Plan, Do, Check, Act: Your Credentialing

Process Utilizing Lean Processes

Session Code: TU05

Date: Tuesday, October 24

Time: 9:30 a.m. - 11:00 a.m.

Total CE Credits: 1.5

Presenter(s): Melissa Walters, MHA, CPMSM, CPCS, MSOW-C

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Plan, Do, Check, Act Your Credentialing Process Utilizing LEAN

ProcessesMelissa Walters, MHA, CPMSM,CPCS, MSOW-C

Sr. Director, Centralized Credentialing

Define: Insanity

“Doing the same thing over and over again and expecting different results”

Albert Einstein

Deming’s Philosophy

“85% of the reasons for failure to meet customer requirements are

related to deficiencies in systems and processes … rather than the

employee.

The role of management is to change the process rather than

badgering individuals to do better.” - W. Edwards Deming

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We’ve ALL heard:

Work smarter not harder

Do more with less

Be efficient and effective

Non-value added

Go LEAN

What’s in it for ME?Why CHANGE?

It will make our jobs easier

» Less confusion, less rework, fewer phone calls

It will improve our quality of life

» Less time at work, less stress

It will help our customers

» Less confusion, less rework, fewer phone calls

Customers – who are they? Who are our customers? people or groups of people who use any of the

information we provide for whatever reason

Medical Staff Offices Credentials Committee Board

C-Suite Practitioners Accrediting Bodies

Risk Mgmt Quality HIM/EMR

Who is our most important customer?

THE PATIENT

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Credentialing Nightmares

• Michael Swango

• John King

• Charles Cullen – (the Angel of Death)

• Patients

• Safe outcome (trust)

• Certify practitioners

• Harm or Death

Our True Role… Protecting our Patients from harm

Patient Harm

Another Provider app

Information Quality

CCO (our slice)

MSO

Credentialing Committee

We can and Must do Better…For our patients and colleagues

Attitude – Where it all begins

Your mood is contagious! Smile, you will be happier

Remember the golden rule – treat others…..

Every day you have the power to decide to be:

Positive – supportive, participative, helpful, kind

Negative – detrimental, non-participative, mean

New Rule: Attitude is just as important as ability!

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Speaking of Ability….

Ability – “Good is the enemy of great”

We need to improve our collective skills/service

Think about Amazon, Trader Joes, Starbucks

Question the paradigms and mental valleys

Listen and consider others ideas to improve

» instead of “this won’t work” think “how could it work?”

Accept that 50% of things tried fail, 50% succeed, but we learn from 100% of these experiences

Think Lean?Lean is the relentless pursuit of the elimination/reduction of waste in a process

It’s a process improvement methodology

» To first see and then attack waste

A “lean” process”:

» Is satisfying to it’s customers

» Reduces lead time (time to do task)

Provides more time to more

important things

Lean is the application of common sense

Waste – what is it?

Waste is any activity that does not add value as defined by THECUSTOMER.

• Who is the Customer? External? Internal?

• Value is defined as what the customer is willing to “pay for”

• All processes have waste

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Overproduction

Producing more than is needed to satisfy demand - Batching or working ahead contributes - More is not always better

» Sending out application

» When to release files

» Working on files in advance vs. those needed

Unnecessary Inventory

Having too much, too little, or the wrong stuff that is needed –Can you find it when needed?

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WaitingDelay between the end of one process activity and the start of the next activity – Hurry up and wait!

Wait for the application to be returned

Wait for the verifications to come in

Practitioner waits to get onboarded

Everybody WAITS!!!!!

Unnecessary Motion

Excess movement and actions of people performing the process – not the right kind of exercise!

