Procuring agile vs.

non-agile

projects in five stages: An overview

Government projects conducted in challenging conditions require trust, collaboration, communication, and project management acumen to succeed. Here are five recommendations for project success.

In today’s dynamic technical, business, and political environment, government projects often come with significant challenges, including undefined scope and unclear deliverables, rapidly changing influencing factors, diverse groups of busy stakeholders, and multiple vendors with work interdependencies. Although these generally are not optimal conditions in which to conduct a project, leaders often choose to move forward anyhow since doing so seems less risky than maintaining the status quo. And when faced with federal, state, or other mandatory requirements, leaders may be forced to move forward with projects they have not prioritized or planned for.

To facilitate success in such situations, projects need to abide by traditional project management best practices. They also demand a commitment to clear, open, and honest communication by all team members – government and vendor alike.

Five important activities to guide complex government projects toward success include:

1. Create a culture of trust and collaboration: Establish trust and collaboration with the project team from the beginning, aligning disparate stakeholders by focusing on common project goals and objectives. Doing so lays the foundation for future project communications and decision making, which is particularly important if times get tough.

2. Establish clear roles and responsibilities: Define roles and responsibilities early in the project to create a strong sense of ownership for assigned tasks. Doing so will ensure that government and vendor project teams avoid duplication of effort, while preventing work from ‘slipping through the cracks’. This also helps people focus on the right tasks at the right time, maximizing their involvement and minimizing their effort so they may effectively continue their ‘day job’.

3. Check in regularly: Hold regular checkpoints and work sessions to discuss the latest project information and changes in the current environment. This allows the team to make and document decisions to ‘correct course’ as needed, keeping the project headed toward its goals while minimizing time- and resource-consuming detours.

4. Define — and redefine — outcomes: Regularly confirm that work products and targeted outcomes remain relevant as factors in the project environment change. As work progresses, it is essential to ensure that links between all vendor work products remain clear and efforts are integrated. If changes are needed, follow a formal change management process, allowing key stakeholders outside of the project team to weigh in on the requested changes and document approved changes for posterity.

5. Communicate risks openly: Understand that risks are a normal and healthy part of any project and openly discuss them. When risks are identified early, without fear of repercussion, they are more likely to be addressed promptly, preventing them from turning into issues that negatively impact project success.

By integrating traditional project management practices with an unyielding commitment to transparency, collaboration, and communication, even the most challenging of government projects may achieve success and deliver tangible, valuable outcomes.

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification effort.

Measuring performance of Medicaid Enterprise Systems (MES) is emerging as the next logical step in moving Medicaid programs toward modularity. As CMS continues to refine and implement outcomes-based modular certification, it is critical that states adapt to this next step in order to continue to meet CMS funding requirements.

This measurement, in terms of program outcomes, presents a unique set of challenges, many of which a state may not have considered before. A significant challenge is determining how and where to begin measuring program outcomes―to meet it, states can leverage a trusted, independent partner as they undertake an outcomes-based effort.

Outcomes-based planning can be thought of as a three-step process. First, and perhaps most fundamental, is to define outcomes. Second, you need to determine what measurements will demonstrate progress toward achieving those outcomes. And the final step is to create reporting measurements and their frequency. Your independent partner can help you answer these critical questions and meet CMS requirements efficiently by objectively guiding you toward realizing your goals.

1. Defining Outcomes
   When defining an outcome, it is important to understand what it is and what it isn’t. An outcome is a benefit or added value to the Medicaid program. It is not an output, which is a new or enhanced function of a new MES module. An output is the product that supports the outcome. For example, the functionality of a new Program Integrity (PI) module represents an output. The outcome of the new PI module could be that the Medicaid program continuously improves based on data available because of the new PI module. Some outcomes may be intuitive or obvious. Others may not be as easy to articulate. Regardless, you need to direct the focus of your state and solution vendor teams on the outcome to uncover what the underlying goal of your Medicaid program is.
    
2. Determining Measurements
   The second step is to measure progress. Well-defined Key Performance Indicators (KPIs) will accurately capture progress toward these newly defined outcomes. Your independent partner can play a key role by posing questions to help ensure the measurements you consider align with CMS’ goals and objectives. Additionally, they can validate the quality of the data to ensure accuracy of all measurements, again helping to meet CMS requirements.
    
