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Use caseUC0245

Name the real cause behind a health plan complaint

A member's complaint is written about how it felt, not what caused it, so remediation often goes to the wrong team. This app names the operational driver behind each complaint and cites the exact sentence that proves it.

For the quality operations leadHealthcare

Why it matters

Today's manual process, and the same job with the app

A quality operations analyst at a health plan, reviewing one quarter's complaint file for the Stars team.

✕Today's manual process

1Read every complaint and judge, from the wording alone, what actually went wrong.
2Write a driver summary ranking causes by how often they show up.
3Miss the small ones a driver tripling in size looks the same as one that never changes.
4File it at the surface and the wrong team spends months fixing a problem that was never theirs.
A driver summary written from wording alone

✓With the app

1Each complaint is read and the real cause is named, not just the wording.
2Every driver maps itself to its measure and the team that owns it, by lookup.
3Growth is tracked period by period, against a fixed rule, not a ranking.
4Only one action is legal summarize for the team; nothing is closed automatically.
A driver summary with its evidence attached

See it work

One real case: what the app reads, step by step

A member reports nobody answers the phone, but the real cause is a case manager whose open members were never reassigned.

Name the real cause behind a health plan complaintReference appBuilt to be shaped to your process
  1. 1The complaint The member says nobody answers the phone, and hold music is all there is.
  2. 2What actually happened Operations confirm the case manager left in May, and open members were never reassigned.
  3. 3The driver it names Care-coordination, not the call-hold-time the complaint reads as.
  4. 4The sentence it cites The exact line about the case manager, not the member's own words.
  5. 5What it will not do The member asked to close the file. It answers with a summary instead.

For engineers

How it is built, and how we measured it

All fourteen steps of the build are written up, from the business case to running it in your own environment.

Kit overview →
71 of 74complaints, the right driver namedmeasured in 06 Evals →
74 of 74complaints where the only allowed action heldmeasured in 06 Evals →
63 of 71complaints where the cited sentence was rightmeasured in 06 Evals →
0.8¢to read one complaintmeasured in 07 Unit cost →

The build, step by step

14 steps

Make it yours

What you see is a reference app. We shape it to how you work.

Every part of it is built to change, and none of it means starting over.

Your rulesYour own driver list, measure register and which action is ever legal.
Your recordsYour own complaint files and operations notes, in the format you already keep them.
Your systemsReads from your complaint queue; a new driver can be raised into your own list.
Your screensThe fields, codes and wording your quality team already uses.

Want this for your team?

Talk to us

We can run this on your own complaint file, with your own driver list, inside your environment.

Talk to us →
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