Worked Example — Policy and Procedure Decision Walk-Through

Content

Worked Example — Policy and Procedure Decision Walk-Through Resource type: Tier 1 Flagship — EAT Walk-Through (Methodology Education, Not Analysis) Adapted from: DHS Equity Analysis Toolkit Guide (Minnesota DHS) — all six steps, applied to a hypothetical policy and procedure scenario Library home: L01 EAT Walk-Through Library Companion to: T02_01 through T02_10 (all EAT walk-throughs), T02_11, T02_12 (other worked examples) IMPORTANT — Scope of this resource: This is an anonymized hypothetical example demonstrating the methodology of the DHS Equity Analysis Toolkit. It does not perform equity analyses on real DSD programs, real communities, or real data. All names, figures, and scenarios are illustrative. Actual equity analyses are conducted by the appropriate authorities — your Equity Champion, the One DSD Equity Team, or the DHS Equity Director for your work area. What this step is for This third worked example applies the EAT to a policy and procedure change affecting multiple service areas — one of the most common contexts in which equity analysis is required but also one where the distributed impact across service areas can make the analysis feel unwieldy. This example demonstrates how to scope and conduct analysis when a single policy change has downstream effects across multiple program areas and multiple communities. Plain-language overview Hypothetical scenario: Standardized Documentation Protocol — Multi-Service Area Procedural Change [Note: All details in this scenario are hypothetical and constructed for methodology illustration only. They do not represent any real DSD program, real data, or real community conditions.] DSD leadership is proposing a new standardized documentation protocol that would apply across multiple service areas. The protocol would require that all client-facing service interactions be documented within 24 hours in a specific electronic format. The change is motivated by audit findings suggesting inconsistent documentation across service areas and is intended to improve accountability and quality of service records. The proposal affects three program areas: a waiver case management unit, a community-based services coordination unit, and a crisis intervention unit. Each area serves overlapping but distinct populations. Walk-through (the methodology) Before Step 1: Equity Lens Needs Assessment Questions: • New or modification? New standardized protocol. • Impact scope? Affects approximately 600 clients across three program areas; affects approximately 80 staff. • CLAS, workforce, contracting? Yes — both workforce (staff) and CLAS (service delivery responsiveness to diverse communities) are affected. • Timeline? 90-day implementation timeline from leadership. Timeline negotiated to 5 months to allow equity analysis and phased implementation. • Previously analyzed? The individual program areas have conducted prior analyses; a combined cross-program analysis has not been done. Needs Assessment conclusion: Equity Analysis Track. Cross-program scope requires multi-team coordination and Equity Director involvement across all three areas. Step 1: Frame the Decision/Issue Proposal: Standardized 24-hour electronic documentation protocol for all client-facing interactions across three named service areas. Internal impacts: • Staff: Case managers and coordinators who currently document at varying intervals or using varying formats will be required to change workflows. Frontline staff who work remotely or in community settings may have limited access to electronic systems within 24 hours of some interactions. • Data: Standardization will enable cross-program data analysis not currently possible. This is a benefit to program leadership but a potential equity concern if data is used in ways that create additional scrutiny for certain communities. External impacts: • Clients: Documentation practices affect how client interactions are recorded, which affects the accuracy of service records, the quality of continuity across service interactions, and the evidence base for client appeals or grievances. • Communities: If documentation requirements create delays in service delivery (because staff prioritize documentation over additional service contacts), certain communities may experience more significant service quality impacts than others. Intended community result: More accurate and consistent service records, enabling better quality review and continuity of care across service providers. Intended organizational outcome: Documentation compliance rate increases; audit findings related to inconsistent documentation are resolved; cross-program data analysis becomes possible. Disparity domains: Health, disability-specific service access, employment (for crisis unit clients with employment-adjacent services). Key questions surfaced at Step 1: • Does the 24-hour documentation requirement differentially affect staff who work with certain populations (e.g., crisis intervention staff who work non-standard hours, or staff who conduct home visits in areas with limited connectivity)? • Does inconsistent documentation affect certain client populations differently — i.e., are clients from certain communities more likely to have service interactions that go undocumented under the current system? • Does the electronic format requirement create accessibility barriers for staff with disabilities? Multi-area coordination: Because this affects three program areas with three different Equity Champions and overlapping Equity Director coverage, the lead Equity Director designates a cross-program coordination team for this analysis. Step 2: Gather Data and Engage Community (Data component) Quantitative data gathered (hypothetical): • Staff access to electronic documentation systems within 24 hours of field interactions: 89% of office-based staff have consistent access; 61% of home-visiting staff have consistent access; 42% of crisis unit staff working overnight shifts have consistent access within 24 hours. (Hypothetical figures.) • Current documentation rates by program area (hypothetical): Case management, 78%; community coordination, 71%; crisis intervention, 52%. • Documentation rates by race of client (hypothetical): Analysis reveals that documentation completion rates are lower for interactions with Black/African American clients (63%) and Indigenous clients (58%) than for white clients (81%). The reason for this disparity is unclear from the data — it may reflect case manager assignment patterns, geographic coverage areas, or other factors. • Staff demographics: The crisis intervention unit has the highest proportion of staff of color (52%) and the lowest documentation compliance rate. This requires careful interpretation — is the lower documentation rate related to the nature of crisis work (which may resist documentation within 24 hours more than other service types), or to other factors? Data gaps: • No data on why specific interactions are not documented within 24 hours — is it because of system access, time pressure, or other factors? • No data on whether documentation gaps have resulted in worse service continuity for specific clients. • The correlation between staff-of-color concentration and lower documentation rates requires more analysis before any conclusions can be drawn. Step 3: Community Engagement [Community engagement is the responsibility of DSD program areas and the CECLC.] Engagement conducted (hypothetical): • Session 1: Focus group with frontline staff (including crisis intervention staff and home visitors) on the practical barriers to 24-hour documentation. • Session 2: Client advisory group for each program area, asking about their experience of documentation and whether gaps in documentation have affected their services. • Session 3: Disability advocacy