3. Reporting Measurements
   Finally, your state must decide how―and how often―to report on outcomes-based measurements. Your independent partner can collaborate with both your state and CMS by facilitating conversations to determine how you should report, based on a Medicaid program’s nuances and CMS’ goals. This can help ensure the measurements (and support information) you present to CMS are useful and reliable, giving you the best chance for attaining modular certification.

Are you considering an outcomes-based CMS modular certification, or do you have questions about how to best leverage an independent partner to succeed with your outcomes-based modular certification effort? BerryDunn’s extensive experience as an independent IV&V and Project Management Office (PMO) partner includes the first pilot outcomes-based certification effort with CMS. Please visit our IV&V and certification experts at our booth at MESC 2019 or contact our team now.

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

As CMS moves away from the monolithic Medicaid Management Information System (MMIS) toward an outcomes-based approach that includes a modular Medicaid Enterprise System (MES), there is now more emphasis on system integration (SI). 

In the August 16, 2016 letter, State Medicaid Director (SMD) #16-010, CMS clarified the role of the system integrator (SI) by stating:

CMS envisions a discrete role for the system integrator (SI) in each state, with specific focus on ensuring the integrity and interoperability of the Medicaid IT architecture and cohesiveness of the various modules incorporated into the Medicaid enterprise. 

While the importance of the SI role is apparent, not all states have the resources to build the SI capability within their own organizations. Some state Medicaid IT teams try to solve this by delegating management roles to vendors or contractors. This approach has various risks. A state could lose:

• Institutional knowledge, as vendors and contractors transition off the project
• Control of governance, oversight, and leadership
• The ability to enforce contractual requirements across each vendor, especially the SI

In addition, the ramifications of loss of state accountability can have wide-reaching implementation, operational, and financial impacts, including:

• The loss of timely decision making, causing projects to fall behind schedule
• State-specific policy needs not being met, impacting how the MMIS functions in production 
• Poor integration into the state-specific Operation and Maintenance (O&M) support model, increasing the state’s portion of long-term O&M costs
• Inefficient and ineffective contract management of each module vendor and contractor (including the SI), possibly leading to unneeded change requests and cost overruns
• Lack of coordination with the state’s business or IT roadmap initiatives (i.e., system consolidation or cloud migration vendor/approach), possibly leading to rework and missed opportunities to reduce cost or improve interoperability 

Apply strong governance and IV&V to tackle risks

Because the SI vendor is responsible for the integration of multiple modules across multiple vendors, you may consider delegating oversight of module vendors to the SI vendor. 

The major benefit states get from using the SI vendor is efficiency. Having your vendor as the central point of contact can quickly resolve technical issues, while allowing easy coordination of project tasks across each module vendor on a continual basis. 

If you choose to use a vendor for the SI role, establish safeguards and governance to make sure your goals are being met:

• Build a project-specific governance model (executive committee [EC]) to oversee the vendors and the project
• Establish a regular meeting cadence for the EC to allow for status updates on milestones and discuss significant project risks and issues 
• Allocate state resources into project leadership roles (i.e., project manager, vendor contract manager, security lead, testing/Quality Assurance lead, etc.)
• Conduct regular (weekly) SI status meetings to track progress and address risks and issues 

You also need a strong, involved governance structure that includes teams of state senior leadership, state program managers, SI vendor engagement/contract managers, and Independent Verification and Validation (IV&V) vendors. By definition, one responsibility of IV&V is to identify and monitor project risks and issues that could arise from a lack of independence. 

Your governance teams can debate decisions and disputes, risks and issues, and federal compliance issues with their vendors to define direction and action plans. However, a state representative within these teams should always make the final management decisions, approve all SI scope items and changes, and approve all contractual deliverables from each vendor or contractor.

Your state staff (business and IT) provides project management decision, business needs, requirements (functional and non-functional), policy guidance, and continuity as the vendors and/or contractors change over time. 

The conclusion? In order to be successful, you must retain certain controls and expertise to deploy and operate a successful MMIS system. Our consultants understand the need to keep you in control of managing key portions of implementation projects/programs and operational tasks. If you have questions, please contact BerryDunn’s Medicaid team.  
 

