Redesign of Complaint Resolution Process: Leading Health Plan

The Customer Service division of a leading health plan used the Fast-Track Change Process to complete in record time a crucial redesign of its multi-regional complaint resolution process, including installation of a new IT system. This project was critical in retaining a 3-year NCQA certification.

The Problem and Opportunity

This newly merged health plan was about to receive its first three-year accreditation from the National Committee for Quality Assurance, a distinction achieved to date by only 40% of the health plans reviewed. NCQA accreditation was absolutely crucial to the company’s growth strategy. However, the accreditation would be given only if the health plan rapidly and substantially redesigned its process for resolving customer complaints.

One big problem was lack of consistency across regions. Prior to the merger, the two health plans had used very different processes, one centralized, one decentralized. The growth of the company into new regions had only increased the inconsistency. The merged health plan needed to demonstrate not only that a consistent, well-monitored process was being implemented. It was also clear that the redesigned process would require a new, customized IT system.

An internally-facilitated cross-functional team of employees had already been working hard on the issue, meeting half-a-day, twice-a-month for a number of months. This team had mapped the existing process, done some analysis, and developed a framework of complaint categories. But they were far from completing the work needed, and they were unsure what would happen to their final report. Too often in the past, task force recommendations had disappeared into a “black hole” of senior management indecision.

At this point, the deadline for demonstrating an improved complaint-resolution process was approaching rapidly. Because the company had already experienced the speed and effectiveness of the Fast-Track Change Process, they turned to us to facilitate the project needed to ensure NCQA accreditation.

The Project

This redesign project was co-led by the VP of Customer Service and a senior member of the Medical Directors Office. An additional project sponsor came from IT and from each of the company’s regional offices. This Sponsor Team clarified the “project challenge:” To develop and implement the common procedures and standards needed for consistent, timely, “customer service and quality focused” resolution of all member concerns. Project participants also had to develop and implement company-wide procedures to generate data and analysis for quality improvement initiatives.

Much faster than other approaches! The process of team-building occurred so rapidly! Excellent facilitation. We will need to use this elsewhere in the organization as we get bigger with so many customers and constituencies.

The corporate commitment was evident and gave the process force. The use of external consultants helped in building Sr. Management teamwork and gaining their collective buy-in.

A cross-functional Planning Team, which included the members of the previous task force, planned a three-and-one-half day Redesign Meeting that involved about 50 people who had an intimate working knowledge of the existing process. At this event, four cross-functional teams, each facilitated and assigned to a different part of the overall process, developed detailed, coordinated recommendations. A fifth team of IT experts simultaneously developed a set of high-level recommendations for the system needed to support the redesigned process.

On the last half-day of the Redesign Meeting, the five teams presented the Sponsors with their recommendations for change. Impressed with what the redesign teams had produced, the Sponsors approved all recommendations with only a few “tweaks.” Project participants were jubilant.

Other [change efforts I’ve been involved in] were no way as effective. This was swift, accurate, taken seriously, and highly prioritized. At the Redesign Meeting, we got literally one year of work done in 4 days, with immediate feedback and buy-in.

As a former facilitator in our quality management area, the speed with which a process can be redesigned and approved in this process is remarkable. Our competitive marketplace demands that we as an organization be able to respond much faster than we have in the past. This approach will help us do that.

The Results

Immediately after the Redesign Meeting, the approved recommendations were converted into a detailed implementation plan, spearheaded by a Project Champion and a Core Implementation Team consisting of key people from the Redesign Meeting. Every 30 days, this team met with the Sponsor Team to review progress. While all Redesign Meeting participants worked on implementation, Sponsors played an important leadership role throughout this phase, removing potential roadblocks to rapid execution. Documentation that this process was well under way won the company its 3-year NCQA certification. Even more importantly, they achieved, in record time, full implementation of a much higher quality process, including the new IT system.

As a project sponsor, I learned that rapid change processes are actually possible! The pre-work to specify the scope, desired outcomes, and challenges really focused the effort. Also, the decision-making coaching for the Sponsors. We should use this tool frequently.

The right people were involved with the planning and redesign, and the decision-makers were immediately available to provide commitment for follow-through and implementation. This allowed objectives to be accomplished in an expedited fashion, especially in areas that need immediate improvement.

More efficient and effective than any other process I’ve been involved in. It is an effective way to accomplish important, big projects in a timely manner.

The consultants were really great. They did an excellent job of keeping us on track.

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