organizations, focused on the accessibility of electronic documentation systems for clients who use assistive technology or who have cognitive disabilities affecting the ability to review and correct their records. Key findings (hypothetical): • Staff: Crisis intervention staff report that the nature of crisis work frequently makes 24-hour documentation impossible — stabilization of a crisis situation does not end at 24 hours. They are concerned that the protocol will either force incomplete documentation or create compliance anxiety that affects care quality. • Clients: Several clients report that documentation inaccuracies (in the current system) have affected service decisions — incorrect information in a record was used by a different service area. Standardization could help, but only if accuracy is also improved. • Disability organizations: Alert the team that the documentation system interface is not screen-reader compatible for blind and low-vision staff — an accessibility gap that was not on the team's radar. Step 4: Identify Burdens, Benefits, and Disparities Benefits: • Accurate, consistent documentation enables better service continuity, especially for clients who interact with multiple service areas. • Cross-program data analysis capability could enable equity monitoring that does not currently exist. • Clients with documentation inaccuracies benefit from standardized review and correction processes. Burdens and disparate impacts: 1. 24-hour timeline is not achievable for crisis intervention. The protocol, as proposed, is incompatible with crisis intervention realities. If the crisis unit is expected to meet the same 24-hour standard, staff will be forced to choose between accurate documentation and service quality. This burden falls disproportionately on the crisis unit, which serves the highest-acuity clients and has the highest proportion of staff of color. 2. Electronic system inaccessibility for blind and low-vision staff. The documentation system is not screen-reader compatible. Implementing a protocol that requires electronic documentation without addressing this creates a workforce equity issue — it disadvantages staff with visual disabilities. 3. Documentation gaps may reflect unmeasured access barriers. The lower documentation rates for interactions with Black/African American and Indigenous clients require further investigation. They may reflect coverage area gaps, assignment patterns that need to be examined for equity, or service type differences — but without more data, the analysis cannot rule out that documentation practices themselves are inequitable. Modifications recommended: • Crisis intervention unit: extend documentation timeline to 48 hours for crisis interactions that extend beyond the initial stabilization period; create a specific crisis-interaction documentation protocol that captures the nature of crisis work. • Electronic system: commission accessibility audit and remediation before mandatory protocol launch. Launch cannot proceed for staff with visual disabilities until the system is screen-reader compatible. Complementary strategies: • Documentation review and correction process: create a standardized process for clients to review and correct their service records, with accessible formats (easy-read, multiple languages, ASL for Deaf clients). • Cross-program equity data dashboard: use the standardized data to monitor service equity across program areas, with public reporting. Step 5: Implementation Planning Strategy — Action/Task — Person Responsible — Deadline — Resources Crisis-specific protocol — Draft 48-hour crisis exception protocol; review with crisis unit staff — Crisis Unit Lead + Equity Champion — 6 weeks — Staff time; legal review System accessibility — Commission screen-reader accessibility audit — IT Lead + ADA Coordinator — 4 weeks — $3,000–$5,000 for external audit System remediation — Remediate identified accessibility issues before launch — IT Lead — 8 weeks — IT budget request Client record review process — Design accessible record review and correction process — Program Lead + CECLC — 8 weeks — CECLC capacity; easy-read design Equity data dashboard — Define metrics; design dashboard; assign monitoring responsibility — Data Lead + Equity Champion — 12 weeks — Data staff time; dashboard tool Feasibility test: Realistic: Yes, with timeline extension. Adequately funded: System remediation requires budget request. Personnel: Adequate if IT prioritizes accessibility. Data collection: Yes — equity dashboard designed. Community engagement: Ongoing through client record review process. Step 6: Monitor, Evaluate, Adjust Quantity: Documentation completion rates by program area and by staff assignment type; documentation rates for interactions with clients of different racial backgrounds. Quality: Documentation accuracy rates (measured through sample audits); client record correction request rates; system accessibility audit findings resolved. Is anyone better off? Service continuity metrics by race; documentation gap disparity (Black/African American vs. white interaction documentation rates) at 6 and 12 months; accessibility audit closure rate. Pre-specified adjustment trigger: If crisis unit documentation compliance rate does not reach 80% within 90 days despite crisis-specific protocol, convene protocol review — the timeline or format may need further adjustment. Feedback loop: Monthly crisis unit staff check-in; client advisory group review at 6 months; IT accessibility progress review at 60 days. IS / IS NOT (for this worked example) This worked example IS — This worked example IS NOT A methodology illustration for a cross-program policy change — Analysis of any real DSD policy, system, or staff situation A demonstration of how to scope a multi-area equity analysis — A finding about any real staff group, program area, or community A teaching tool for handling complex, cross-cutting decisions — A template that can be used without a real equity analysis Common questions This seems very complex. Is every policy change this involved? The complexity here reflects the cross-program scope of the hypothetical. A single-program policy change with a narrower scope would require less coordination and shorter analysis. The Equity Lens Needs Assessment calibrates the depth. This example is deliberately complex to demonstrate how the methodology handles multi-area decisions. What if the IT team says the accessibility remediation will take too long? This is exactly the kind of finding that the equity analysis is designed to surface early — so that the implementation timeline accounts for it. If accessibility remediation is required before launch, the launch cannot proceed without it. This is not a negotiating position; it is a legal requirement under Section 508. Surface the constraint to leadership with the equity and legal framing. Connection to DSD goals Policy and procedure changes are among the most consequential decisions organizations make — they define how work gets done for everyone, every day. This example demonstrates that the EAT's equity discipline applies to operational decisions, not just programmatic ones. DSD's equity commitments extend into how its internal processes work, including how staff are expected to document their work. Sources • DHS Equity Analysis Toolkit Guide — Minnesota DHS (https://mn.gov/dhs/) (primary source) • Racial Equity Impact Assessment Guide — Race Forward (https://www.raceforward.org/sites/default/files/RacialJusticeImpactAssessment_v5.pdf) • King County Equity Impact Review (https://blog.homelessinfo.org/wp-content/uploads/King-County-Equity-Impact-Review-checklist_Mar2017.pdf) • DHS Equity Policy — Minnesota DHS (https://mn.gov/dhs/assets/equity-policy_tcm1053-646921.pdf) • One DSD Program Charter v1.1 (one-dsd-program-charter) Always defer to the person in front of you.

