1. “Seeing With Fresh Eyes” Collaborating with Compliance & Using Lean Management Tools to Improve Process Jean Ball, PT, M.Ed., CPHQ Chief Compliance Officer Michelle Butler, MS, CPMSM, CPCS, RHIA Administrative Director, Medical AffairsApril 27, 2016

7. Process Overview  Discovery  Audit  Findings & Risks  Action Items 7

8. Discovery – Actions Taken  August –October 2015- Initial Concurrent Audit » 13 files reviewed in flow » Revealed process inconsistencies and documentation gaps  August-October 2015 Retrospective & Concurrent Audit » Timeframe January-October 2015 appointments » Random sample volume Based on TJC guidelines for population size as mitigation of survey risks » Total Sample 87 files audited 100% of known Temporary Privilege Files-18 Sample of Reappointment & Initial Appointments-69 8

10. Full Audit Sample Distribution by Month Appointed 10 Report to Compliance & Medical Affairs N= 87 files audited

11. 15 of 87 Audited Files found with Problems- by Month Appointed 11 17% defect rate

12. Temporary Privileges May be granted under 2 circumstances: » Complete file awaiting full privilege board approval » Special patient care need- skill or provider  Both require essential documentation  Both require CEO/CMO approval  Not to be used as a timing workaround  Should be the exception 12 Department# Anesthesia2 Family Medicine2 Dermatology1 Hospitalist2 Neurology1 Ophthalmology1 Pathology1 Pediatrics2 Psychology2 Radiology4

13. 13 Themes Identified Timing of Process Pressures on MSO- Accommodations made Documentation tracking / missing follow up Temporary Privileges Request did not meet MS Bylaws requirements-need not defined Incomplete packet expedited or core requirements not met Approval process bypassed Documentation within any file Signatures/Dates missing fields and/or approval Date not by original signatory Malpractice Coverage rider discrepancies Not Primary sourced Coverage dates don’t align with start date

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16. Action Plan and/or Mitigation of Risks  Compliance, Risk Management & MSO mitigated discovered risks  MSO tightened the requirements around requesting temps » Detailed temporary privilege request/approval page » Educated leadership on purpose/requirements for temporary privileges  Temporary privileges to be included at MEC/QPAC/BOT » Added to Appointment grids for purpose of tracking and awareness  Education of Medical Staff leaders responsible for reviewing clinical appointment files prior to approval at MEC/QPAC  Credentialing Committee re-staffed » Education of new Chair and structured file review guidelines  Process to be examined- future RPIW » Leaders understand and respect the process-Executive Leadership reinforces » Future random audits 16

17. Lean Management Tools 17 Observe & Measure Process Create Value Stream Identify areas of concern Calculate Takt Time Set targets for improvement Host RPIW Waste Walk 5S -sort, simplify, sweep, standardize, self-discipline Generate new ideas Perform test of change Create Standard Work Continue to measure 30, 60, 90 day report outs

18. Credentials Rapid Process Improvement Workshop (RPIW) RPIW process: Full week improvement effort using LEAN tools to allow those most knowledgeable about the process to examine and propose tests of change. Participants/Areas represented: Medical Staff Office, NSPG Physician Services, North Shore Health Systems, NSMC Human Resources, Marblehead Provider, NSMC Hospitalist Program, NSPG Practice Manager, Compliance. Issues: Lengthy credentialing process resulting in delays in patient care and lost revenue. Production pressure on MSO staff, duplicate processing for recruiters, MSO staff, and physician applicants. Theme: Delays in credentialing ultimately cause delays in patient care and lost revenue. With quicker credentialing, patient access improves and patients get more timely care with the doctor they want to see and more revenue is generated.

22. Initial Metrics and Goals Processing Time  Lead Time: Time application sent to MD to time it reaches MEC » Current state: 87 days; Goal of < 60 days  Sub-lead Time: Time application sent to MD to time returned to MSO » Current state: 37 days; Goal: 14 days Ensuring a complete/defect free packet for processing  Defect rate elimination » Current state: defect rate is 75%. By streamlining application, including FAQ, and implementing production board for ongoing monitoring and intervention able to avoid an incomplete application. Organization and Set up Reduction – Mistake Proof  5S’d the Application » 100+ pages down to ~65 » Improved instructions, Added FAQs » Postage paid return envelope » Reach out to applicant and offer face to face application assistance » Reduced sub-lead time: Cut time from 47 min to 15 min to create packet

23. Mistake Proofing leads to Defect Free Process  Streamline Application Packet  Successive Quality Checks » Virtual Production Board  Rigorous NSPG Interview Process including reference verification and background screening  Standard work process for MSO staff  MSO Manager performs 100% quality review  Standard work process/application review for Section Chief & Department Chair  Standard work process/application review for Credentials Chair  Standard review by MEC membership

24. Process Improvements & Early Successes  Reduce duplicate work – reduce defect rate  5 s / streamlined application packet-reduce creation time from 47 minutes to 21  5 s / streamlined application packet, included FAQs, simplified instructions, and notable messaging-reduce return time from 37 days to 11 (small sample size)  Standardize application request process: All NSPG recruitment offers to go through NSPG recruiters-reduce waste in MSO  References were being checked by both NSPG Physician Services and the MSO. Created new reference check form which will only be sent out one time by NSPG  Simple switch to a double monitor for CAQH data entry allows worker to drag info instead of copy and paste: decreases time from 45 min to 23 min.  Monitoring Process – standardize work – mistake proofing  Production Board (2x/week): MSO staff, Recruiters, ED/AD staff  Improve communication, ongoing monitoring, early intervention  Ongoing Auditing by Compliance-Trust but Verify

25. Questions? 25