Compliance is a floor!

To state the obvious to many who might read this, the world of LTSS is highly regulated.  Federal grants have multiple reporting requirements to ensure that the funds are being spent appropriately. Nursing facilities operate in an incredibly complex system of regulations designed to ensure that residents are safe and that they are receiving quality care. In Medicaid-funded HCBS, CMS requires numerous assurances about the type and quality of services being provided and how the state is ensuring that participants are protected from abuse, neglect and exploitation. Rules and regulations can also create shared definitions, shared goals, and level playing fields for providers.

Everyone would agree that health and safety and protection of individual rights are worthy goals; however, it can become very easy for these rules and regulations to take on a life of their own. Compliance driven processes are created and the original intent can get lost.  Compliance itself becomes the outcome. In some cases, performance and quality measures are equated with compliance rates.

We have had the enormous good fortune to work with highly dedicated and mission-driven public servants through the years, but we have also seen compliance-focused organizational culture and business process impede quality improvement and necessary change time and again. It shouldn’t sound radical to propose that compliance is a floor and regulations are an opportunity, but it feels a bit radical!

While compliance is a good (or even a great) outcome, it should not be the only outcome. Processes and systems can be designed to maximize compliance, ensure outcomes consistent with policy goals, and achieve operational excellence.

It is easy for highly regulated environments to stagnate. Building in continuous improvement to the program or process design may alleviate this risk and create opportunities for periodic review. Creating operational excellence focused on accuracy, consistency and efficiency, can create expectations for both compliance and effectiveness and can mitigate building in unnecessary compliance-focused redundancy.

Ensuring that each individual in the process clearly understands the policy objectives and performance goals associated with a process can mitigate the tendency for a system or process or report to be done “just because it’s required”. It is also a great opportunity to empower individuals with the tools and knowledge that they need to support efforts to continuously review and improve operations. Continuous quality improvement happens when everyone feels empowered to ask “why”!

Regulatory requirements at both the state and federal level are updated, or new requirements are introduced on a regular basis. Each of these changes is an opportunity for positive change. In compliance-driven systems, change is feared because of the need to learn new ways to manage a process or system and still be compliant. Instead changing regulations can be a catalyst for change, an opportunity to reevaluate “how it’s always been done”.

When quality assurance is perceived as something that is completely different from, or separate from, quality improvement, systems can be fragmented and more expensive. While these are separate concepts, they can be developed and implemented in tandem with each other to achieve better outcomes and improve efficiency, leading to administrative savings.

Sometimes a fresh perspective helps to recognize the positive potential that changes in regulatory requirements present to your systems – or the fresh look that is created when you have new eyes looking at your system. The same kind of opportunity is created by the development and implementation of new technology.

We are doing a series of issue briefs: “In a Nutshell:  Fresh Perspectives on LTSS Issues” to outline our thoughts more specifically about what these opportunities look like and how to capitalize on them when they present themselves. The first one up is about the promise of PASRR to support policy objectives such as Medicaid rebalancing, or Olmstead planning. More are planned on topics like Electronic Visit Verification, the HCBS Settings Rule, NAPIS reporting – the list could go on and on! Of course, we would love to be that set of fresh eyes for any organization that is trying to figure out how to leverage the opportunity to go beyond compliance. Check us out at!

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