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

When I was growing up, my dad would leave the Bureau of Motor Vehicles or hang up the phone after talking with the phone company and say sarcastically, “I’m from the government (or the phone company) and I’m here to help you. Yeah, right.” I could hear the frustration in his voice. As I’ve gotten older, I understand the hassle of dealing with bureaucracy, where the red tape can make things more difficult than they need to be, and where customers don’t come first. It doesn’t have to be that way.

In my role performing Independent Verification and Validation (IV&V) at BerryDunn, I hear the same skepticism in the voices of some of my clients. I can hear them thinking, “Let me get this straight… I’m spending millions of dollars to replace my old Medicaid Management Information System (MMIS), and the Centers for Medicare and Medicaid Services (CMS) says I have to hire an IV&V consultant to show me what I am doing wrong? I don’t even control the contract. You’re here to help me? Yeah, right.” Here are some things to assuage your doubt. 

Independent IV&V―what they should do for you and your organization

An independent IV&V partner that is invested in your project’s success can:

• Enhance your system implementation to help you achieve compliance
• Help you share best practice experience in the context of your organization’s culture to improve efficiency in other areas
• Assist you in improving your efficiency and timeliness with project management capabilities.

Even though IV&V vendors are federally mandated from CMS, your IV&V vendor should also be a trusted partner and advisor, so you can achieve compliance, improve efficiency, and save time and effort. 

Not all IV&V vendors are equal. Important things to consider:

Independence―independent vendors are a good place to start, as they are solely focused on your project’s success. They should not be selling you software or other added services, push vendor affiliations, or rubber stamp CMS, nor the state. You need a non-biased sounding board, a partner willing to share lessons learned from experience that will help your organization improve.

Well-rounded perspective―IV&V vendors should approach your project from all perspectives. A successful implementation relies on knowledge of Medicaid policy and processes, Medicaid operations and financing, CMS certification, and project management.

“Hello, we are IV&V from BerryDunn, and we are here to help.”

BerryDunn offers teams that consist of members with complementary skills to ensure all aspects of your project receive expert attention. Have questions about IV&V? Contact our team.
 

As the Project Management Body of Knowledge^® (PMBOK^®) explains, organizations fall along a structure and reporting spectrum. On one end of this spectrum are functional organizations, in which people report to their functional managers. (For example, Finance staff report to a Finance director.) On the other end of this spectrum are projectized organizations, in which people report to a project manager. Toward the middle of the spectrum lie hybrid—or matrix—organizations, in which reporting lines are fairly complex; e.g., people may report to both functional managers and project managers. 

Problem: Weak Matrix Medicaid System Vendors

This brings us to weak matrix organizations, in which functional managers have more authority than project managers. Many Medicaid system vendors happen to fall into the weak matrix category, for a number of different reasons. Yet the primary factor is the volume and duration of operational work—such as provider enrollment, claims processing, and member enrollment—that Medicaid system vendors perform once they exit the design, development, and implementation (DDI) phase.

This work spans functional areas, which can muddy the reporting waters. Without strong and clear reporting lines to project managers, project success can be seriously (and negatively) affected if the priorities of the functional leads are not aligned with those of the project. And when a weak matrix Medicaid system vendor enters a multi-vendor environment in which it is tasked with implementing a system that will serve multiple departments and bureaus within a state government, the reporting waters can become even muddier.

Solution: Using a Project Management Office (PMO) Vendor

Conversely, consulting firms that provide Project Management Office (PMO) services to government agencies tend to be strong matrix organizations, in which project managers have more authority over project teams and can quickly reallocate team members to address the myriad of issues that arise on complex, multi-year projects to help ensure project success. PMOs are also typically experienced at creating and running project governance structures and can add significant value in system implementation-related work across government agencies.

Additional benefits of a utilizing a PMO vendor include consistent, centralized reporting across your portfolio of projects and the ability to quickly onboard subject matter expertise to meet program and project needs. 
For more in-depth information on the benefits of using a PMO on state Medicaid projects, stay tuned for my second blog in this series. In the meantime, feel free to send your PMO- or Medicaid-related questions to me. 
 

