Meet me April 13, 2011 in Orlando for Two LTC Expert Panels on Best Practices in Compliance

Please join me at the HCCA’s 2011 Compliance Institute in Orlando where I will lead two expert panels on Wednesday, April 13. My sessions will provide timely information and valuable insight on some of the long-term industry’s most crucial challenges from the perspectives of government, monitors, executives, operations and compliance. Panelists include:

• Lisa Re, Deputy Chief, Office of Counsel to the Inspector General, Department of Health & Human Services  
• David Zimmerman, Ph.D. , President, Long Term Care Institute
• Michael Torgan, President, Country Villa Health Services
• Rachel C. Bennett, Chief Operating Officer, Country Villa Health Services
• Tammy Pirhekayati, R.N., B.S.N., Senior Vice President of Professional Services, Country Villa Health Services

Session One: April 13 at 8:00-9:45 am
Best Practices in Long-Term Care Compliance: Part 1 – Perspectives from the Ground
Discover how the experts assess quality of care and mitigation of risk in the real world – and learn the tips that every long-term care professional needs to know. Ask panelists your most pressing questions on compliance, and hear how they address key concerns raised by other audience members – be prepared to take notes!

Session Two: April 13 at 10:00-11:45 am
Best Practices in Long-Term Care Compliance: Part 2 – Improving Organizational Performance
Find out why some organizations repeatedly re-solve the same compliance issues, while others resolve compliance issues — and keep them resolved.  Discover a comprehensive model of compliance designed especially for long-term care.  Ask the experts your burning questions on this most timely and challenging of topics.

What questions would YOU like to see addressed at these panels? I look forward to your thoughts....

AHCA/NCAL Conference Coming Up

Rachel Bennett, COO of Country Villa Health Services, and I will be presenting at AHCA/NCAL's 61st Annual Convention and Expo in Long Beach on October 11. We're going to be talking about Leading for Quality and everyone who attends will walk away with a comprehensive tool to promote the kind of leadership we'll be presenting.

Our premise is that quality leadership arises from and is supported by ethical culture. Therefore, quality and compliance are inseparable sides of the same coin in long-term care.

You can download a graphic that shows in detail a big-picture perspective of compliance and quality in long-term care on our website at http://healthcareqc.com/upcoming-events/.

This symbiosis between quality and compliance may be a marriage of necessity rather than romance, and it is not made in heaven, but what we have demonstrated is that everyone has a role in ethical culture, that when everybody does their part, quality and excellence are the rule of the day. We will show that it is possible to build infrastructure and systems and lead in such a way that these results are fostered. We'll give you a detailed, real-life example that shows how to do it.

Of course, what we really want to do is talk with all of you about what you think is important.

What you think the most important leadership strategy is right now for long-term care leaders? 

Considering everything happening right now--like MDS 3.0 and RUGIV--just to name two, and what you see coming in the near-term, what do you think industry and facility leaders should be focused on?

Post your comments here and bring them to the Convention--it promises to be a good one all-around.

A Health Care Plea from Bended Knee

Wincing as I sit down to blog today on quality improvement and the patient experience, my left knee compels me to share its humble story:  the cautionary tale about a systemic problem that if left untreated could have staggering consequences for you and me.

On Memorial Day, I injured my knee and was treated at an urgent care clinic within my insurance network. I left on crutches, wearing a knee brace; and carrying a prescription for pain medication and an order to see an orthopedic surgeon -- all provided to me by the the clinic.  Several weeks later, I received my insurance company's Explanation of Benefits telling me that the clinic's invoice was paid.  Now, let's fast forward to September, when an unexplained bill for $500 from a company I never heard of arrived in my mailbox.  My insurer explained that the bill was for “medical equipment” -- the crutches and knee brace -- provided to me because the urgent care clinic's medical equipment supplier is not in my insurance network.

How is the consumer able to make an informed decision under circumstances like these?
With all the talk about waste in medicine, all the hoopla about reform, all the uncertainty and staggering costs, how can the consumer ever make informed decisions under circumstances like these?  Here I am in pain, doing my best to make sure my visit is covered, following my insurance company’s rules, and still I end up paying $500  for crutches and a brace that I could have purchased from a network vendor for a fraction of that had anyone bothered to inform me that the equipment would be billed separately and that the clinic’s vendor was not in my insurance network. As a consumer, could I possibly have known this information?

It’s a buyer-beware health care environment, but every effort is made to make costs, insurance payments, and all other financial aspects of receiving health care services as confusing and obscure as possible for patients.

It's not just that I’m out of pocket $500 in addition to my $1,000/month health insurance premium.  It's about wasted dollars due to lack of transparency. 
It's the fact that an injured patient in pain was charged $500 because she was not informed that the medical equipment was not covered by her insurance.  It's the fact that she could have been given a choice to purchase it for $500 at the clinic, or for $100 at a local drugstore.  The system provided no transparency or choice to the patient, who then had no choice except to pay $400 for the system's lack of transparency.

Multiply this type of experience by each of us several times a year, plus all the other ways this same scenario plays out, and it's easy to see billions of wasted dollars paid to health care providers who take no responsibility for providing information that helps consumers make informed choices.

I think it's highway robbery, no different from Medicare fraud or any other rip-off of a government program, except that it is happening to individual consumers like you and me. If I can be given an estimate of costs by other professionals, why can’t medical providers do the same?  That way, we could all participate in helping to control and bring down the costs of health care.

Multi-million Dollar Jury Damage Awards…. It’s a New Day for LTC

Last week Skilled Healthcare Group, Inc., one of the nation’s largest providers of skilled nursing, rehabilitation, and hospice services, settled an understaffing lawsuit for $50 million in its skilled nursing facilities, avoiding a $677 million jury award. On news of the settlement, the Company’s stock value rose as much as 31%. The class-action lawsuit resulted in a jury award of $677 million in damages for allegations that the company understaffed 22 of its California facilities, which is thought to be the largest award in the US this year.

Skilled Care seems to have a strong compliance program and presence. It has a code of ethics and business conduct. The Company seems ahead of many in the compliance arena. So, what went wrong?

This story is a harbinger of more compliance risk to come.
Compliance can no longer address mere minimums to reduce risk; it cannot be driven entirely in response to regulators. Compliance has to grow out of an ethical culture that rewards honest reporting and other processes such as audits and independent investigations that are reported at high levels. These practices cause important findings to be triaged and addressed with the sense of urgency they require. If problems were identified with the staffing data being kept by Skilled Healthcare, compliance systems were needed to escalate those problems quickly to high levels where they could be analyzed fully and corrected company-wide. If facilities were not following the Company’s policy in regard to staffing, compliance needed to be there with the capability of raising the issue in whatever way was required to get it resolved.

