?


March 7, 2011

Project Zombies – 1

We’ve all seen them and maybe even been them.  The walking dead on a project.  We’re not talking about being tired because you’re on the last few weeks of a project and everyone is working hard to push it over the goal line.  We are talking about those projects where you can’t see the goal line but you continue to dazedly slog down field through the mud hoping that your efforts lead to something productive.  Or worse, just hoping the end is near irrespective of the outcome.

Symptoms

So how do you know if you have project zombies on your team?  Here are a few symptoms:

  • A measurable drop in individual or team performance;
  • A general drop in morale;
  • Long hours being put in on the project well before that final push;
  • Grumbling, complaining, or dead silence about assignments; and
  • Missed milestones and deadlines.

Causes

If those are the symptoms what are the real causes?  We’ve seen many but the top six in our experience are:

  • A high level of politics in a project (we’ve noticed a lot of this lately around anything to do with the Affordable Care Act!);
  • Unrealistic goals and desired outcomes for the project;
  • Unrealistic timelines and scope (asking people to do more than is possible in time allotted);
  • Working staff above or below their skill level (asking them to routinely perform tasks they feel overqualified to do or that they are not skilled enough to do);
  • Constantly changing deadlines or scope (moving the goal posts); and
  • Outside forces (vendors, management etc) pushing the use of “silver bullet” tools or techniques to justify unrealistic deadlines or outcomes.

We know there are more but there are always at least one of these on any project suffering zombies.

Impacts

So why care if your project is full of zombies?  Projects with even a single zombie can:

  • Miss milestones and deadlines;
  • Make good staff leave the project;
  • Result in poor quality work; and
  • Fail outright.

As a sponsor or manager of a project it is your job to cure project zombies.  We’ll discuss some cures to “project zombie-izm” in the second (and final) part of this series.   In the mean time you might want to read  Ed Yourdon’s book “Death March“.   Though targeted at software projects much of the insight it provides generalizes to any project.

February 7, 2011

Getting the Right Number of Staff in Your Organization

We were recently praised by one of our clients (the head of a state health and human service agency) for our work helping the agency rethink both its staffing levels and business processes. We refer to this work as a “staffing study”.  The director stated that our work was not only valuable in its own right but for the impact it had on starting the agency examining and redesigning its business processes and even its business model.

Here is an overview:

  • The project was authorized by the State Legislature to find a more precise way than client/staff ratio to determine the number of staff needed to provide services (although truth be told they really wanted to prove that the agency had too many staff) and to identify process improvements and other cost savings (who wouldn’t want that).
  • We studied Food Stamp and Medicaid Eligibility, Adult Protective Services, Case Management in Long Term Care and TANF, Vocational Rehabilitation Counseling and Employment Related Day Care and Medicare Part D.
  • Our methodology was rather innovative. Historically staffing or workload studies are often done to determine federal reimbursement and use Random Moment Time Studies where workers carry a beeper and record what they are doing when the beeper goes off. This produces a lot of data but only quantifies what workers are doing now -  not what has value or what could be done differently and how much time could be saved. We developed a “triangulation” method – using multiple sources to quantify workload and improvement opportunities. We typically used site visits with staff interviews, direct observation and process mapping (much of the site visits protocols we now use were developed here); electronic surveys of all program staff (with “reasonableness” checks); best practice searches,  and focus groups.
  • Our results were presented as high level process maps that showed tasks, how long each task took, and how often the task would be done each month. For example, we calculated how many minutes it takes to process a food stamp application multiplied by the expected number of applications and divided by the number of minutes available per worker to give us a staffing level. We could demonstrate the savings in time and dollars if tasks were done differently. We also proposed some major changes in the model for doing case management and vocational rehabilitation counseling – using the case manager as a team leader with para-professionals doing tasks that did not require case management credentials and expertise.
  • Much to the delight of the legislature -we showed the  expected cost savings for process improvements. For example, one of the easiest process improvements recommended and subsequently implemented was to synchronize eligibility redeterminations for clients. Clients were typically receiving multiple services from the agency (Food Assistance, Medicaid, etc.) but the time periods for re-determining eligibility for each service was different. Agency staff would review the same information for a client for one service and then later review the same information for the same client for a different service. By synchronizing the time periods for these reviews the agency could save approximately 2.6 million dollars per biennium (one-half of which was the state’s share).

We have used this methodology in both large (as noted above) and small studies as well such as a study of clerical services for a county senior services office and found equally successful results.

February 2, 2011

Rulings on Health Care Reform

Many of our clients are asking us about the recent ruling in Florida on Health Care Reform and what it means to their efforts implementing the legislation.  First off we are not attorney’s and we don’t make policy or laws.  We simply help you implement policies and laws.  We’re the first to admit we don’t have expertise in constitutional law. That said, it does appear that the ruling is headed for the Supreme Court at some point in the future. Despite sensational headlines the rulings in the 4 cases to date have been split.  Florida is the only court that has declared the entire law unconstitutional.  Further, if history is any judge lower court rulings are not good predictors of a Supreme Court decision.