Printing

Faxing

Emailing

Scanning

Unnecessary Transportation

Movement of the “thing” in the process from one location to another

Workflow processes

File transfers

Manual faxes

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DEFECTS

Process errors, mistakes, or missing critical items – “It

happens”– but does it have to? Internal audits

CCO f/u forms

Overprocessing

Additional work done in process that does not, in and of itself, add value to the customer – it’s the “just to be sure” stuff

FSMBAMA ProfileNational Student Clearinghouse

Lean Daily ManagementHuddle Board

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Huddle BoardWhat is it? A 4’x6’ white board or bulletin board that is used to facilitate staff huddles

Why use it? It is a visual tool to align strategic priorities with departmental/staff improvement efforts using a standardized approach

How do you do it?1. Create the board and place it in a location in the workplace that is large enough for all staff to gather around it.2. Choose 2 strategic initiatives/goals and develop key metrics (meaningful to the dept.) for each that will support these

domains. Example TAT & Audit Pass Rate (Performance)3. Create a histogram (per later slide) and post4. A facilitator (usually representative from leadership or senior specialist) will lead the team through the huddle, working

the board, moving the idea cards, and updating verbiage as needed.5. Begin with Recognition (keeping it brief – we call these “Shout Outs”)6. Idea cards will move to various boxes to reflect their status and brief verbiage will offer additional information as needed.7. Once ideas have been successfully completed they are moved to a different board– see later complete board

Role of leadership (Critical to success):• Lead by example – be present at as many huddles as possible, ask questions, cheer lead and hold team accountable for

conducting the huddle daily at designated time

Key Metric

Process Metric

Histogram

Problem: xxxxxxx

Idea Idea

Hard

High

LowEasy EFFORT

BENEFIT

Just Do It

PossibleNot Now

Challenge

Key Metric

Process Metric

Histogram

Problem: xxxxxxx

Idea Idea

Do Its Status

A3

A3

Domain Domain

Today’s Date

P

D

C

A

P

D

C

A

Escalate/Research Status

Unit Name

Recognition

C

D

E

F

G

J

H

I

K

B

A Board KeyA) Department name, date is updated each time the

board is roundedB) Recognition – Updated prior to rounding – brief

mention E.G. Congrats Susie for earning your CPCS certification!

C) Domain and Key Measure (2) – Domain is the strategic theme selected and the measure is a macro measure of the performance –typically measured weekly/monthly quarterly E.G Domain = Performance, TAT & Audit Pass Rate

D) Process Metric – A specific, quantifiable driver of the key measure that is more actionable. E.G. TAT for reappointments is at or better than 45 days

E) Histogram/Problem – graph depicting various root causes on the X-axis and the frequency of the number of each observed/reported on the Y-axis. E.G.. Team determines which to work on.

F) Idea card– the team generates suggestions for improvement writing one idea on one card (see later slide for example) These idea cards then physically move about the colored boxes as they board as they are considered.

G) Benefit/Effort Matrix – Each idea is evaluated based on the level of benefit in solving the problem (low/high) vs. how easy or hard it will be to implement. (see slide for further detail)H) Just Do It – Ideas are placed here once approved to do. Specific status of each is noted on the board.

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Board Key (Continued)

I) Escalate/Research – Ideas are placed here with verbiage on status should they require approval or if more info. is needed before further consideration/action. E.G. Working with software vendor to implement.

J) PDCA – ideas requiring piloting progress through the cycle of Plan, Do, Check, Act. The card is placed with verbiage explaining status in the box marking the current stage – see later slide on for detail.

K) A3 – Ideas that are larger in scope requiring a project approach are transitioned into an A3 document – see later slide for detail

C

D

E

F

G

J

H

I

K

B

A

HistogramWhat is it? A histogram is a graphical representation of the distribution of numeric data

Why use it? It helps identify which defects occur most often in order to fix the biggest problems first.

How do you do it?1. Observe the process and note all defects that impact the process metric2. Determine how to collect this data over a sufficient period of time to understand the issue3. Various methods:

• Create a form with defects and check boxes that staff doing process can fill out real time (audit spreadsheet)• Auditors gather data without biasing staff• Chart review or electronic data capture

4. Create histogram either manually (if info is captured individually real time) or using software if data is collected and summarized.

1. List defects on X-axis2. Create a Y-axis with a scale to indicate # of occurrences 3. Record the number of times the defect occurs by drawing a bar graph

5. Use completed chart to determine which defect to address (typically the tallest or second tallest (if deemed more actionable)

6. Ask why this defect happens again and again (5 why technique) to determine the root cause of the defect in order to obtain ideas for improving the real issue.

Histogram Example

In this example the team will collectively decide which issue to address.

Did not verify board certification occurred the most often.

15

14

13

12

11

10

9

8

7

6 X

5 X

4 X

3 X X X

2 X X X X

1 X X X X X

AUDIT DEFECTS

DEFECTS

claims hx

MD ref

No CO

I

Board Cert

ref incomplete

This chart can be hand written or generated using software.

Whatever works!

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Idea CardWhat is it? A index size card used to capture a single idea for eliminating or reducing the impact of the specific problem being addressed

Why use it? It captures/documents individuals thoughts ideas for the team to evaluate

How do you do it?1. Blank idea Cards are distributed to staff with additional cards located next to the preprinted

headings should include:• “Idea”” or another name decided by the team as the header• Date created• Name of submitter• Idea description

2. All staff members are encouraged to submit ideas by placing the cards on the board under respected problem listed in one of the two columns

3. The person leading the huddle will read each new card aloud and facilitate placement on the Benefit Effort matrix.

4. Completed idea cards should be relocated to a complete board with atheme chosen by the team. Once the outline is filled in with cards a the team will be recognized in some fashion such as a party. See example

IDEADate:Submitted by:Idea description:

_________________________________________________________

Example of a Compete board

Benefit Effort MatrixWhat is it? A tool to prioritize and categorize ideas

Why use it? It provides a standardized method for team evaluation of every idea and selection of those to be acted upon.

How do you do it?1. During every huddle, read each submitted idea and have the team determine which of the 4 quadrants is the best fit based

on the following criteria• Level of effort to complete (based on combination of time, cost, and resources required). Typically those that affect or

involve other areas are more difficult (hard)• Benefit indicates the level for which the problem will be solved or addressed. High benefit typically solves or has major

favorable impact on the problem.2. Ideas that are easy to do and offer high benefit (upper left) should be done immediately and be moved to the Just Do It box.

Move those requiring final approval should be moved to the Escalate/Research box. These should typically be completed in <2 weeks.

3. Ideas in the Not Now (lower right) should be removed from the board.4. Ideas in the Challenge box (upper right) are worth doing but have a larger scope. They can move to the following areas:

• Escalate research if more information or approval is needed• PDCA if it can be done via a pilot• A3 if it will involve a strategic project to implement

5. Ideas in the Possible box (lower left) should be done once all “just do its” are completed if the team believes there is enough benefit. They then move to the Just Do It box.

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PDCA, aka PDSA

What is it? A tool used to pilot, evaluate, and refine an intervention consisting of 4 steps -Plan, Do, Check (Study), Act

Why use it? It is a time tested tool that utilizes the scientific approach to repeat the cycle in order to obtain a robust solution

How do you do it?1. Plan – Detail the specific intervention and determine the specific goal, scope, timeframe,

and resources required to pilot. Also communicate to all affected/involved stakeholders.2. Do – Pilot the intervention as planed 3. Check – Constantly monitor and evaluate during and post-pilot to determine

effectiveness and incorporate changes and enhancements into the plan to restart the cycle.

4. Act – Upon achieving successful results, incorporate into policy, train, and roll-out to all appropriate areas/individuals to create a new standard

The idea card should be placed in the appropriate box to reflect the current cycle phase. Brief documentation of status should also be included

A3What is it? One page project summary for your team’s work – dynamic vs. static

Why use it? It provides a structured framework for lean thinking and team collaboration for project level initiatives

How do you do it?1. Complete the Define section (see next page) of the document prior to the first team meeting2. The measure section should include all key metrics as measured during a baseline (current) timeframe as well as

a process map depicting the process3. The Analyze section should reflect what was learned in measure and provide a logical path to the interventions

selected in improve4. The improve section should list all key interventions and their status at each revision of the A3. It should indicate

who is responsible and the estimated date of completion. Once the interventions are completed the key metrics should be measured to determine if the goal has been achieved and the process finalized through updated procedures and training

5. The Control section is completed once all are satisfied that the results are sustained. An ongoing system of measurement should be established to determine if the new process degrades over time. If so, a control plan will detail specific remediation actions and persons responsible.

Note that the A3 is a dynamic document that changes over time. It should be periodically updated to reflect the current project status.

List improvements and their impact on key metrics

Indicate methodology to sustain gains

Background: Problem StatementState current situation resulting in the current undesirable condition.

(What problem are you trying to fix?)

Objective / Goal:Reduce or eliminate current problem

from XX to YY

Current Performance:Add measurement graphs or tables here. Be sure to include your KEY METRICS and period of

measurement.

Additional data/findings/root causes/graphs1. List2. List3. List4. List

Key Metrics:1. List2. List

Team Members:

Define: Describe the performance issue

Measure: Capture current performance

Analyze: Identify and prioritize root causes of poor performance

Improve: Pilot interventions and evaluate effectiveness

Control: Sustain performance

A3 Owner: _________________________Revision Date:______________________

Lean A3 Template

3 elements must agreeExample:• Problem – process takes too long• Goal – reduce the time it takes• Key metric – time to complete process

A3 Template 2 Column.ppt

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Additional and Optional Elements

Optional Component - Add MESS concept - Clean up our mess before the customer sees it!

Why use it? It is a structured way to ensure the delivery of a completed application.

How do you do it?1. While rounding the huddle facilitator will ask the team for any current or anticipated issues dealing with the

following:• Method – Are we doing something that doesn’t make sense or is difficult to do?• Equipment – Anything broken, malfunctioning, in need of repair or missing? • Supplies – Any issues with shortages, stocking, defects?• Staff - staffing level for the shift, temp. labor, overtime needed, assistance w/ difficult practitioners.

Additional elements are needed to optimize/enhance board function1. Huddle Rules which include huddle times, standard questions asked, expectations of those huddling, and length

of huddle – located next to the board2. Additional idea cards and pens to write them – located next to the board3. Whiteboard markers, magnets or push pins for holding idea cards – located on or by the board4. Designate a time keeper to ensure that the huddle time doesn’t exceed the rule.5. Designate a scribe to take notes if needed.

Credentialing Process Improvement

Background:Prior to April 2014, the Central Credentialing office (CCO) was responsible for obtaining, verifying, and packaging provider credentialing documentation (both initial and reappointment) for JHH, JHBMC, and JHCP. In April-July of 2014, Howard County, Sibley, and Suburban hospital credentialing migrated to the CCO. Each of these entities performed the function individually in their own credentialing offices which are currently maintained as support to the overall process. In October 2014 the CCO migrated to new credentialing system – MSOW. In addition to a significant “learning curve”, the system both gained and lost specific functionality requiring new process workflows. Quality and process issues have contributed to long throughput timesthat may result in the inability to maintain credentialing due dates. This could potentially lead to provider’s inability topractice, departure of existing providers, potential lawsuits, and regulatory sanctions if not remedied.

Goal: Reduce lead time by June 2015:Initial Fast Track from 81 to 33 daysInitial Normal from 114 to 57 daysReappointment from 104 to 60 days

Improvement Verification & Future Stability:Ongoing measurement of KPIs, huddles and Huddle board

Key Metrics:KPI (Y) – Lead (Throughput) time from submittal of application to hand-offPath Y – First pass yield as measured by CCO staff

Team Members: M. Walters, S. Mealey, J. Travagline,

Key StakeholdersP. Schafer, C. Umstot, L. Kander, N. Miller, J.Rein

Define

Measure

Analyze: Identifying & Prioritizing root causes of failures

Improve

Control: Achieving High Reliability

A3 Owner Melissa WaltersRevision Date May 27, 2015

KPI Data:

# Action Responsible Due * Status

1 Develop a standard audit tool & capture audit defects by

category – add quality measure to huddle boardMelissa, Scott,

Sr. Specialist

6-30 In-process

2 Establish idea huddle board for team led continuous

improvement and engagement

Melissa, Scott,

Rich

4-30 Initiated &

in process

3 Establish a uniform service agreement to determine CCO

deliverables for all MSOsMelissa in

concert w/MSOs

4-15 now

7-15

In-process

4 Review existing CCO workflow, identify standardization

opportunities, train, and monitor

Melissa, Scott,

Rich

6-15 On-Track

5 Assess/limit of files released to Specialists vs. all applications

as receivedMelissa, Scott 7-15 On-Track

6 Establish individual productivity target for CCO teams Melissa/Rich 6-15 On -Track

7 Fill open position and explore new vehicles for recruitment Melissa 6-15 On-Track

• Non-standardized processes for CCO internal audit (1st pass yield)• Excess inventory in system – (# of applications creates overproduction/prioritization issues)• Process/task variation – communication, use of MSOW, method of obtaining information• Defects accepted and passed along – perception is that they are a normal part of the process• Culture of Firefighting vs. proactive improvement • Lack of standardization among MSOs for deliverables• Frequent use of faxing for communication – vs. phone, e-mail• Labor required to reduce initial backlog is hampering ability to engage team in process improvement • Acceptance and Audit criteria at MSO’s vary

* Initial Application Lead time Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15

Fast Track LT (goal 33 days) 89.5 95.1 87.9 59.8 65.2 66.4 83.8 93.5 73.8 58.3 71.2 84.6

Normal LT (goal 57 days) 102.2 88.6 106.3 101 122.2 101.1 118.7 103 127.6 110.7 120.3 85.9 71.7 81.6

* Reappointment Lead time

All Reappointments (goal 60 Days) 95 112.4 101.8 109.5 103.1 113.2 106.7 102 106.8 102.7 105.1 102.2 91.7 94.1

*Avg. Lead Time - In days - from request to completion by the CCO

First Pass Yield - CCO Audit Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Mar-15

Initial File Audit 86% 97% 83% 83% 73% 65% 61% 63% 62% 69% 71% 73% 66% 72%

Reappt File Audit 87% 90% 91% 90% 70% 83% 81% 84% 82% 79% 88% 96% 94% 94%

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Uncle Sam

1. Report to update email addresses

2. Fix fax email error

3. “Click here for privileges” link

4. Auto-handling of certain emails

5. Huddle recap

6. Auto-sequence ID numbers

7. Mini processes

8. Add specialist name to fax cover sheet for 2nd and 3rd

requests

9. RVW report

10. MSOW browser compatibility

11. Eliminate MD- AIM verification

12. Order varidesks

13. Work from home

14. Add applicant name to “audit ready” email

15. Email address on fax forms

16. PSV Playbook

17. Hardenbergh temps productivity requirements

18. Employee suggestion box

19. Individual RightFax accounts

20. Re-assigning files in MSOW (rework)

21. Remove the “x”

22. Fax distribution solution

23. Off-season 4-day work week

Winter

1. Hire more specialists

2. Scanning: discerning document or response

3. Time allotted for sr. specialists to triage credentialing issues

4. Remove “N/A” from reappointment DOP question

5. Default training reference task to “post to work list”

6. Add instructions for references to sign/date evaluation if not submitted online

7. ECFMG for foreign education

8. Common audit error reviewed at staff meetings

9. Front desk call routing process

10. Add task “item needed based on prep for review”

11. Audit checklist

12. Use dropdown box to source internal reference records

13. Previously verified doctors may be used without init/date or re-scanning

14. Add CDS original issue date to MSOW

15. Access to JHH CME database

Metric Benchmark Sep '15 Oct '15 Nov '15 Dec '15 Jan '16 Feb'16 Mar'16 Apr '16 May '16 June '16 July '16

Initiation Time

#days from request rec'd to app sent

(for initials comp during the month) 2 days 1.5 (68) 1.4 (59) 1.9 (48) 1.8 (71) 2.2 (57) 1.8 (91) 2 (100) 1 (121) 1 (155) 1 (165) 1 (100)

Applicant TAT

#days from app sent to app rec'd by CCO

(for initials comp during the month) 10 days 27.8 (68) 19.7 (59) 16.3 (48) 13.3 (71) 24.3 (57) 12.8 (91) 16 (100) 13 (121) 19 (155) 16 (165) 19 (100)

Fast Track Avg

#days from app rec'd to file completed by

CCO (for fast tracks comp during month) 21 days 43.1 (27) 44.9 (26) 59.1 (24) 61.4 (32) 60 (24) 58 (27) 50 (22) 50 (21) 49 (27) 40 (49) 51 (34)

Fast Track Median

#days from app rec'd to file completed by

CCO (for fast tracks comp during month) 21 days 37 (27) 32 (26) 47 (24) 58.5 (32) 47.5 (24) 43 (27) 41 (22) 39 (21) 47 (27) 31 (49) 42 (34)

Avg Verification TAT

#days from app rec'd to file completed by

CCO (for initials comp during the month) 45 days 60.1 (41) 66.3 (33) 77.6 (24) 79.7 (39) 80 (33) 45 (64) 54 (78) 59 (97) 67 (128) 78 (116) 85 (66)

Median Verif TATMedian of Verification TAT above

45 days 53 (41) 63 (33) 70 (24) 71 (39) 71 (33) 33 (64) 43 (78) 51 (97) 65 (128) 68 (116) 83 (66)

Reapplicant TAT

#days from reappt sent to reappt rec'd

(for reappts comp during the month) 15 Days 30.0 (348) 30.8 (244) 31.5 (216) 26.7 (236) 27.3 (229) 33 (270) 31 (357) 24 (254) 24 (216) 19 (234) 15 (100)

Verification TAT

#days from reappt rec'd to file completed

by CCO (for reappts comp during month) 45 days 74.3 (348) 58.8 (244) 57.4 (216) 47.9 (236) 55.9 (229) 48.9 (270) 47 (357) 48 (254) 44 (216) 42 (234) 39 (175)

Median Verif TATMedian of Verification TAT above

45 days 77 (348) 45.5 (244) 49 (216) 44 (236) 46 (229) 45 (270) 42 (357) 43 (25) 39 (216) 35 (234) 32 (175)

416 303 264 307 286 361 457 375 371 399 275

Initial File Audit % of initial files passing internal CCO audit 70% 71% 59% 60% 69% 74% 88% 62% 64% 69% 70% 72%

Reappt File Audit

% of reappt files passing internal CCO

audit 85% 96% 92% 93% 94% 94% 96% 96% 97% 92% 94% 94%

Initial File

Acceptance Rate

% of initial files comp monthly with no

errors as reported by entity 95% 94% 93% 98% 99% 100% 98% 97% 100% 99% 98% 99%

Reappt File

Acceptance Rate

% of reappt files comp monthly with no

errors as reported by entity 99% 98% 97% 98% 99% 98% 98% 99% 99% 99% 98% 99%

NRD

NRD =

11/30/15

NRD =

12/31/15

NRD =

1/31/16

NRD =

2/28/16

NRD =

3/31/16

NRD =

4/30/16

NRD =

5/31/16

NRD =

6/30/16

NRD =

7/31/16

NRD =

8/31/16

NRD =

9/30/2016

Timely reappts = reappt apps rec'd by

CCO 30 days or greater before due date Due Date

comp as of

9/30/15

comp as of

10/31/15

comp as of

11/30/15

comp as of

12/31/15

comp as of

1/31/16

comp as of

2/29/16

comp as of

3/31/16

comp as of

4/30/16

comp as of

5/31/16

comp as of

6/30/16

comp as of

7/31/16

Workflow

Management

% of timely reappts (N) completed 60

days in advance of NRD 95% 80% 80% 86% 78% 76% 81% 88% 94% 96% 100% 88%

JHHS CCO Metrics - Based on Month file completed at CCO

Wo

rkflo

w

Initia

l F

ile

sQ

ua

lity

Re

ap

pt F

ile

s

Total monthly files (initial and reappointment - No duplication)

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Metric Benchmark Aug '16 Sept '16 Oct '16 Nov '16 Dec '16 Jan '17 Feb '17 Mar '17 Apr '17 May '17 June '17 July '17 Aug '17

Initiation Time

#days from request rec'd to app sent

(for initials comp during the month) 2 days 1 (96) 1 (89) 1 (85) 1 (74) 1 (99) 1 (103) 1 (88) 1 (127) 1 (127) 1 (138) 1 (170) 1 (91) 1 (108)

Applicant TAT

#days from app sent to app rec'd by CCO

(for initials comp during the month) 10 days 14 (96) 16 (89) 20 (85) 18 (74) 20 (99) 18 (103) 15 (88) 17 (127) 18 (127) 18 (138) 19 (170) 20 (91) 23 (108)