It’s a new day where compliance is concerned. One thing we know for sure is that the regulators, advocacy groups, lawyers and juries will be happy to “catch” us and create the pain that often precipitates change. We need to do this for ourselves so that we are not continually dragged around by outside forces, paying handsomely and living under threat of being bankrupted by forces we cannot control. Doing this will require new thinking, new actions, new commitments from long-term care. It will require significant change.

Ethical culture is deeper than mere compliance--it is everyone in the organization “doing the right thing” simply because it is the right thing to do, not because they fear negative consequences. In an ethical culture, all staff, visibly led by executive staff, are completely invested in doing well by doing good, even when it isn’t easy. This produces a much more positive, life-affirming environment in which to live and work because it is driven by doing good rather than by fear. Doing good breeds doing good and fear breeds fear.

Long-term care has done so much unrecognized good—we need to build on that with our compliance programs and practices.  Many organizations are doing this successfully.  I'd be interested to have you share your thoughts about how your company is doing this.

On Leading the Charge for Charge Nurses

This morning, I was glad to read that the American Society of Consultant Pharmacists has come out strongly in favor of nurses being able to “act on behalf of physicians in prescribing pain medications.”  I agree with their position, and blogged on this topic when the DEA first decided to start a drug war in the hallways of our facilities.

While long-term care calls its nurses “charge nurses,” historically we have not really known how to put them in charge.
We'll put a charge nurse in the station to deal with physicians, residents, families, visitors, regulators, vendors, lost and found, emergent and urgent issues such as abuse allegations, falls, changes of condition and risk-related events, wheel chairs, CNAs, activities, tray accuracy, and of course med passes and charting. Yet, our charge nurses are offered little in the way of supervisory development so they can have the skills needed to be successful in managing these complex stakeholders and all their competing and varied interests.

Truth be told, we in long-term care work around our charge nurses quite a bit.
When the director of nursing or director of staff development is on duty, she or he often problem solves directly with CNAs, RNAs, families and visitors, leaving the charge nurse out of the communications loop.  Then on weekends while visiting our residents, families often address their questions, issues and concerns to the one person who tends not to be included in problem solving: the charge nurse.  So why are we surprised to learn that "I don't know" is the most common response families and visitors hear from the charge nurse?  Clearly this response offers no comfort or sense of confidence to the family or visitor, and colors their perceptions about our facilities.

As an expert in organizational change, I have worked with companies to build supervisory strength in their charge nurse core. Improving charge skills and also ensuring that they can really use their new skills in the work place are both essential components of developing supervisory strength. Generally the role of RN supervisors and the DNS and DSD also come into play and need to be sorted out to ensure that the charge nurses are well positioned to use their supervisory skills. Companies that have been successful with this endeavor have seen improved customer satisfaction, reduced charge nurse and CNA turnover, a downward trend in work-related injuries while providing care, and in some cases even improved quality indicators (i.e., favorable trends in weight loss, falls, and participation in activities, among others).

All of this leads me to believe that empowering charge nurses to be in charge is an idea whose time has come.
By giving charge nurses not only supervisory skills development training but also including them in communications about problem issues and problem solving.

The charge nurse is the hub of the wheel of change.
With all the demands facing long-term care today and the incredible pace of sweeping change coming with health care reform, QIS surveys, MDS 3.0, RUGS IV, among others, we are in a place of not knowing and not being able to predict how the environment will change and how we will have to adapt in the coming years. What we do know is that those who can shift fast enough with confidence and strength will come out ahead. At the facility level, the charge nurse is the hub of the wheel of change—and the key to rapid and effective adaptation in times like these.

What are your thoughts about strengthening the role of the long-term care facility charge nurse?

Quality is as Quality Does

Soon after announcing about my plans to write a book on quality improvement in long-term care, I received an email from LTCI Lead Analyst Patti Zoromski with some interesting food for thought on the topic of “What sets up high quality in long-term care facilities?” I’d like to quote from Patti’s email because I agree completely with the well-earned wisdom she shares:

“…In case you need additional questions/issues to ponder, here are a few from my Pandora’s Box (keeping in mind that my most recent experience is in working in facilities which have been seriously challenged for one reason or another):

•  …there is never time to “do it right” but there is always time to “do it over”
• Accountability – I believe staff have a right to and a need to know their corporation’s (up to date) policies and procedures and need their feet perhaps “held to the fire” (no pun intended)
• Not all staff are self directed – many need supervision, not because they are “bad” people but because they do not know how to manage their time
• Speaking of supervision: people are not instinctively born to supervise, great nurses may turn out to be good supervisors; however, they need mentoring
• Until we get out of the “in-service” mode (which is really just a “reminder” and not anywhere close to being an actual in-service) we will continue to reap poor outcomes to action plans
• Do we help staff reach their highest potential or do we allow them to slip into mediocrity?
• Do we see residents, particularly those who are long term residents, as beyond help – have we come to accept they will have UTIs, that they will have behaviors, etc. and therefore “stop trying” because we are so pressed for time elsewhere?"

Doing it right vs. doing it over.
Patti’s insight brings to mind how enforcement has been carried out over decades in long-term care, the industry has been trained to “do it immediately” and this does not always translate into “doing it right.” We have a pretty engrained habit of jumping to solutions without analyzing the conditions that are keeping problems in place. As I have said many times before, we just set ourselves up to “do it over” (over and over again) by allowing ourselves to fall into this trap.

Supervision is key at every level.
I believe that effective supervision supports people in knowing their responsibility and accountability for excellence in care and service. Nurses are not trained to supervise in nursing school and most find themselves willing but not prepared to do the right thing. I have trained many charge nurses and directors on how to supervise people. My supervisory training hits right at the heart of issues in supervision in long-term care, which is a unique setting. In addition, I advocate periodic “check ins” with nurses to provide ongoing support to them in their pivotal role.

The biggest barrier the nurses perceive to holding staff accountable is the same one their supervisors feel, which is that if they have to let someone go they will work short of staff and face great difficulty finding the right person to fill the opening. This leaves the entire facility in a weakened position. In a sense, this inaction “holds us hostage” to poor performance; and is an important mindset to change.

Change comes from learning, not training.
Patti correctly notes that long-term care organizations need to “get out of in-service mode.” (Ah…the tyranny of the in-service as the sole solution to every problem.)

I believe that while ongoing in-service training and periodic training on issues that arise is essential, training in the absence of accountability only leads to more training: it generally does not change behavior.

Let’s face it, if many of life’s challenges were knowledge problems that training could solve, we would all be thin, drive only the safest cars, and live our perfect values.
None of us can say that because we know something, we do it. But the fact is, if we don’t know it, we can’t do it. So knowledge is the basis of behavior change, but learning (actually changing our behavior) is quite a different challenge that has more to do with what happens after training. I think we need more learning to go with our tremendous knowledge in long-term care.

Both residents and staff can be seen as people with potential, or not. I see that often the two flow together—how we perceive staff as having hope and potential matches whether we see residents as being “beyond help” and stop trying. Most long-term care organizations I have worked with are willing and open to develop their staff, although they don’t always know what is needed to do so. But the fact that the intention is in the right place gives me faith that they are also seeing residents as able recipients of care and service. This has been my experience in general.

Thank you, Patti, for sharing such valuable insight from your “Pandora’s Box.” Your views from the frontlines of long-term care enrich all of our professional experiences.

What’s in your Pandora’s Box?
I encourage you to click “comments” at the end of to posting and share your valuable insights.

CMS' Five-Star Rating System Fails Facilities, Residents, and the Public

Intended to be much like the one used for restaurants’ health ratings, the Centers for Medicare & Medicaid Services’ (CMS) Five-Star Rating System was designed to be posted conspicuously in the front window of a nursing home for all to see.  The facility's rating of 1 to 5 stars is intended to give consumers the ability to compare nursing homes in order to make discerning judgments about resident care. Recently published research findings that compared the Five-Star Quality Rating scores of nursing homes to the actual satisfaction level of residents and family members suggest that there is little correlation between customer satisfaction ratings and facility five-star ratings from CMS.

This is quite a problem because facilities will soon be required to post their ratings -- and yet apparently the ratings do not predict how satisfied consumers will be with the care they will receive nor whether residents of that facility are inclined to refer their friends and family.

According to Holleran, the national research firm specializing in the not-for-profit senior living sector that conducted the study, this lack of relationship with customer satisfaction is shown in several areas of satisfaction. “One such example is the fact that those nursing homes rated as a 1-star facility (the lowest according to CMS’ standards) overall had a higher willingness, on average, to select the facility again than all other facilities.”

Essentially, what is being said here is that once the ratings of CMS are posted in facilities, some of those most preferred by customers will be the lowest rated.

Turning people away from the places preferred by their peers is a striking failure for a rating system. These ratings will influence customer perceptions of care and potentially do harm to some of the facilities that residents consider to be the best for their comfort and care.  This gap must be understood and closed before consumers should rely on these ratings in their decision making.

Adding Value Through My Summer Vocation

Pardon my hiatus from blogging as I’ve been working on several conference presentations, including one I gave this week at the 2010 QCHF Institute and CAHF Summer Conference in South Lake Tahoe. (I’ll tell you more about that presentation in an upcoming blog.)  I’ve also been developing new ideas and tools that both synthesize and expand my thinking about compliance and quality. I've decided to write a book on quality improvement in long-term care, and my summer respite has allowed me the space to think very broadly about compliance and quality in terms of the real world, day-to-day challenges that face all of us in long-term care.  Hence my thesis:

"How can long-term care companies meet their business imperatives while adding value in all of its forms and, as a result, not only be successful, but thrive as never before?"

I believe that addressing this question will spark the single most important conversation we need to have in our industry.  And so as I prepare for upcoming presentations, develop new tools, work with my clients, and try to enjoy what's left of summer, I am making time for reflection to take a fresh look at some of the basics of our business with a more critical eye and asking myself:  How can long-term care organizations get better and better at doing what we do and meeting the imperatives we face?  How can we improve, how can we simultaneously add value for all those we serve as well as for those who work with us to provide the services?   And how can we improve and add value in such a way so that our organizations can truly thrive?

Some Perspectives on Adding Value.
Excellence in clinical quality is part of value for employees as well as residents. Physical and emotional comfort is part of value for both residents and employees. A sense of belonging and making a difference is part of value for employees, and there are related aspects of value for residents. And high value delivered for residents and employees produces the kind of value every organization wants in its marketplace and allows the company to be in an expansive mode even in these challenging times.

Long-term care has never been an easy business; perhaps it shouldn’t be since it provides services to some of our most vulnerable citizens. But there certainly are proven methods that can be applied to make it all flow more effectively and efficiently and get us out of our fire suits. This would be a tremendous accomplishment for an industry that has spent most of its existence in crisis mode. It is time to do something radically different that creates a win-win-win for everyone involved. I’m putting out the call.

On Quality Improvement Action Planning --

Welcome back to what is now Part 3 in my description of Quality Improvement Action Planning®.

My last post ended with Plan 2—Plan to get data. So I'll start this one with completing Step 2—What is causing the problem?

Our team has developed a list of possible root causes and then carried out the plan to get data. At this point in the process, they analyze the gathered data to determine whether they have identified the most important root causes and what the data tells them about how to solve the problem.

This analysis involves reviewing all data, categorizing it in relationship to the problem and the possible root causes, and answering the question, “What have we learned about this problem?”

Once the team has analyzed root causes, Step 3 can be completed—answering the question, “What is the goal?”

A single problem might lead to the identification of multiple root causes. Each root cause might lead to several goals.

This is why it is so important to take your time and define the problem well. Otherwise, the whole process can become unwieldy and hard to manage. Keep the problem narrow enough so that when multiple root causes are identified, and each of those has several goals, the team can successfully implement and track its results. Too many goals is a set-up for trouble. If need be, prioritize the root causes and act on the top three, then the next set, and so forth as you are successful.

Goals should be stated clearly. This means that each goal should address only one thing the team wants to change. If necessary, you can state several goals for one root cause. Just don’t bunch several things into one goal because it will be impossible to measure.

I don’t think goals always have to have end dates, but they should be stated in such a way that you will know when you have achieved them. “There are sufficient equipment and supplies to carry out scheduled activities” is a good goal; and might also need to be partnered with a goal that says, “All staff know where equipment and supplies are stored, what is available, and how to access it;” and perhaps also a goal such as, “A cleaning and maintenance schedule for equipment and supplies will be in use.” These goals, while they do not have end dates, are clearly stated, each one addressing a different aspect of root causes of equipment availability, and it would be easy for anyone to tell whether they have been achieved.

Now that the goals are clear, the team moves to Plan 3—Plan to act. This plan answers the question of Step 4—What actions will we take to reach our goals?

Action steps are basically the bridges between the problem (where we are now) and the goal (where we want to be). Each action step must have a champion (an individual, not a group) and an end date by which the action step will be completed.

The Plan to act should paint a picture of the actions that staff are taking to reach the goal in such a way that an evaluator can come in at any point and tell exactly where the group is in the process. This part of the QIAP process is what is generally called “action planning.” As you can see, the problem identification, root cause analysis, and goal setting that come before it set the stage for an action plan that is more comprehensive and likely to yield robust results.

Finally, based on the action steps it has written, the team or leader can now develop Plan 4—Plan to validate.

Plan 4 has two distinct parts, Step 5—How will we know staff are following the plan? And Step 6—How will we know the plan is working.

• Validation is about ensuring that the action steps are being implemented and also that they are having the desired impact on the problem.
• Actions to be taken for validation should have a person assigned, and also a due date by which the analysis will be completed. Generally, data is brought back to the leader or team at some point so that decisions can be made to change the action steps or conduct more staff training, or to correct the course in some way in order to ensure that the goals are met.

This should be built into Plan 4:

• Who will review what data and when
• How the plan itself will be changed if it is not working or if staff are not able to implement it as it was planned.
• Addressing the overall effectiveness of the plan and when the plan is considered to have been successful. Often, teams set a threshold (such as, “When this goal is achieved at 100% compliance for three consecutive months”), and then refer the oversight to the CQI or PI Committee (such as “the CQI Committee will continue to monitor audits until it determines that the goals have been met”). This brings the plan into the purview of the QA or CQI committee so that oversight can be broader.  It involves leadership and often physicians in the process of oversight, further reinforcing the success achieved.

My one last piece of advice on this—notice your successes and celebrate with all staff who contributed to the solution. I’m not sure who it was who said, “Nothing builds success like success” but it is certainly true. Keeping people encouraged, letting them know what they have done to be part of a significant achievement, and involving them in celebration of success will entice them to jump in more and more as you use Quality Improvement Action Planning to create lasting, meaningful solutions to complex problems. People who use this process consistently learn that no problem is unsolvable if they invest in doing the job right.

On Quality Improvement Action Planning: How it Works

The goal of Quality Improvement Action Planning® is to produce lasting results—to get the leader and/or team where they want to be because they are achieving the results they choose. Of course, no process is a panacea, and QIAP does involve an investment of time and effort on the part of the leader and/or team. Those who have made this investment, however, are reaping great rewards. The following chart summarizes QIAP's key parts:

Here’s how QIAP works…
When a problem is identified, either through your quality improvement processes or by an outside agency, the first consideration is Plan A. This is a set of steps the facility will take immediately to reduce and minimize harm to residents. We might call these steps “quick fixes” or “band aids”—they are taken quickly and are not intended to be the final solution. This, however, is the number one error leaders and teams make in problem solving—they stop with Plan A. The results are often not satisfying because as soon as the problem seems to get better, it crops back up with different names and faces. Then more band aids are applied while the underlying causes fester. This is exactly what keeps leaders in the weeds—rushing from problem to problem in the best of worlds or crisis to crisis in the worst.

As Plan A is being carried out, the leader or team turns their attention to Step 1—What is the problem? This step requires an analysis of the situation and the creation of a well-defined problem statement. Often, the problem that is first identified gets revised as data is collected in Step 2.

Step 2—What is causing the problem? This is more than just a quick brainstorm by team members or leaders. Too often, I see people sitting around a table in thirty minutes and “deciding” what the causes are. This is something like a detective never going to the scene of the crime and sitting at his or her desk writing down how the crime happened and who did it. This method leaves out so much evidence that any decisions and actions that arise from it will inevitably be inadequate to the task. Hence, it is absolutely predictable that any complex problem approached in this way will occur again—because it has yet been really solved.

What is needed is an in-depth analysis of possible root causes. The interdisciplinary team may brainstorm possible root causes in order to decide what data it will need to move to Step 3—What is the goal? After brainstorming an exhaustive list of possible root causes, the leader or team can categorize the list. Generally I have found that teams end up with two or three main categories.

The possible root cause categories drive the design of Plan 2—Plan to get data. All actions to be carried out as part of Plan 2 must be assigned to a particular individual (not the team) and have a due date by which the step will be completed. Based on the possible root causes, a plan is developed for gathering information from residents, families, vendors, staff, medical records, physicians, and anyone else who might have knowledge to share or who will be impacted by the solutions that might be implemented.

This is where the process of organizational change begins—when people are invited into the problem in constructive ways, they often begin to change their behavior to be more in line with the goals, even before the goals are clear.

I advocate staff interviews, even of staff not often included in such analyses such as housekeepers, laundry staff, and dietary staff. For example, a team studying improving activities in their facility included housekeeping staff in interviews. They brought a whole different perspective about why residents weren’t attending—they noted that when they ask residents why they aren’t going to activities, residents reported that they were in pain or depressed. This led the interdisciplinary team into a whole new set of questions about effective assessment of depression and pain as they relate to participation in activities. This came from the housekeeping staff, not nursing.

I will take on more of the process in my next post…

On Quality Improvement Action Planning

Having put Quality Improvement Action Planning® in real-world practice for quite some time now, I’ve been able to refine the process and tools for quality and performance improvement in long-term care facilities. Although I’ve used it routinely with clients for several years, I haven’t (until now) blogged its virtues. After all, it’s my own work and I don’t want to sound self-serving. However, the fact is that people have been really noticing the positive impact that QIAP makes in their teams and facilities. So today, let me tell you a bit about QIAP: what it is, what it does, and how I came to developing it.

Closing the Execution Gap
QIAP is a deceptively simple process that builds team strength while simultaneously producing lasting improvements. I like to say it closes the execution gap—the chasm between what long-term care leaders want and what they get much of the time.

Let me explain. In my 30 years in long-term care, and in my 20+ years of management consulting in numerous organizations (healthcare and otherwise), the one constant I have observed almost everywhere is a striking gap between goals set and outcomes achieved. The same problems come back over and over (and over) again -- and people literally get burned out spending their precious time and effort reworking the same old things. This sets up a crisis-management cycle that can keep leaders spinning:  chasing problems rather than really solving them. 

Solving a Problem (Once and For Good) with an Iterative Approach
Soon after getting involved with compliance, I developed QIAP. Knowing that quality and compliance are inseparable in health care, what was needed was a way to routinely produce solid, data-based, lasting solutions. The process had to be complex enough to accomplish that result; and be user-friendly so interdisciplinary teams and bedside staff can easily understand and use it. To meet my requirements, it had to prove itself over time and be validated by someone other than me and my own experience. Most of all, it had to build the solution to the problem into the problem-solving process itself. In other words, as part of the process of designing a solution, the team that uses QIAP is taking steps to implement the solution by engaging all staff involved in thinking about the problem and how best to solve it.

What I have now observed, which has been validated by the independent monitor multiple times as well as by facility and corporate leaders, is that QIAP meets all these requirements. The process involves answering six questions by carrying out four plans. The result, regardless of the opening problem, is a broad, systematic analysis that leads to an action plan that solves the problem.

In my next post, I’ll explain each of the six steps and four plans. Stay tuned.

Why Pain Goes Untreated and the Drug War Gets Fought in Our Nursing Homes

Recommended reading for all long-term care leaders is a recently published report by the Quality Care Coalition for Patients in Pain about what the U.S. Drug Enforcement Agency is doing and how it runs counter to effective pain management in long-term care. The study, Patients in Pain: How U.S. Drug Enforcement Administration Rules Harm Patients in Nursing Facilities, points out that current DEA rules:

• Categorize nursing home residents as outpatients 
• Require nursing facility residents to be treated under restrictive provisions designed to prevent diversion of drugs for street use, rather than view the nurse in the long-term care facility as the prescriber’s agent, as is the case in hospitals and clinics

It further states that a nurse employed by a long-term care facility, even after receiving a verbal order from a physician for a controlled substance:

• Cannot use emergency kit medications for immediate administration
• Must wait until the doctor personally has either called or faxed a prescription order to the pharmacy and the nurse has called the pharmacy to confirm that the pharmacy has received the doctor’s order

According to the study, “These additional steps can significantly delay and even deny patients needed treatment, leaving sick and dying patients without adequate symptom relief to treat pain, seizures, psychiatric conditions, and end-of-life symptoms, among others. Some reports indicate that patients have been left suffering for hours and even days as their caregivers struggle to comply with these and other DEA requirements.”

Why doesn’t the DEA recognize nursing facilities as health care institutions?
It is outrageous that the DEA fails to recognize the capability of today’s long-term care nurses’ ability to assess and act in the best interests of residents. The DEA rules explicitly permit prescribers to rely on agents, but then does not treat the licensed nurse in the skilled nursing facility as such.

Why is the DEA Fighting the Drug War in the hallways of nursing homes?
Since 2009, the DEA has audited long-term care pharmacies and nursing facilities to ensure compliance with the Controlled Substances Act rules for prescribing and dispensing controlled substances to nursing home residents. As they audit our facilities, you’d think they’d notice the hospital-like environment and the tremendous involvement of skilled nursing staff in all aspects of resident care.

How the DEA Puts Clinicians in Conflict with Standards for Quality Care
The QCCPP study surveyed over 900 clinicians nationwide and revealed that “delays in treatment caused by DEA rules are forcing nursing facilities to send some patients back to the hospital for treatment and readmission. These practices are costly, difficult for the patients and completely avoidable” and that, “Physicians, nurses, pharmacists and other clinicians also find that the DEA rules put them squarely in conflict with federal and state requirements establishing quality standards for nursing facility care. Some are questioning whether they can continue to practice in an environment where they are unable to provide appropriate care to their patients.”

Why do these extra DEA rules apply in this environment?
As a compliance officer, I firmly support the regulation and monitoring of nursing facilities. And as a compassionate human being, I think that DEA officials need to take a hard look at this question and make rules that fit what is actually going on. The DEA misapplication of the Controlled Substances Act in the nursing home environment is a case in point.

The 11th Deadly Sin of the Nursing Home Administrator

Mark Tuggle’s article, 10 Deadly Sins of the Nursing Home Administrator, is a must-read. His commentary is broad-based, ranging from marketing to financial management to personal emotional reactions and the challenge of “managing friends.”  Let me propose, however, the Eleventh Deadly Sin: 

Failure to see quality as a compliance issue.

Long-term care administrators are, too often, fire fighters. Responding reactively to one problem after another day after day, they see no opportunity to manage differently because they're too busy putting out fires. While it's true that there's an aspect of reactivity built into our industry as the external environment of regulators and customers who “drop in” with ever-increasing demands, the frequency of fire fighting is also contingent upon our willingness to accept them as the way we do business.

As Stephen Covey says, when we say “yes” to one thing, we are de-facto saying “no” to another because there is only so much time and energy to spread around. So, for Long-Term Care Administrator to continually say “yes” to spending time managing crises, means they are continually saying “no” to investing time on organizational performance improvement.  This gives rise to the deadly sin of failure to see quality as a compliance issue.

Another way to say it is that the administrator chases after regulations, regulators, and customers instead of stepping back and taking a broader view that would include capacity building, trending and tracking, critical analysis, and quality improvement action planning.

Let’s face it, the only answer to the ever growing demands upon leaders is to work smarter, not harder. And for nursing home administrators, this means making performance improvement a way of life. For those who have been engulfed in crisis management, it will mean doing both for a while. This requires effort above and beyond the ordinary day-to-day. But the payoff is huge—getting out ahead of crises, of regulators, of customers—and managing things instead of things managing you.

Wouldn’t that feel better?

Bribe to Prescribe—the Omnicare Debacle Continues

Mariner Health Care of Oxnard, California is the latest entity to get caught in the Omnicare Pharmacy kickback scandal that I wrote about in Could Carrots be at the Root of Psychotropic Trends back in January. The Justice Department alleged in the most recent case that both SavaSenior Care and Mariner conspired to direct nursing home business to Omnicare for 15 years in exchange for $50 million.

According the US Attorney’s Office District of Massachusetts, Mariner has entered into a Corporate Integrity Agreement with the OIG and agreed to pay a $14 million settlement to the US government. The CIA centers around ensuring that the company does not enter into arrangements that violate the antikickback statute. In addition, the Office of the Inspector General reserves its right to seek exclusion of Sava and all principals involved from participation in Medicare and Medicaid programs in the future.

Last time I wrote about Omnicare I focused on the possible relationship between pharmacy kickbacks for certain psychotropic drugs and the frequency of use of those drugs in nursing homes. I did that because I thought the antikickback statute was well known. Since this scenario continued to unfold, however, I thought I’d clarify the statute itself for my readers.

The antikickback statute is part of the Medicare and Medicaid Patient Protection Act of 1987 (42 U.S.C. 1320a-7b) and, in brief, states that anyone who knowingly and willfully solicits or receives any remuneration in return for referrals or purchase or in return for purchasing or recommending any service or item, and anyone who willfully and knowingly offers and pays any remuneration to induce referrals or purchase of any item paid for under the Medicare or a State health program shall be guilty of a felony. The statute prohibits solicitation, offering, and receiving any type of remuneration (in cash or in kind, directly or indirectly) for the defined activities.

There can be no health care driven by anything other than the true needs of residents in long-term care. This is why most long-term care organizations have rules against staff taking tips, because throwing money into the mix of resident care decisions muddies the water and makes it more difficult to be clear and clean in our judgments about who should receive what. I don’t know whether the kickbacks alleged in the Mariner and SavaSenior Care cases resulted in any wrongdoing by the companies or their facilities, but perhaps that’s the point—we can’t know for sure. As the US Attorney in this case wrote, “Nursing home residents and their families are entitled to have decisions about who provides care to them free of the distortions caused by illegal kickback schemes.”

The very existence of kickbacks gives cause for suspicion about how health care decisions are made, and that is enough to warrant action on the part of society to ensure that kickbacks do not occur at all in any form. You would certainly hate to be vulnerable, sick, and lying in a hospital bed having to wonder whether the medications being prescribed to you are the ones that would be best for your needs or the ones the pharmacy is bribing the hospital to prescribe.

Do Database Deficiencies Spell Danger for Residents?

Years ago, as a licensed nursing home administrator, I was 100% responsible under regulation for everything my staff did in my facility 24/7. I accepted this responsibility. I took it seriously, making certain that background checks and extensive pre-hire screenings were carried out on all applicants. These days, facilities with Corporate Integrity Agreements are required to screen all new hires and all employees annually against Federal Exclusion lists. And many long-term care companies are now going above and beyond: screening all employees annually as part of their routine compliance activities, even though they are not required to do so.


Despite the best of intentions, even annual screenings of employees can be woefully inadequate when it comes to protecting vulnerable populations against dangerous caregivers.

Sadly McKnights Long-Term Care News reports that the long-awaited national database of caregivers to be unveiled March 1 is incomplete .

According to the Los Angeles Times, 22 years have elapsed since Congress ordered the national database deployed and next week's release date debuts a deficient database. Their investigations showed that many states submitted reports only occasionally, and some states submitted incomplete information on registered nurses. States were especially deficient in reporting more recent disciplinary actions taken against problem workers. Apparently some of the missing cases were people who had done harm to residents, “a nurse, for instance, whose license was pulled after she injected a patient with painkillers in a drugstore parking lot and improperly prescribed methadone to an addict who later died of an overdose.”

With the burden of responsibility resting squarely on the shoulders of individual long-term care leaders, what does it take to get complete and accurate information from those who hold us accountable for resident safety?

The industry as a whole has never been more serious about preventing resident abuse and carefully screening job applicants in the interest of protecting residents. To wait 22 years and then have the database be incomplete and inaccurate is an insult to the tremendous efforts being made by long-term care leaders. Certainly it is in the public interest to get this right.

Good Company Policies: the road to good healthcare practices or to a 3-ring circus?

Companies that take the time to conceive good policies set the stage for good practices in healthcare. I say conceive because all too often, there’s a long road between the idea of the policy, and even the preparation of the policy, and its translation into practice on the floor. And the closer you get to the bedside, the longer that road becomes.

Michael Rasmussen, president of Corporate Integrity LLC, outlines a very clear process for making sure that policies stay relevant and current. He proposes a “lifecycle” approach to policy management that includes four elements, creation, communication, management and maintenance. Creation is an iterative process of ownership, authorship and approval. Communication involves publication, training, and attestation. Management includes enforcement and exception management. Finally, management includes review and archival.

I find this scheme very useful for its simplicity and easy application. The process itself is challenging, but this framework is a user-friendly road map.

Rasmussen also makes a compelling argument for the importance of well-managed policies in compliance and risk management. Since organizational psychology defines culture as the way work gets done, it’s easy to see the essential role that policies and procedures play by defining the way work gets done and establishing clear expectations for compliance.

The Proverbial 3-Ring Circus....

Why is it then, as vital as good policies are, that so many long-term care companies focus on policy binders rather than on content? 

So why is it, as important as they are, that so many long-term care companies focus on their binders rather than their content, burying themselves under so many policies that it becomes virtually impossible to manage the binders much less the policies effectively?  

Too often, I find that when a monitor or surveyor reviews a policy, they find it outdated or not being followed. In my own work over 30 years, I have universally found policies to be little known and little used tools. Thus, the very policies that should articulate our culture of service, care, and compliance actually work against us. Or maybe we work against them.


I think it is time to rethink the way we create, communicate, manage, and maintain organizational policies and procedures so that they serve the needs of the organization and its customers in real time. I’d like to see policies that make the organization think and learn and grow so that policies grease the wheel of performance improvement, continuously moving the company toward greater and greater achievements. Working with clients to develop tools and policies in tandem so that the principles of performance improvement are built into every practice is a major focus of our work for this very reason.

The result of regulation? It’s all in how you look at it…

Brian Garavalia, Ph.D. makes a compelling case about the relationship between regulation and environmental improvements in long-term care facilities. Hinting that regulation has led the industry to improve the appearance of physical plants, he observes that the resulting improvements don’t necessarily make facility surroundings more homelike for residents. I agree. You don’t judge books by their covers or choose post-acute facilities by theirs.

In an industry dedicated to protecting vulnerable populations, regulation has been a catalyst for improvement. It is also true, however, that highly regulated organizations naturally tend to pull control upwards—to the top—and then maintain compliance through the application of heavy monitoring mechanisms throughout the organization. Hence, we have audits of the audits; and monitors who monitor other monitors. This is true at the facility level and at the State and Federal regulatory level. Any facility that has had a look-back survey understands this dynamic.

So the downside of regulation occurs when a company focuses so hard on basic compliance—measuring quantity, not quality—that decision-making moves away from the bedside and then rests with the monitor.

A quantity-focused company will scrutinize whether this or that form is in the chart, or whether the note is written to reduce risk; and then check to see whether this or that audit was completed before the survey begins.

Instead, a quality-focused company asks whether the whole story of the person is in the record; if a given incident is fully and critically analyzed for root causes by the interdisciplinary team; and whether a personalized care plan is visible. Moreover, its true litmus test might be, “Do we have data to validate that we are doing for residents what we say we will do and what they need most?”

Complex and sometimes conflicting regulations can work against a person-centered approach to compliance.

In such a regulated environment, it’s easy to see how a company might pay more attention to meeting the floor of compliance to please its regulators, and less time on achieving the highest possible quality of care and life that is attainable for its residents. Telling the story can inadvertently reveal information that makes facilities vulnerable to regulatory backlash. Facilities and companies are reluctant to say too much that could potentially make them open to more difficulty.

While it takes a real commitment from their management and staff, the best long-term care companies focus on attaining the best possible quality of care and life for their residents and, within that framework, meets and then exceeds the regulatory requirements.

Shouldn't the Stars that Rate Facilities be the Residents?

Who decides whether a nursing home gives good care? And who has the measures to say definitively whether a facility provides an excellent quality of life for its residents?

USA Today seems invested in the Five-Star rating program. Predictably, they reported that for-profit long-term care facilities rate much lower than nonprofit homes, noting that 27% of the for-profit homes listed in their analysis rated only one star.

By contrast, industry experts like AHCA, the American Health Care Association, say that the Five-Star program is flawed because it rates on a curve, meaning that fully one-fifth of all facilities must fall in the one-star category, regardless of how they perform. Furthermore, fifty percent of what constitutes a star rating is state survey findings, which are notoriously unreliable and variable from state to state, within states, and among evaluators. There is a lot of room for individual interpretation and preference in evaluator ratings, so it is easy to see how a facility’s profit status might influence even evaluators’ ratings, leading to poorer ratings for for-profit facilities and thereby resulting directly in fewer stars.

My point, though, is not to comment on the Five-Star program, but instead to raise the issue that in all of this rating and evaluating, customer satisfaction, the customer experience is absent. In the Guest Blog, CMS Five-Star—Friend or Foe, long-term care commentator and blogger Anthony Cirillo cites the 2008 study by the research and consulting firm Holleran, “In an analysis of data from more than 12,000 nursing home residents and family members across 32 states, Holleran found little to no association between the one through five ratings given by CMS and actual satisfaction ratings. Holleran's research reflects satisfaction across skilled nursing facilities primarily in the nonprofit sector. Nursing homes rated as below average by CMS are garnering satisfaction ratings in the mid 80s, according to Holleran, which suggests these results show there are missing key elements in the Five-Star Rating system.”

I think this is unfortunate and really misses the point, since long-term care consists of human beings providing intimate services to other human beings. It seems logical that the views of the recipients of care quality of life would be directly influential in determining how a facility ranks in the Five-Star system.

Even though this is the case, and I agree that the Five-Star system is flawed, I do believe it is here to stay. I think the public demand for transparency is growing as the boomers enter the marketplace for long-term care services and I hope the industry will do what it has historically done—rise to the occasion and use the Five-Star rating system to raise the bar on compliance and performance. I look to long-term care to capitalize on this program as an opportunity for reflection, analysis, and continuous improvement.

Sad Commentary on Long-Term Care....

St. Louis Post-Dispatch’s Robert Patrick blogs about the Cathedral Rock plea that, “…the companies will be sentenced in April, likely to some term of probation in addition to fines and penalties. Corporations cannot be sentenced to prison.” Even more amazing are its 22 reader comments, most of them reflective of myths and old ideas about long-term care facilities. One person wrote, “Man, I bet that those places stunk! Old folks’ homes, or deaths waiting rooms, smell bad even when people are following all the rules.”  This comment, and others like it, reflect not only on Cathedral Rock but also on all long-term care companies.

The public is very ready to believe the worst about long-term healthcare and bad news like the Cathedral Rock story hit the industry hard. As is often said, trust is built over years and destroyed in five minutes.

This is sad because in actuality long-term care provides an extremely valuable and necessary service to society. It is part of the healthcare continuum and for the most part, the thousands of facilities and their operators and staff in this nation provide excellent quality of care and a high quality of life for the people they serve. The industry has changed rapidly in the past decades and has professionalized greatly. It is unfortunate that the public’s appetite for horror out of long-term care is fed once again.

Several of the comments about Cathedral Rock picked up on the fact that, as Patrick put it, “Corporations cannot be sentenced to prison.” Those who commented want to see individuals personally punished for these crimes against seniors. Indeed, it is easy to follow this logic. It should be understood, though, that in long-term healthcare there are other options that Patrick did not mention, such as being permanently barred from participation in Federal and State reimbursement programs. The perpetrator’s name is added to exclusion lists maintained by the Office of the Inspector General and accessible to the general public.

Companies and individuals who are seeking services can search these lists to see if the provider they are considering has been involved in some wrongdoing. Companies and individuals who are listed cannot receive government monies, even in the form of salary or payment. Many long-term care facilities check all new hires and contractors against these lists to ensure that they do not employ or use the services of anyone or any company on the exclusions lists. This at least prevents those who are convicted of criminal offenses in the provision of healthcare from repeating their offenses.

On Healthcare Quality and Compliance

Health Care Law Blog: WVHCA: 2010 CON Capital Expenditure Minimum

HIPAA and HITECH Add IT to Compliance Challenges

As the use of electronic medical records increases in long-term care, I’d like to share some words to the wise about the protection of Personal Health Information (PHI) required under HIPAA and HITECH, both parts of the American Recovery and Reinvestment Act of 2009.

In the first enforcement action under the Health Information Technology for Economic and Clinical Health (HITECH) Act taken by the Connecticut Attorney General, and subsequently blogged about by health care lawyer Bob Coffield, Health Net of Connecticut, Inc. allegedly failed to notify the AG and other officials of a missing portable computer hard drive containing PHI. This action reflects HITECH’s increased capacity for enforcement since it allows state attorneys general to file complaints on behalf of the public.

Two parts of this news stand out to me: 1) that HITECH is alive and well – so long-term care needs to be mindful about encrypting PHI data before electronically sharing or storing it; and 2) that compliance professionals take heed of HITECH reporting requirements to facilitate corporate compliance.

In addition to sharing great insight, Bob references a more extensive blog post by attorney David Harlow, that adds valuable information about compliance with HITECH.

I highly recommend both posts to you.

Could Carrots be at the Root of Psychotropic Trends?

On Friday, the US Department of Justice filed a civil False Claims Act complaint against Johnson & Johnson and two of its subsidiaries. It claims that the companies paid millions of dollars in kickbacks to Omnicare, Inc., the nation’s largest pharmacy specializing in dispensing drugs to nursing home residents. In November 2009, Omnicare entered into a $98 million dollar settlement agreement that resolved its civil liability under the False Claims Act for taking kickbacks from J&J.

The government alleges that J&J viewed Omnicare pharmacists as an extension of its sales force because Omnicare pharmacists reviewed nursing home patients’ charts, and subsequently recommended to the patients’ physicians which drugs should be prescribed for each patient. It also contends that these physicians accepted Omnicare pharmacists’ recommendations more than 80 percent of the time. In addition, the government asserts that J&J paid several forms of kickbacks to Omnicare, including rebates for the pharmacy’s implementation of programs designed to increase J&J prescriptions; paying for “data” never provided; and providing substantial “grants” and “educational funding” as inducements to recommend J&J drugs.

This weekend as I read the government’s complaint, I was especially troubled to see that listed among the drugs eligible for J&J kickbacks to Omnicare for use in nursing homes was its antipsychotic drug, Risperdal.

In recent years, I have seen a growing tendency of physicians to prescribe psychotropic medications to nursing home residents, with or without a psychiatric diagnosis.

If these allegations are true, I’m left to ponder the extent to which Big Pharma carrots contribute to healthcare providers’ selection of drug interventions without first attempting non-pharmacological interventions.

And while I'm on the topic of patient assessments prior to psychopharmaceuticals are prescribed...

I have noticed that PASRR (Pre-admission Screening and Annual Resident Review) assessments sometimes don’t match the drug regimen. Not uncommonly, a PASRR on admission to the facility will note no mental illness or disability and yet routine anti-psychotic or antidepressant medications are ordered.