We base our advice on empirical data.  The most conservative stance (from a business perspective) we can take based on the data available to us is that our clients should continue to prepare for the implementation of the law.  We’re in for a long road ahead (both the legal battles associated with and work required to implement the ACA) and the deadlines are looming

December 27, 2010

Some Challanges of Health Benefit Exchanges

Despite recent court rulings the ACA will likely be implemented substantially intact (one of the most rational analysis we’ve seen is here). This means many of our clients are beginning work on a Health Benefit Exchange (HBE) – a kind of super store for insurance shoppers. Over the next few months we’ll examine the challenges our clients face in planning and implementing HBEs and the solutions they find to those challenges. We’re going to start with just a few of the obvious challenges:

  • Many of these initiatives are falling on state insurance commissions to implement because of their knowledge of state insurers. The interface for an HBE is required to determine eligibility and enroll eligible participants on the spot. This part of an HBE makes it more like an entitlement or grant program (Medicaid, TANF/SNAP etc). There are two technical challenges here. First, insurance commissions don’t have experience running large scale eligibility and enrollment programs. Second the IT staff of insurance regulators is typically quite lean, i.e. they don’t have the staff necessary to build and run the infrastructure required for such programs.
  • States will need to make a decision early if they will support a single solution for all HBE needs or have separate solutions for individuals and small businesses. The needs of these two groups are different and alternatives must consider requirements for both groups.
  • Developing an effective user interface (UI) to compare plans will be difficult. Insurance plans are not developed in a manner that promotes easy comparison. Different insurance companies often use variations in the way plans are presented to market their strengths. In addition to the policy implications associated with this there are also technical development considerations: How can plans be displayed and prepared? Should there be other features on an HBE site (e.g. health education information)? And, what are the best ways to design sites focused on consumers?
  • The Federal Government recommends that states have a common web based front end for HBE Subsidies, CHIP and Medicaid programs (section 1413 and 2201 of the ACA). This includes both determination of eligibility and enrollment for these programs. Developing effective web front ends for any application is challenging. Finding an effective means of utilizing other state information services (eligibility determination and enrollment for these other programs) represents a challenge few states have conquered. Collaboration between agencies running entitlement and grant programs and the insurance agencies technology divisions will be a must to make an HBE work.
  • Related to eligibility and enrollment, the volume of potential enrollees in an HBE supported plan will dwarf the current number of Medicaid users in a state. They will enroll over a relatively short time period. Insurance providers will need to be in the system. HBE projects need to plan an approach that gets insurance providers in the system and can screen a large number of applicants in a short time.

We are working with our clients to address these challenges. As common solutions emerge we’ll share those with you (along with other challenges we find!).

November 24, 2010

Happy Holidays

The crew at Public Knowledge wishes all of you a happy holiday season.

Thanks to all our clients who have helped make this one of the best years ever for us.  We appreciate you and the work you have entrusted us with.  We look forward to continuing to serve you in 2011.

November 17, 2010

Should Government Be In The IT Business?

We asked the Chief Information Officer (CIO) of a large state health and human services agency an interesting question recently: does he need a large information technology (IT) organization? We had been discussing the “core competencies” of a health and human services agency and wondered if IT was one of them. He granted it was a fair question. Here’s the context and summary of our discussion:

The CIO was engaged in the procurement of a Medicaid Management Information System (MMIS). The project was stretching his resources thin and he was relying on us (PK) to supplement his staff with MMIS procurement expertise. We were leading a discussion of procurement strategies and the question came up “Why can’t we just outsource the whole thing, why do we need to buy an MMIS – can’t we just rent one like other people rent applications like Salesforce?” The CIO had been reading a lot about Software as a Service (SaaS) and this seemed to make some sense to him. The potential benefits are large:

  • He’s already being asked to cut his capital (one time expenditure) budget and this could provide a significant reduction. It may even offer operating budget cuts as well;
  • He has been worried about getting and keeping the staff required to implement and maintain a large system. He has had a lot of staff attrition due to retirement and difficulty in recruiting and training new staff;
  • He has wanted to devote his staff efforts to more strategic projects (as opposed to the operational nature of an MMIS) that would better support the agency.

There were some obvious roadblocks:

  • A waiver from CMS would be required – the law technically says states have to construct and maintain an automated system to handle Medicaid claims;
  • Most MMIS vendors, despite what their marketing literature tells you, are not prepared to run Medicaid as a software service;
  • He believed vendors would try and create lock-in with their product through proprietary data formats and unique features. After some discussion the realization dawned this is the case with the way things work now.
  • There was a long discussion about privacy and security. How would that be ensured? The technical staff in the discussion assured us through the use of Virtual Private Network technology such a set up would be no less secure than their existing systems.

Overall it was a thought provoking discussion. Though we didn’t reach any definitive conclusions we all realized this approach has significant potential. The recent elections emphasized government agencies will have to live with less. This CIO is on the forefront of identifying ways to deal with these budget shortfalls and on effectively using technology to further the mission of his agency.  We’re continuing to work with the agency to flesh out the implications of this strategy.

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