As your organization works to modernize and improve your Medicaid Enterprise System (MES), are you using independent verification and validation (IV&V) to your advantage? Does your relationship with your IV&V provider help you identify high-risk project areas early, or provide you with an objective view of the progress and quality of your MES modernization initiative? Maybe your experience hasn’t shown you the benefits of IV&V. 

If so, as CMS focuses on quality outcomes, there may be opportunities for you to leverage IV&V in a way that can help advance your MES to increase the likelihood of desired outcomes for your clients. 

According to 45 Code of Federal Regulations (CFR) § 95.626, IV&V may be required for Advanced Planning Document (APD) projects that meet specific criteria. That said, what is the intended role and benefit of IV&V? 

To begin, let’s look at the meaning of “verification” and “validation.” The Institute of Electrical and Electronics Engineers, Inc. (IEEE) Standard for Software Verification and Validation (1012-1998) defines verification as, “confirmation of objective evidence that the particular requirements for a specific intended use are fulfilled.” Validation is “confirmation of objective evidence that specified requirements have been fulfilled.” 

Simply put, verification and validation ensure the right product is built, and the product is built right. 
As an independent third party, IV&V should not be influenced by any vendor or software application. This objectivity means IV&V’s perspective is focused on benefiting your organization. This support includes: 

• Project management processes and best practices support to help increase probability of project success
• Collaboration with you, your vendors, and stakeholders to help foster a positive and efficient environment for team members to interact 
• Early identification of high-risk project areas to minimize impact to schedule, cost, quality, and scope 
• Objective examination of project health in order for project sponsors, including the federal government, to address project issues
• Impartial analysis of project health that allows state management to make informed decisions 
• Unbiased visibility into the progress and quality of the project effort to increase customer satisfaction and reduce the risk and cost of rework
• Reduction of errors in delivered products to help increase productivity of staff, resulting in a more efficient MES 

Based on our experience, when a trusted relationship exists between state governments and IV&V, an open, collaborative dialogue of project challenges—in a non-threatening manner—allows for early resolution of risks. This leads to improved quality of MES outcomes.    

Is your IV&V provider helping you advance the quality of your MES? Contact our team.

Modernization means different things to different people—especially in the context of state government. For some, it is the cause of a messy chain reaction that ends (at best) in frustration and inefficiency. For others, it is the beneficial effect of a thoughtful and well-planned series of steps. The difference lies in the approach to transition - and states will soon discover this as they begin using the new Comprehensive Child Welfare Information System (CCWIS), a case management information system that helps them provide citizens with customized child welfare services.

The benefits of CCWIS are numerous and impressive, raising the bar for child welfare and providing opportunities to advance through innovative technology that promotes interoperability, flexibility, improved management, mobility, and integration. However, taking advantage of these benefits will also present challenges. Gone are the days of the cookie-cutter, “one-size-fits-all” approach. Here are five facts to consider as you transition toward an effective modernization.

1. There are advantages and challenges to buying a system versus building a system internally. CCWIS transition may involve either purchasing a complete commercial off-the-shelf (COTS) product that suits the state, or constructing a new system internally with the implementation of a few purchased modules. To decide which option is best, first assess your current systems and staff needs. Specifically, consider executing a cost-benefit analysis of options, taking into account internal resource capabilities, feasibility, flexibility, and time. This analysis will provide valuable data that help you assess the current environment and identify functional gaps. Equipped with this information, you should be ready to decide whether to invest in a COTS product, or an internally-built system that supports the state’s vision and complies with new CCWIS regulations.
    
2. Employ a modular approach to upgrading current systems or building new systems. The Children’s Bureau—an office of the Administration for Children & Families within the U.S. Department of Health and Human Services—defines “modularity” as the breaking down of complex functions into separate, manageable, and independent components. Using this modular approach, CCWIS will feature components that function independently, simplifying future upgrades or procurements because they can be completed on singular modules rather than the entire system. Modular systems create flexibility, and enable you to break down complex functions such as “Assessment and Intake,” “Case Management,” and “Claims and Payment” into modules during CCWIS transition. This facilitates the development of a sustainable system that is customized to the unique needs of your state, and easily allows for future augmentation.
    
