Possibly the Longest Government Form in the World?
45 pages, 1,000 questions, 18,000 words
In 2015, citizens in the state of Michigan seeking public benefits had to fill out this application form (DHS-1171), administered by the Michigan Department of Health and Human Services (MDHHS).
How successful do you think you would be at filling the above form out? The absurdity of the form is overwhelming.
We literally would have people who had a Ph.D. and say, ‘I can read this, but I actually don’t understand this’
-Michael Brennan, Civilla
Civilla, a non-profit design firm in Detroit, decided to take on the challenge of this form, on behalf of the millions of citizens in Michigan and the caseworkers forced to use it on a daily basis. Without a contract in hand or any resources to support the work, they formed a team and used the process of user-centered design to understand the difficulty experienced by clients applying for public benefits.
They eventually partnered directly with MDHHS to reimagine that form with a 2–3 year engagement, conducting research, design, and implementation to create a new form that was “short, simple, and relevant”.
Here is the revised version of the form compared with the old form:
It was a design success!
There were: 60% fewer pages, 80% fewer questions, and 80% fewer words.
With regard to outcomes, the percentage of individuals who successfully completed the application, jumped from 72 to 94 percent with the new form.
The average time it took to fill out the form decreased from 40 minutes to 16 minutes.
Civilla has won a number of design awards (Core 77, IDA, and the Harvard University Top 25 Innovations in American Government) for Project Re:form, which makes me pause and think:
What lessons from Project Re:form can we apply to Healthcare?
Understand that Lack of Design Leads to Poor Design
It’s not as if the policymakers or state officials were deliberately trying to create pain points for the users of the public benefits form, but:
“Over time, as legislation and federal regulations changed, the form just grew and grew. Things kept getting added, but nothing was removed. Over the years, we tried to downsize it, but there were always other priorities or limited resources.” Terry Beurer, Deputy director for field operations administration for the MDHHS.
This is exactly what happens in healthcare. The undesigned pieces of a complex system become a horrible mess that is very difficult to manage when you don’t have a user-centered approach.
Wield the Power of the Artifact
Before the state even knew that they were working on this design challenge, Civilla invited leaders from the Michigan Department of Health and Human Services to an immersive storytelling exhibit at their design studio in Detroit:
When the government leaders got off the elevator, Brennan and his team had fixed up the hallway to look like a public benefits office, complete with chairs, people filling out forms and ambient office noises piped in over speakers. Brennan gave them a copy and asked them to complete the form, waiting a full 15 minutes as they struggled with questions, including a now-infamous inquiry asking the dates an applicant’s children were conceived.
“That was the first time some of them had seen the application,” said Lena Selzer, Civilla’s director of design. “I think it was really eye-opening for them.”
Afterward, the team led the state officials into the storage room where the blueprint for lasting and effective change was spread on the floor, all 100 feet of it, taking attendees through a journey of what happens after a resident turns in an application.
Brennan apparently carried that scroll with him in his briefcase for about 6 years, trying to provoke leaders through “their head and their heart”.
The exhibit was used not only for engaging state leadership but it was also critical for reaching stakeholders while conducting a rollout of the form across the state:
“Rather than communicating through traditional government memos or powerpoint presentations, Civilla built a 5,000-square-foot exhibit that brought to life real stories of the people at the center of the work: residents and caseworkers. Civilla began building relationships through one-on-one meetings and tours of the Project Re:form exhibit in the Detroit studio. To better reach stakeholders in Lansing, the team created a copycat exhibit within walking distance of the Capitol building.
One MDHHS Stakeholder stated: “I have been involved with many initiatives within the State of Michigan over the years. I haven’t ever experienced the way this initiative is being communicated. You didn’t just tell us — you involved us.”
Target a well defined problem that people can understand
The form was an obvious and compelling problem experienced by millions of residents in Michigan who have little time and bandwidth to navigate such a confusing system. As Adam and Lena Selzer describe in this video, Civilla could have framed the design challenge as “reimagining the entire public benefit system”, a challenge that might have been considered too broad and too complicated from the perspective of leadership at the state.
The team decided to focus on the redesign of the form as it was a concrete deliverable that could be easily understood by stakeholders. This makes total sense, as the form is the object/artifact that introduces and mediates the interactions between users, caseworkers, and the larger system.
Partner and Innovate Within Institutions
I doubt Civilla would have been able to accomplish what they did without partnership from the state, given the size and scale of the population being served by MDHSS.
Here is a copy of the application before the redesign. The red areas represented legal text (wow that’s a lot of red!), and the windows with text cut out represented redundancies where the same information was repeatedly asked of the user multiple times.
The team was able to remove close to 80–90% of the form, and created a document that met “ALL federal, state, and departmental policy requirements”.
This seems miraculous given that lawyers and government regulators were involved. No doubt the complexity of state and federal regulation could have killed the best designed prototype ever.
I do truly appreciate Civilla’s lens toward innovation, which focuses on change from within public institutions. As they describe on their website:
Civilla originated from our team’s shared belief that there is untapped power in our public-serving institutions to create positive social change on a massive scale.
Use Design to Save Lives.
There is increasingly a greater awareness of the impact of social determinants on the overall health of individuals and populations. If you can’t apply for food or cash assistance or obtain coverage through Medicaid because of a complicated and confusing enrollment process, this will have significant negative consequences for your health.
Decreasing the friction of the enrollment process and increasing access will no doubt improve health outcomes and save lives in the state of Michigan. Apparently the state ended up paying Civilla $830,000 for the project, which is truly incredible value for health!
Bravo Civilla!
I tweet and blog about design, healthcare, and innovation as “Doctor as Designer”. Follow me on Twitter and sign up for my newsletter!
Click here for information about creative commons licensing. Disclosures: T1D Exchange, Grant funding from Lenovo.
Learn more about Civilla and their work at these links:
