Provider Management –

A Fundamental Component
of your HRO Journey

February 4, 2021
 Over 12,000 CPHQs worldwide

Confidential, Copyright © National Association for Healthcare Quality

 Education at Every Level

Confidential, Copyright © National Association for Healthcare Quality

Provider Management –
A Fundamental Component
of your HRO Journey

February 4, 2021
Healthcare Quality Competency Framework

Workforce Report pg.9

 Thank you for joining us today for a discussion
Hello!
on provider management & high reliability

Chris has over 25 years of industry

experience with a focus on strategy,
high reliability, and provider
management solutions.

Joined RLDatix from his prior role as a

Chris Malanuk founder of Verge Health (acquired by
SVP Provider Solutions RLDatix in October 2020)
Agenda

• About RLDatix
• Overview of High Reliability
• Core Elements of HRO
• Review of Frameworks & Maturity Models
• Value of Connected Processes & Data

• The Integral Role of Provider Management

• Core Elements of Credentialing
• Centralized Provider Management Model
• Attribution & Connected Workflows
• Actionable Analytics & Platform Integration
• Risk Profile Development & Use

• Questions
About RLDatix & Verge
Mission Vision Values
To be the global A world where patients • Authentic
provider of insights have access to the best • Dynamic
and tools that drive and safest care possible • Bold
improvement, • Purpose-Driven
efficiencies and safety • Passionate
in healthcare
 Healthcare continues to evolve
with new challenges, mandates, and changes
 We are partners with you We collaborate with you

on your safety journey and to build products that meet

pursuit of zero harm your needs and challenges

We are evolving and

growing, but still

on a mission to help you

provide safer care
Overview of High Reliability
Industry Shifting to Proactive, “Left of Bang” Approach

Proactive: Left of Bang Reactive: Right of Bang

High Reliability requires a proactive pre-occupation with safety, and with

an approach that includes your provider management strategies
Defining High Reliability

“
A systematic process to evaluate enterprise risk in real-time through the
alignment of people, processes and integrated technology.

A comprehensive approach for leaders to effectively drive quality and

”
safety, evaluate risk, and become a Highly Reliable Organization.

Includes practices more commonly known across the industry as:

• Enterprise Risk Management

• GRC – Governance Risk & Compliance
• ASI – Applied Safety Intelligence
Core Tenants of HRO

5 Guiding Principles:
1. Sensitivity to operations

2. Reluctance to simplify Change in

Change in Processes and Improved
Thinking about Environments Patient Safety
3. Preoccupation with failure Patient Safety Affecting Outcomes
Patient Safety
4. Deference to expertise

5. Commitment to resilience

An HRO is:
An organization that experiences fewer than anticipated accidents or events of
harm, despite operating in a highly complex, high-risk environment.
 A Journey based on maturation of two central themes:
Defining High Reliability 1) Leadership
2) Safety Culture

Leadership Element Beginning Developing Advancing Approaching

Board Limited Involvement Defined & committed goal

CEO/Management Focused on accreditation Focused on zero harm

requirements
Physicians Rarely lead quality Routinely drive quality & safety
initiatives
Quality Strategy Not identified as a Quality is highest prioritized
strategic priority goal
Quality Measures Not prominently Routinely displayed internally
displayed or reported & reported publicly
Information Plays little to no Tools are leveraged to drive
Technology supportive role sustainable improvement

Excerpt from “High-Reliability Health Care: Getting There from Here;” The Millbank Quarterly, Vol. 91, no.3, 2013 ; M.R. Chassin and J.M. Loeb
 A Journey based on maturation of two central themes:
Defining High Reliability 1) Leadership
2) Safety Culture

Safety Culture Beginning Developing Advancing Approaching

Trust Trust or intimidating High levels of trust exist & are

behavior not assessed routinely measured
Accountability Emphasis on blame Pervasive ownership of safety
culture w/ transparent & equitable
disciplinary procedures
Identifying Unsafe Causal analysis limited Close calls & unsafe conditions
Conditions to significant adverse routinely reported with
events improvements widely
communicated
Strengthening Limited review of System defenses proactively
Systems defense systems assessed to repair weaknesses
Assessment No measures of safety Measures are part of strategic
culture exist metrics for board & management

Excerpt from “High-Reliability Health Care: Getting There from Here;” The Millbank Quarterly, Vol. 91, no.3, 2013 ; M.R. Chassin and J.M. Loeb
 Simplified Maturity Scale EMBEDDED

INTEGRATED
Embedded in
FRAGMENT ED
Culture -
Best Practice Sustainable
How do we get there? REACTIVE
Organization –
Best Practice
Key Implementation IMMATURE Facility – Consistent Repeatable and
Strategies and Repeatable Scalable
Growing Capabilities
Limited Capabilities
✓ Develop leadership
• Lack of Structure • Siloed Structure • Uniform Process Template • Structure Is Managed and • Promotes Benefits Across
across the organization Sustainable Organization
• No uniformity • Begin to Implement • Standards
✓ Support a culture of Quality –PDSA • Commitment to QA/PSDA • Proactive Analytics
• Dependent on Individual • Initiatives and Vision
safety • Resistant to Change Aligned • Increasingly Sophisticated • Risk Strategy Aligned with
• Undocumented Process Rollout Business Strategy
✓ Build & use data • Unclear Objectives
• Little Uniformity • Planning/QA – PSDA
• Best Practice Utilized • Information Shared at All
Incorporated
systems to track • Limited Planning Levels
• No Clear Accountability • KPI Targets Established,
• Occasionally Repeatable
• Minimal KPI Tracking Tracked and Acted Upon • Clear Accountability and
progress • No KPIs
• Automation Integration • Process Measured and
Responsibility
• Process Per Project
✓ Provide training & • Manual/Spreadsheets Starting Predictable • Inputs from One Process
• Lack of Understanding of
• Not Ready for Change • Organizational Rollout Lend to Another
learning opportunities HRO Value • Well-Documented
Standards • Continual Process
for all providers & staff • Innovative Culture
• Some Reference to Improvement
• Metrics Track and Acted • GRC Automation
Innovative Thought
✓ Do not hesitate to Upon for Relevant Areas Integrating At Facility or
• Constant Steam of
• Accountability for Project Innovative Ideas
For One GRC Focus Area
implement interventions Performance Across Health System • Driven, Innovative Culture
Evidence Brief: Implementation of High
Reliability Organization Principles; Dept.
of Veterans Affairs; S. Veazie, K.
Peterson, & D. Bourne; May 2019
Simplified Maturity Scale
EMBEDDED

INTEGRATED
Embedded in Culture
FRAGMENTED - Sustainable
Best Practice
REACTIVE
Organization –
Best Practice Facility
Repeatable and
IMMATURE – Consistent and
Scalable
Growing Capabilities Repeatable
Limited Capabilities

HIGH
RELIABILITY

INVESTMENT HRO yields improved outcomes and financial performance

Simplified Maturity Scale
EMBEDDED

INTEGRATED
Embedded in Culture
FRAGMENTED - Sustainable
Best Practice
REACTIVE
Organization –
Best Practice Facility
Repeatable and
IMMATURE – Consistent and
Scalable
Growing Capabilities Repeatable
Limited Capabilities

What is the role of provider management?

✓ Leverage a shared practitioner data model to ensure a single source of truth
✓ Establish uniform processes for verification & application processing to capitalize on best practices
✓ Define opportunities for practitioner attribution across safety and compliance efforts
✓ Develop provider risk profiles as a core element of your professional performance evaluation process
 APPLIED SAFETY INTELLIGENCE

ENTERPRISE DASHBOARD

PROVIDER
SAFETY COMPLIANCE
MANAGEMENT

✓ Safety Event Reporting ✓ Policy / Procedure

✓ Enterprise Risk Register ✓ Credentialing ✓ Contract Management
✓ Patient Feedback ✓ Peer Review MD/RN ✓ TJC/CMS/DNV/etc Assessments
✓ Patient Experience ✓ Provider Profile ✓ Compliance Rounding
✓ Infection Surveillance ✓ Instructions for Use/Safety Alerts
✓ Claims / Worker’s Comp
✓ Powered by PSO

T R A I N I N G & E D U C AT I O N

✓ High Reliability Maturity Model ✓ Communication Assessments

✓ Safety and Risk Management Optimization ✓ CANDOR Training and Syndicated Education
✓ Provider Data Management
 Explore Ways to Manage Risk
High Reliability Requires Collaboration:
& Quality on One Platform

INCIDENT + CLAIMS + RCA + PEER REVIEW + CREDENTIALING + PATIENT RELATIONS

Patient Relations
Incident Occurs: Finance is
A practitioner
is immediately notified
Unite: System enables Department
involved with
of the event
✓ Risk fast reporting and Claims is alerted by claims
Integrated
the incidentcase
so
early communication Claims
Department to trigger reserve
management
✓ Safety Department a Peer
management
Review
or
easily manages involves a virtual
is triggered
✓ Claims receives
the claims process payments
committee for
Findings can
✓ Finance notification
& shares for review. Findings
Patient Safety
earlyTeam
review be forwarded
✓ Legal responsibilities
is alerted to see if an are recorded
directly into the
Legal Department
✓ Clinical RCASystem
iswith is used to
designated
needed Credentials
is contacted by Claims and easily
✓ Patient Relations complete a groups
causal analysis Folder
brought into the process
✓ Credentialing Patient Relations
✓ Compliance follows up with the Findings are sent to the
patient and risks are Patient Safety Committee
managed for targeted action
Manage Risk & Quality on One Platform

INCIDENT + CLAIMS + RCA + PEER REVIEW + CREDENTIALING + PATIENT RELATIONS + COMPLIANCE

Claims
Management

Connect otherwise
disparate systems
Reported
and manage a Practitioner
Adverse
broader view of risk Event Performance

Patient Safety
Patient Investigation
Relations
Key Elements of a Successful Program
Broaden Data
Capture & Discovery
✓ Enable Collaboration Across
your Safety Platform
✓ Leverage Automated
Workflows – Event Referrals
✓ Active Monitoring of key
events (eg mortality or
infection)
Drive Organizational
Engagement
✓ Make Data Actionable with
Interactive Dashboards &
Visualizations
✓ Daily Huddle Teams Share
Custom Views
✓ Mobile Rounding: Build
Process Ownership, not just
Participation
✓ Continuous Readiness:
Mock Surveys
Align Provider Management
with Operations
✓ Leverage a shared practitioner
data model
✓ Establish uniform processes for
verification & application
processing
✓ Define opportunities for practitioner
attribution & profile development
with an integrated platform
The Integral Role of Provider
Management & Credentialing
Defining Provider Management

“
A comprehensive approach for managing provider relationships that
extends beyond primary source verification and robust data
management to also include the evaluation process with direct
connections to safety & compliance.

The inclusion of effective processes for the attribution and review of

”
provider data is key to becoming a Highly Reliable Organization.

Provider Management Strategies Include:

• Efficient & Scalable Credentialing & Privileging
• Network Management & Quality
• Peer Review – Clinical Excellence Transformation
• Integration of Provider Risk Profiles
Provider Management
Credentialing & Privileging
The practice of verifying data with primary
sources to clearly document & assess:
▪ Education & Training
▪ Licensure & Certification
▪ Clinical Competence
Additional elements:
▪ Assign privileges or scopes of practice
based on assessed competence
▪ Establish rigor & accountability in the review
process
▪ Maintain records for renewal and sanctions
monitoring
▪ Align review of verification content to
include provider risk profiles
Integrated Peer Review
The process of evaluating provider
performance (FPPE) through an
established process defined by the
organized medical staff.
▪ Clinical excellence focus should be leveraged
to drive open reporting & attribution
▪ Mitigate historical connotations of punitive or
retaliatory behaviors
▪ Ensure findings drive actions
▪ Aggregate & share data to support provider
risk profiles with an integrated view for the
credentialing process
Core Tenants of Credentialing & Privileging

Application Management Relationship Management

▪ Application Administration ▪ Recruitment & On-boarding

▪ Primary Source Verification ▪ Application Review & Workflow Coordination
• Education
▪ Committee Management & Accountability
• Training
• Licensure ▪ CME Management & Support
• Board Certification
▪ Compliance Integration
• Affiliations & Work Hx
• Integrated Peer Reference Collection (for associated privileges) ▪ Organization Specific Records
• Malpractice Coverage • Attestations
• Claims Hx • Immunizations & Health Documents
• NPDB & Other Sanctions Screening • Activity & Attendance
• General Correspondence
▪ Privilege Administration
• Organization Specific Competency Requirements ▪ Competency Assessment Prcesses
• Status Management & Publication
▪ Privilege Criteria
▪ Review & Evaluation Process ▪ External Relationship Considerations (payers &
• Support for Departmental review and collection of evaluation forms
• Presentation & Investigation for Credentials Committee agencies)
• Coordination of Recommendations to MEC and Board
• Close out application, notify practitioner & Update Privileges
▪ Monitoring of Expiring Records
• Courtesy reminders
• Primary Source Verifications
• Manage Escalations
• Document Effort/Diligence
• Multi-factorial Sanctions & Exclusions Monitoring
 Provider Data Confirmation
Centralized Provider Management (pre-populated)