Fast Track Avg

#days from app rec'd to file completed by

CCO (for fast tracks comp during month) 21 days 43 (26) 38 (34) 51 (36) 58 (19) 43 (26) 29 (40) 42 (18) 24 (18) 27 (18) 24 (27) 25 (33) 27 (25) 23 (28)

Fast Track Median

#days from app rec'd to file completed by

CCO (for fast tracks comp during month) 21 days 29 (26) 38 (34) 47 (36) 49 (19) 25 (26) 21 (40) 34 (18) 20 (18) 16 (18) 19 (27) 24 (33) 21 (25) 23 (28)

Avg Verification TAT

#days from app rec'd to file completed by

CCO (for initials comp during the month) 45 days 74 (70) 70 (55) 70 (49) 69 (55) 54 (73) 49 (63) 41 (70) 38 (109) 45 (109) 55 (111) 67 (137) 55 (66) 66 (80)

Median Verif TATMedian of Verification TAT above

45 days 70 (70) 64 (55) 61 (49) 55 (54) 44 (73) 39 (63) 33 (70) 32 (109) 43 (109) 50 (111) 66 (137) 44 (66) 59 (80)

Reapplicant TAT

#days from reappt sent to reappt rec'd

(for reappts comp during the month) 15 Days 22 (211) 19 (176) 22 (190) 24 (245) 22 (229) 22 (265) 19 (159) 18 (222) 20 (257) 25 (328) 27 (295) 30 (306) 25 (261)

Verification TAT

#days from reappt rec'd to file completed

by CCO (for reappts comp during month) 45 days 33 (211) 41 (176) 42 (190) 37 (245) 38 (229) 39 (265) 39 (159) 33 (222) 44 (257) 43 (328) 38 (295) 40 (306) 44 (261)

Median Verif TATMedian of Verification TAT above

45 days 26 (211) 43 (176) 33 (190) 31 (245) 35 (229) 36 (265) 35(265) 28 (222) 45 (257) 42 (328) 31 (295) 32 (306) 41 (261)

307 265 275 319 328 368 247 349 384 466 465 397 369

Initial File Audit % of initial files passing internal CCO audit 70% 62% 78% 72% 48% 78% 73% 75% 84% 87% 90% 89% 85% 83%

Reappt File Audit

% of reappt files passing internal CCO

audit 85% 96% 98% 94% 95% 97% 96% 92% 95% 96% 97% 98% 96% 97%

Initial File

Acceptance Rate

% of initial files comp monthly with no

errors as reported by entity 95% 99% 100% 100% 96% 99% 99% 100% 99% 100% 99% 100% 99% 99%

Reappt File

Acceptance Rate

% of reappt files comp monthly with no

errors as reported by entity 99% 99% 100% 98% 98% 99% 99% 98% 99% 99% 98% 99% 100% 100%

NRD

NRD =

10/31/2016

NRD =

11/30/2016

NRD =

12/31/2016

NRD =

1/31/2017

NRD =

2/28/2017

NRD =

3/31/2017

NRD =

4/30/2017

NRD =

5/31/2017

NRD =

6/30/2017

NRD =

7/31/2017

NRD =

8/31/2017

NRD =

9/30/2017

NRD =

10/31/2017

Timely reappts = reappt apps rec'd by

CCO 30 days or greater before due date Due Date

comp as of

8/31/16

comp as of

9/30/16

comp as of

10/31/16

comp as of

11/30/16

comp as of

12/31/16

comp as of

1/31/17

comp as of

2/28/17

comp as of

3/31/17

comp as of

4/30/17

comp as of

5/31/17

comp as of

6/30/17

comp as of

7/31/17

comp as of

8/31/17

Workflow

Management

% of timely reappts (N) completed 60

days in advance of NRD 95% 97% 92% 97% 97% 97% 99% 97% 94% 95% 97% 95% 95% 97%

Wo

rkflo

w

Initia

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ile

sQ

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Re

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pt F

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Total monthly files (initial and reappointment - No duplication)

QUESTIONS????