3. Use Organizational Change Management (OCM) techniques to mitigate stakeholder resistance to change. People are notoriously resistant to change. This is especially true during a disruptive project that impacts day-to-day operations—such as building a new or transitional CCWIS system. Having a comprehensive OCM plan in place before your CCWIS implementation can help ensure that you assign an effective project sponsor, develop thorough project communications, and enact strong training methods. A clear OCM strategy should help mitigate employee resistance to change and can also support your organization in reaching CCWIS goals, due to early buy-in from stakeholders who are key to the project’s success.
    
4. Data governance policies can help ensure you standardize mandatory data sharing. For example, the Children’s Bureau notes that a Title IV-E agency with a CCWIS must support collaboration, interoperability, and data sharing by exchanging data with Child Support Systems?Title IV-D, Child Abuse/Neglect Systems, Medicaid Management Information Systems (MMIS), and many others as described by the Children’s Bureau.
   
   Security is a concern due to the large amount of data sharing involved with CCWIS systems. Specifically, if a Title IV-E agency with a CCWIS does not implement foundational data security measures across all jurisdictions, data could become vulnerable, rendering the system non-compliant. However, a data governance framework with standardized policies in place can protect data and surrounding processes.
    
5. Continuously refer to federal regulations and resources. With the change of systems comes changes in federal regulations. Fortunately, the Children’s Bureau provides guidance and toolkits to assist you in the planning, development, and implementation of CCWIS. Particularly useful documents include the “Child Welfare Policy Manual,” “Data Sharing for Courts and Child Welfare Agencies Toolkit,” and the “CCWIS Final Rule”. A comprehensive list of federal regulations and resources is located on the Children’s Bureau website.
   
   Additionally, the Children’s Bureau will assign an analyst to each state who can provide direction and counsel during the CCWIS transition. Continual use of these resources will help you reduce confusion, avoid obstacles, and ultimately achieve an efficient modernization program.

Modernization doesn’t have to be messy. Learn more about how OCM and data governance can benefit your agency or organization.

Truly effective preventive health interventions require starting early, as evidenced by the large body of research and the growing federal focus on the role of Medicaid in addressing Social Determinants of Health (SDoH) and Adverse Childhood Experiences (ACEs).

Focusing on early identification of SDoH and ACEs, CMS recently announced its Integrated Care for Kids (InCK) model and will release the related Notice of Funding Opportunity this fall.

CMS describes InCK as a child-centered approach that uses community-based service delivery and alternative payment models (APMs) to improve and expand early identification, prevention, and treatment of priority health concerns, including behavioral health issues. The model’s goals are to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable APMs. Such APMs would align payment with care quality and support provider/payer accountability for improved child health outcomes by using care coordination, case management, and mobile crisis response and stabilization services.

State Medicaid agencies have many things to consider when evaluating this funding opportunity. Building on current efforts and innovations, building or leveraging strong partnerships with community organizations, incentivizing evidence-based interventions, and creating risk stratification of the target population are critical parts of the InCK model. Here are three additional areas to consider:

1. Data. States will need information for early identification of children in the target population. State agencies?like housing, justice, child welfare, education, and public health have this information?and external organizations—such as childcare, faith-based, and recreation groups—are also good sources of early identification. It is immensely complicated to access data from these disparate sources. State Medicaid agencies will be required to support local implementation by providing population-level data for the targeted geographic service area.

• Data collection challenges include a lack of standardized measures for SDoH and ACEs, common data field definitions, or consistent approaches to data classification; security and privacy of protected health information; and IT development costs.
• Data-sharing agreements with internal and external sources will be critical for state Medicaid agencies to develop, while remaining mindful of protected health information regulations.
• Once data-sharing agreements are in place, these disparate data sources, with differing file structures and nomenclature, will require integration. The integrated data must then be able to identify and risk-stratify the target population.

For any evaluative approach or any APM to be effective, clear quality and outcome measures must be developed and adopted across all relevant partner organizations.

2. Eligibility. Reliable, integrated eligibility and enrollment systems are crucial points of identification and make it easier to connect to needed services.

