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Reader Question 23. What are the Core Features of your Recommendations for Managing Medicaid

Question: “I have reviewed your articles 84, 85 and 86 and followed the Insight Articles in Governing Magazine. Would you please respond to the following article ‘The Replication Challenge’ by Robert D. Behn. Behn suggests that to successfully replicate an innovation in government you must understand the core driving features of the innovation and its interaction with other key elements.”

Answer: The part of the article “The Replication Challenge” by Robert D. Behn that you are probably referring to follows: “… before the innovation can be replicated, someone has to answer two questions.

First: What are the core characteristics of the innovation? To employ the innovation in a different jurisdictional, political or organizational context, the replicators obviously need to know what, exactly, are the driving features of the innovation.

Second: What are the cause-and-effect interactions among the core features of the innovation, the context within which the innovation was implemented, and the consequences that it produced? Because the context in which any innovation will be replicated is bound to be somewhat different from the original set of circumstances, it is necessary to understand how its driving features work. After all, to make the innovation work in a new setting, it will need to be adapted in some way(s) — perhaps conspicuously, perhaps subtly. Yet, to be effective, such adaptations need to maintain not only the core features of the innovation but also the cause-and-effect relationships among these features and the context to ensure that the adaptation still produces similar benefits.

Innovating is relatively easy. Specifying the core components of the innovation and the cause-and-effect relationships among these components in such as way as to permit other jurisdictions to replicate the innovation is, however, a significant challenge.”

I will try respond directly to the challenge of Robert Behn’s excellent article. The “Team Improvement Idea” was implemented first in Japan and then became popular in American industry in the 1980s. It was known mostly as “Total Quality Management” and has since been adopted by some government agencies. The core Idea espoused by the Japanese was to build better quality products. Which was a direct result of the bad reputation that Japanese products had for being cheap and of poor quality in the 1950’s. Since there are few physical products produced by government the core idea has shifted to the Team Improvement idea. I call these “Work Improvement Teams” which focus on improving the processes of the function that they are involved with at the lowest level of the organization. I have expanded the Team improvement Idea to all levels of the government organization. First in the governor’s Blue Ribbon Committee and then to the High level Cross functional team. The key driving element to my recommended approach is in having personnel have responsibility for decision making power at their level in the organization. The result is the pooling of the innovative resources of the entire organization to focus on improving the problems at hand. The process can be stated as the driving down of the decision making process to the lowest level of effectiveness. Another way of putting this is to have those who “own” a problem participate in the solving of that problem. The immediate effect is to awaken the idea within individuals that they can make a difference the exact opposite of a bureaucratic environment where individual initiative is generally squelched.

The second innovation is in determining labor hours and therefore staffing more precisely by budgeting personnel. Budgeting personnel have long estimated the labor hours and other expenses that go into the making of a function’s budget these estimates are at best educated guesses. The following example can best explain this innovation. The key is in requiring all of the WITs to Flow Chart all of the processes of the function they are associated with. This is necessary to describe in detail how improvements to processes are to work. There may actually be two Process Flow Charts one showing the current process flow and one showing the improved process flow. These two Flow Charts are usually presented to management by the team for approval. The Flow Process Flow Charts are then given over to the budgeting personnel to calculate the savings that the team has generated. The man hour calculations although they appear to be estimates are relatively precise because of the need to find the least costly process by the WIT. Staffing of the WIT is even more precise because of the gross decision in deciding the number of personnel required. In other words you cannot staff with one half of a person making the staffing decision much simpler.

The staffing level of both employees and management along with all expenses incurred by the function is summed and divided by the number of either “units produced” or “people served” for a one month period. The result is a funding formula which when multiplied by the estimated future “units” or “people served” becomes the next years budget. The funding formula which may be valid for several years with minor changes can be used as a direct input to the Performance Budgeting system thus simplifying the entire budgeting process while significantly increasing its accuracy. The increased budget accuracy allows law makers to know with greater certainty which functions have failed to manage their budgets. The core of this process is in strengthening the budgeting process by making inputs simpler and more precise.

I hope this answers your question. The difficulty I have in the above example is that although I have presented several detailed examples as to how this process can work no one has yet implemented the entire method as a unit.

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