In a study of the use of the PASRR to assess serious mental illness in nursing home residents, PASRRs from 44 states and 24 nursing homes were studied by reviewing medical records. The authors of the study concluded that, “Nursing facility compliance with administration and documentation of PASRR screens appears problematic. Nevertheless, there do not appear to be excessively high numbers of residents with serious mental illness, suggesting that state PASRR programs may contribute positively to the identification of people with serious mental illness. Many nursing facility residents, however, have some type of psychiatric illness, and PASRR legislation does not appear to have enhanced their ability to gain access to mental health services beyond standard psychiatric consultation and medication therapy.”

If there are not excessively high numbers of residents with serious mental illness, why does there seem to be so many on psychotropic medications?

Are we observing behaviors then seeking diagnoses to justify the use of drugs? If so, this is problematic for both quality of care and quality of life.

A more life-affirming approach is to observe behaviors, drill down to the root cause of the behavior—what exactly is triggering or causing it—and then address the root cause with non-drug interventions on a case-by-case basis. When it has been proven that all else fails, a medication may be appropriate.

Of course, medications are required for some mental health diagnoses. Even still, many medications such as antidepressants were never designed to be used indefinitely. Instead, they were developed to allow the individual to regain enough reserve to deal with the problems they face and once they improve, the drug can be slowly withdrawn.

In addition to searching out root causes of behavioral symptoms on a case-by-case basis, we encourage our client facilities to have their Behavior Management Committees track and trend behavioral triggers facility-wide. In this way, root causes that are common in the facility can be addressed more globally as the interdisciplinary team can design facility-wide interventions that solve problems for many residents at the same time. This process also allows facilities to identify areas for performance improvement such as staffing shortages at certain times or staff skills competencies that need development before they become bigger regulatory or compliance problems. This is how facilities are getting ahead of the behavior management challenges they increasingly face in today’s environment.

So, what should long-term care do with news like the allegations against Omnicare and J&J?

Clearly it can’t monitor all the marketing programs of drug manufacturers; and correlate them to the drug recommendation proclivities of pharmacists and the prescription-writing trends of physicians. It would be beneficial, however, to implement the kind of quality and performance improvement measures I have discussed so that facilities can rely less on their pharmacy consultants and more on the critical analysis of their interdisciplinary teams, armed with excellent data about root causes and trends. This process would improve quality indicators throughout the industry.
Most of all, we as an industry need to put quality of life as the top priority and stop turning to drug interventions as the first line of defense for problem behaviors. Where psychotropic drugs are concerned, doing so would have thwarted Omnicare and J&J at the door.

Cathedral Rock: A Call to Action for Us All

This week, five Cathedral Rock nursing homes pleaded guilty to felony health care fraud for failure to provide adequate care to Medicare and Medicaid beneficiaries. In the criminal prosecution and civil settlement agreements, the US Attorney’s Office of the Eastern District of Missouri cited Cathedral Rock’s failure to perform essential patient-care responsibilities like wound care and medication administration. The five facilities have since been closed. Cathedral Rock had been fined $1.6+ million. The two former employees of Cathedral Rock who filed the qui tam complaint will be rewarded $94,200 from the civil settlement.

I’ve been wondering how Cathedral Rock – or any organization in long-term care -- could find itself in this position, losing so much for what appears to be flagrant violations of standards of care and an alarming breakdown in their systems of care delivery. Like many organizations in post-acute care, Cathedral Rock’s senior management appears to be a group of highly experienced individuals with excellent credentials. Their company mission statement is both moving and laudable: “Integrity first, service above self, and excellence in everything we do.”

How can an organization that has every good intention of providing a high quality of care and service admit in plea agreements that “medical records were falsified and a ‘charting party’ occurred at Springplace to fill in medical records so that it appeared that all medication had been properly given, regardless of whether the medication was actually given or not.”?  Why is it that in highly regulated environments, people feel the need to build Potemkin villages—impressive, showy facades designed to mask undesirable facts and look good to the powers that be? Sadly and way too often, behind those facades are fallen heroes, broken promises, and downright bad practices that do harm. I’ll wager that this was not how it all started at Cathedral Rock, but this is clearly where it ended for five of its facilities.

So, what’s the learning here? How do long-term care facilities problem solve and manage in a way that broadly engenders an understanding that the company does well by doing good?

I see quality improvement coupled with compliance management as the answer. Today, Cathedral Rock is faced with the daunting challenge of rapidly implementing a comprehensive compliance program, but compliance is just part of the picture. Without a focus on improving performance in quality of life and care, without developing the systems and skills throughout the company to manage and continuously improve quality of life and care, Cathedral Rock, like so many others, will flounder on the edge of excellence and fail to fulfill its mission of integrity, service, and excellence -- over and over and over again.

And later this week…

...I saw David Zimmerman, President of the Long-Term Care Institute. He shared an astute observation with me about the dual challenges faced today by long-term care organizations. He pointed to their need to care for higher acuity patients coming out of hospitals, as well as for younger, more psychosocially challenging residents who are referred to them in growing numbers -- and the need for adaptation at every level to this new environment.

Charles Darwin couldn’t have said it any better.

In the environment David described it’s paramount that long-term care companies adapt their performance in both quality and compliance. In part, this means improving the tools and management systems that we use to assess, triage, action plan, and manage to meet complex needs at both ends of the spectrum – and every need in-between.

And so to literally practice what I preach, I am leading my company in taking stock of the suite of tools and management systems we use offer long-term healthcare companies. I plan to refine them with an eye toward organizational performance adaptation. To do this, I am pulling together a team of experts to work with me as a think tank with a goal of taking a critical look at the current landscape of long-term care compliance and identifying what’s needed to fill the gaps and refine my tools and systems. Clearly, it isn’t good enough to stand still or to chase after the latest regulatory focus anymore.

Cathedral Rock is a call to all of us in long-term care to do better. I wish Cathedral Rock much success in their efforts because I know their achievement will affect the lives of the many people who live and work in the facilities they manage. And there will be everything to celebrate in that.

Compliance's Paradigm Shift to Quality

While compliance professionals have been focused on their acute healthcare organization’s utilization and medical necessity documentation, compliance enforcement officials have been looking beyond these regulatory minimums.

Today, quality of care is the paramount issue in long-term care compliance.

This means that organizations must manage quality of care not only case-by-case, but also facility-wide, regionally, and company-wide. In short, to avoid compliance problems or to solve them once they occur, long-term care companies must focus on quality improvement.

To do so means first gathering data related to sentinel events and other quality indicators that can be readily analyzed for root causes across cases or incidents. Then organizational processes are required to put measureable and sustainable actions into place. In fact, when compliance enforcement action is required, leaders must verify that problem-solving actions are working to improve quality.

This requires long-term care leaders to think broadly about resident care and quality of life, and then problem-solve from that wider perspective.