Ask: Does the 24-hour documentation requirement differentially affect staff who work with certain populations (e.g., crisis intervention staff who work non-standard hours, or staff who conduct home visits in areas with limited connectivity)?

Ask: Does inconsistent documentation affect certain client populations differently — i.e., are clients from certain communities more likely to have service interactions that go undocumented under the current system?

Ask: Does the electronic format requirement create accessibility barriers for staff with disabilities?

Identify Burdens, Benefits, and Disparities

Ask: What if the IT team says the accessibility remediation will take too long?

Define the decision, compare evidence and impacts, document limits, and name the owner using Worked Example — Policy and Procedure Decision Walk-Through.

Verify current authority, preserve rights and exceptions, and route interpretation questions using Worked Example — Policy and Procedure Decision Walk-Through.

For policy regulatory analysts, use Worked Example — Policy and Procedure Decision Walk-Through to define the decision, compare evidence and impacts, document limits, and name the owner; trace each recommendation to current authority, preserve exceptions, and document the decision record. Start by ask: Does the 24-hour documentation requirement differentially affect staff who work with certain populations (e.g., crisis intervention staff who work non-standard hours, or staff who conduct home visits in areas with limited connectivity)?

Verify the current primary authority and effective date; this resource does not provide fact-specific legal advice or replace authorized program interpretation.

Do not replace official legal, policy, clinical, supervisory, program, or Tribal authority.

Do not infer an individual's identity, preferences, needs, or experience from group-level information.

State uncertainty, use current authoritative sources, and escalate when the decision exceeds the user's role.

IMPORTANT — Scope of this resource: This is an anonymized hypothetical example demonstrating the methodology of the DHS Equity Analysis Toolkit. It does not perform equity analyses on real DSD programs, real communities, or real data. All names, figures, and scenarios are illustrative. Actual equity analyses are conducted by the appropriate authorities — your Equity Champion, the One DSD Equity Team, or the DHS Equity Director for your work area. Step 1. Ask: Does the 24-hour documentation requirement differentially affect staff who work with certain populations (e.g., crisis intervention staff who work non-standard hours, or staff who conduct home visits in areas with limited connectivity)? Step 2. Ask: Does inconsistent documentation affect certain client populations differently — i.e., are clients from certain communities more likely to have service interactions that go undocumented under the current system? Step 3. Ask: Does the electronic format requirement create accessibility barriers for staff with disabilities? Step 4. Identify Burdens, Benefits, and Disparities Step 5. Ask: What if the IT team says the accessibility remediation will take too long? Step 6. Define the decision, compare evidence and impacts, document limits, and name the owner using Worked Example — Policy and Procedure Decision Walk-Through. Step 7. Verify current authority, preserve rights and exceptions, and route interpretation questions using Worked Example — Policy and Procedure Decision Walk-Through.