• Applicants for one-benefit programs should be screened for eligibility for all programs they may need to achieve positive health outcomes.
• Any agency at which potential beneficiaries appear should also have enrollment capability, so it is easier to access services.

3. Payment models. State Medicaid agencies may cover case management services and/or targeted case management as well as health homes; leverage Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services; and modify managed care organization contract language to encourage, incent, and in some cases, require services related to the InCK model and SDoH. Value-based payment models, already under exploration in numerous states, include four basic approaches:

• Pay for performance—provider payments are tied directly to specific quality or efficiency indicators, including health outcomes under the provider organization’s control. 
• Shared savings/risk—some portion of the organization’s compensation depends on the managed care entity achieving cost savings for the targeted patient population, while realizing specific health outcomes or quality improvement.
• Pay for success—payment is dependent upon achieving desired outcomes rather than underlying services.
• Capitated or bundled payments—managed care entities pay an upfront per member per month lump sum payment to an organization for community care coordination activities and link that with fee-for-service reimbursement for delivering value-added services.

By focusing on upstream prevention, comprehensive service delivery, and alternative payment models, the InCK model is a promising vehicle to positively impact children’s health. Though its components require significant thought, strategy, coordination, and commitment from state Medicaid agencies and partners, there are early innovators providing helpful examples and entities with vast Section 1115 waiver development and Medicaid innovation experience available to assist.

As state Medicaid agencies develop and implement primary and secondary prevention, cost savings can be achieved while meaningful improvements are made in children’s lives.

A year ago, CMS released the Medicaid Enterprise Certification Toolkit (MECT) 2.1: a new Medicaid Management Information Systems (MMIS) Certification approach that aligns milestone reviews with the systems development life cycle (SDLC) to provide feedback at key points throughout design, development, and implementation (DDI).

The MECT (recently updated to version 2.2) incorporates lessons learned from pilot certifications in several states, including the successful West Virginia pilot that BerryDunn supported. MECT updates have a direct impact on E&E systems—an impact that may increase in the near future. Here is what you need to know:         

Then: Initial Release

In February 2017, CMS introduced six Eligibility & Enrollment (E&E) checklists. Five were leveraged from the MECT, while the sixth checklist contained unique E&E system functionality criteria and provided a new E&E SDLC that—like the MECT—depicted three milestone reviews and increased the Independent Verification and Validation (IV&V) vendor’s involvement in the checklists completion process.

Now: Getting Started

Completing the E&E checklists will help states ensure the integrity of their E&E systems and help CMS guide future funding. This exercise is no easy task, particularly when a project is already in progress. Completion of the E&E checklists involves many stakeholders, including:

• The state (likely more than one agency)
• CMS
• IV&V
• Project Management Office (PMO)
• System vendor(s)

As with any new processes, there are challenges with E&E checklists completion. Some early challenges include:

• Completing the E&E checklists with limited state project resources
• Determining applicable criteria for E&E systems, especially for checklists shared with the MMIS
• Identifying and collecting evidence for iterative projects where criteria may not fall cleanly into one milestone review phase
• Completing the E&E checklists with limited state project resources
• Working with the system vendor(s) to produce evidence

What’s Next?

Additionally, working with system vendors may prove tricky for projects that already have contracts with E&E vendors, as E&E systems are not currently subject to certification (unlike the MMIS). This may lead to instances where E&E vendors are not contractually obligated to provide the evidence that would best satisfy CMS criteria. To handle this and other challenges, states should communicate risks and issues to CMS and work together to resolve or mitigate them.

As CMS partners with states to implement the E&E checklists, some questions are expected to be asked. For example, how much information can be leveraged from the MECT, and how much of the checklists completion process must be E&E-specific? Might certification be required in the near future for E&E systems?

While there will be more to learn and challenges to overcome, the first states completing the E&E checklists have an opportunity to lead the way on working with CMS to successfully build and implement E&E systems that benefit all stakeholders.

On July 31, 2017, CMS released the MECT 2.2 as an update to the MECT 2.1.1. As the recent changes continue to be analyzed, what will the impact be to current and future MMIS and E&E projects?

Check back here at BerryDunn Briefings in the coming weeks and we will help you sort it out.