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To address the ever-changing landscape of the healthcare industry and improve clinical strategy and operations, a large healthcare organization decided to integrate two utilization management (UM) functions.

In less than five months, with the help of SDLC Partners, the organization performed a comprehensive transformation of UM function resulting in mapped processes for desired-state with efficiencies, on-site support for operational compliance, improved customer service as a result of decreased cycle-time and reduced backlog, and savings of approximately 4,500 full-time employee hours/year.

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The Challenge

The client launched a comprehensive strategy to objectively assess and improve both clinical strategy and operations to optimize administrative costs while reducing care costs. Through prior engagements, SDLC Partners discovered major synergies between UM functions of the Pharmacy Department and Medical Department and recommended an organizational integration. In response, the health plan escalated this initiative to capture immediate organizational value and enable significant savings.

Successfully integrating the two departments required identifying and addressing several specific challenges including: compliance and industry standards, culture, process and metrics for monitoring performance, and technology.

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The Solution

The healthcare organization called upon SDLC Partners to provide the necessary due diligence and industry expertise to effectively integrate the two organizations.  The SDLC team which included healthcare specialists, technical analysts, and report developers applied SDLC’s business transformation delivery framework to execute the following in just under five months:

  • Physical Relocation: Planned and supervised the relocation of over fifty personnel, with minimal to no impact on daily operations
  • Business Process Re-engineering: Documented, analyzed and re-engineered over seventy business processes for a future TO-BE state that brought cohesiveness between the two departments and drove process
  • Reporting: Designed and developed over fifteen reports in Cognos to improve transparency, accuracy, and fact-based decision
  • Technical Requirements, Design Evaluation, & Implementation: Performed an evaluation of the desired-state UM system to enable successful, compliant Pharmacy operations over a two- year period. This evaluation compared:
    • Modifying the existing Medical UM platform to accommodate integrating Pharmacy operations
    • Enhancing the in-house Pharmacy platform to address compliance requirements. In preparation for development, the team recommended/developed more than ten requirements use cases targeting critical system functionality
  • Operations Governance: Monitored and trended daily operational volume across functions and audited samples of cases for compliance errors
  • Change Management & Training: Produced seven desktop reference guides, conducted end-user training, and supported implementation efforts. One-on-one management support, weekly status meetings, and management updates were used to facilitate collaboration, cross-communicate issues, and enact changes to day-to-day operations.

Business Transformation Delivery Framework

SDLC Partners has created a unique, end-to-end delivery framework that provides easy to understand, actionable solutions that deliver customer quality and improved financial performance. This comprehensive package of services provides for a range of organizations’ business objectives and maturity needs.

Capability PrintTM: Takes ad-hoc processes performed differently across departments and assesses process maturity, documents AS-IS state, and analyzes gaps to TO-BE capabilities
Lean PrintTM: Takes managed processes that lack consistent standards and are weakly integrated and analyzes process value, develops efficient TO-BE processes, and establishes performance metrics
Capacity PrintTM: Improves standardized processes through balancing volume and capacity, staffing models, knowledge-sharing, and clear business cases for technology platforms and roadmaps to predictable levels of efficiency and productivity
Improve PrintTM: Coordinates predictable processes and their metrics using balanced scorecards and governance processes for change management, to facilitate management decision making, strategic planning, capital allocation, and optimized processes
Readiness PrintTM: Provides critical support for implementation, documentation, production support, and project and change management to ensure a ready and successful transformation.

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The Results

In less than five months, the Pharmacy department was integrated and new operations and performance levels were becoming business as usual. The integration initiatives yielded the necessary short-term wins and set the department on a course for their long-term strategy and substantial administrative savings. Over the course of the integration, the healthcare organization made the following accomplishments:

Improved Compliance

  • Reduced cycle-time for preparing Medicare Part D and URAC accreditation data using new reporting
  • Delivered requirements use cases for improved control and assignment of request inventory to ensure on-time completion
  • Reduced in-process errors through new quality control responsibilities for personnel, until system changes were made
  • Improved correct and timely reporting to the CMS Independent Review

Reduced Costs

  • Eliminated approximately $200,000 annualized excessive overtime expenses through improved daily scheduling that aligned staffing capacity to accommodate peak demand hours
  • Re-engineered processes that aligned with best practices, leveraged relationship with other health plan stakeholders, and eliminated non-valued added steps
  • Re-tooled the reporting catalog to enable more efficient, transparent, and fact-based decision making for management and compliance

Improved Customer Service

  • Improved customer satisfaction and reduced overall cycle-time and errors when processing cases by implementing a new process for handling requests over the phone
  • Eliminated the backlog of work that contributed to long turnaround times and established a management approach to sustain a zero-backlog

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