System & Staff Interface

✓ Maintain unique application content
✓ Share data across departments & facilities
✓ Establish uniform processes and data Entity/Organization Affiliation Management
management policies Comprehensive Services Centrally maintain provider
records; Consolidate primary source verification

Position your organization to leverage a

single instance of a credentialed provider
to drive attribution across the safety
platform with a unified view of data
Surgery Acute Care Health Plan Partnerships/ACOs
Centers Hospitals Relationships & Group Practices

Entity appointments are fully managed by a central process as part of the comprehensive
services model. Additional entities are supported through the use of integrated tools that
enable the enterprise to leverage the shared data model of the verified provider dataset.
*Credentialing processes should be designed to meet one or any
combination of compliance conditions for CMS, TJC, HFAP, URAC,
NCQA, AAAHC, or other state specific criteria.
Provider Networks – Challenge of Expanding Populations

Network Quality remains paramount, particularly in an era of expanding complexity

1. Hospital Credentialed
staff – formerly a
Health System Credentialed Staff
“simple” relationship
Health System Enrolled Providers
(Typically limited to employed groups or an
organized practice plan for the system)

2. Health System Community Providers in medical

Medical Groups:
Practice Plan + group NOT affiliated with hospital–
must now also be credentialed or
managed the Health System to
organization of ALL measure quality
Health System
employed providers Credentialed Providers
- Already known
Leverage Provider Data with Advanced Dashboards

• Create transparency across the

health system or payer network
with shared views of provider data

• Seamlessly manage roster data

across multiple environments with
clear visualizations by assigned
status definitions or organizational
structures and specialties
Ensure Transparency Across Record Management Tasks

• Ensure record management is never at risk for

a gap with shared access to licensure &
certification renewals

• Establish enterprise-wide policies to efficiently

govern waiver programs or manage
exceptions and grandfathered conditions

BHZ23 demo
Ensure Application Processing is Aligned with Goals

• Set procedures to ensure reappointments conform

with established review schedules and committee
evaluations

• Keep close watch on application processing to help

ensure efficient on-boarding as well as workflow
tracking to support a thorough review process
Leverage Peer Review Integration to Build Profile Data

SMHealth

• Introduce reporting tools

for health system staff to
directly share concerns
(good or bad)
Peer Review

• Use Peer Review

methodology and system to
coordinate an internal
investigation.
• Data collection forms should
be customized and designed
to trigger workflow actions
across your safety and
compliance efforts.
Maximize Data Connections
Enable lookups wherever possible to ensure data
quality with ease of capture and attribution For Consideration:
Real time HL7
Connection to the
client EMR
(not required)

Integrated
Organizational
Hierarchy & Settings
for Location or Brand
Tracking/Segregation

Direct attribution of
your Credentialed
Roster
 Design systems to review organizational
Aggregate Peer Review Data and provider specific metrics with ease
Expand Your View & Pivot Siloed Data to Create Provider Risk Profiles

Sample Risk Profile:

Provider specific views of
activity across your safety
Capin
platform can offer advanced
Farming
Montana
solutions for performance
Sojour monitoring and on-going
professional practice
evaluation processes
Integrate Safety Findings with Provider Management

Risk profiles should be posted in

the credentialing record with
seamless sharing across facilities
and pulled directly into the next
reappointment or OPPE review
packet along with any other activity
or performance profiles.
Remember – Connected Workflows Help Drive Success
Integrate Provider Management in Your Approach to Safety

INCIDENT + CLAIMS + RCA + PEER REVIEW + CREDENTIALING + PATIENT RELATIONS + COMPLIANCE

Claims
Management

Connect otherwise
disparate systems
Reported
and manage a Practitioner
Adverse
broader view of risk Event Performance

Patient Safety
Patient Investigation
Relations
Marking Your Maturity in High Reliability

Leverage Processes & Technology to Drive an Integrated

Approach to Provider Management

▪ Establish a single source of truth for provider data across the health system /enterprise
▪ Drive attribution of credentialed providers across your safety & compliance reporting systems
▪ Enable pathways for shared discovery of risk
▪ Share actionable data & risk profiles as a fundamental element of your credentialing and
privileging program
▪ Become CPHQ certified and help drive the future of health care quality and patient safety!
 THANK YOU!

Questions & Answers

Additional Questions?
marketing@rldatix.com

Chris Malanuk
cmalanuk@rldatix.com
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