April 2022

As Yvonne and Erika and I launch Sage Squirrel Consulting 2.0 and plan for our future, we pause for a minute to recognize and appreciate how we got here.  In 2017, Debbie Pierson had a vision.  I thought it was bananas, but I also trusted her because she was the most competent person I have ever had the good fortune to work with. Debbie – probably to no one’s surprise – turned out to be a natural-born consultant, and her vision became a reality. Sage Squirrel Consulting became a legitimate consulting firm

When Debbie passed away this summer, I thought that Sage Squirrel Consulting was going to pass away too.  Much to my amazement and good fortune, that is not the case.  This month, we renew Debbie’s vision for a consulting firm dedicated to the idea that good policy, combined with accurate, consistent and effective operations in a person-centered system, are the keys to states being able to help vulnerable people get the resources and supports that they need, where and when and how they need them. 

I could go on at length here about how special Debbie was, but we don’t have the space for that. If you ever worked with her, you know what I’m talking about.  If you never worked with her, I’m sorry that you missed out.  Her spirit was definitely at work bringing the three of us together last fall and I hope we continue to channel that spirit as we take the firm into the future. 

I am more grateful to Debbie than I can ever express for how she supported and guided me to learn the ropes – first in the Division of Aging and later as a consultant. Her faith buoyed me then and continues to help me believe in myself. The best way for me to express that gratitude is to carry on the work that she loved, so with that, we begin (again). 

In memoriam – Debbie Sue Pierson

Accuracy is the first principle of ACE, but accuracy alone isn’t enough if it is not applied throughout your organization. Consistency is the second principle of ACE and it is just as important as accuracy is in establishing your credibility. The Oxford Dictionary defines “consistent” as:  always behaving in the same way, or having the same opinions, standards, etc.

Accuracy means you are getting it right – consistency means you are getting it right all the time. Consistency may mean that you always put two pickles on the sandwich, but it also means that different people come to the same correct decision about matters of interpretation. You may recognize the latter as “inter-rater reliability”. Inter-rater reliability is the extent to which multiple people come to similar conclusions and establishes the consistency of any given system of assessment or evaluation.

Consistency can also refer to process. Regardless of individual decision or outcome, the process involved in making that decision is consistent. That consistency of process is also part of how you reach “inter-rater reliability”. 

Achieving operational consistency takes a combination of coaching and tools, including the use of technology. As we discussed in our last post, tools and technology are good ways to facilitate accuracy by limiting the scope of human error. The use of tools and technology also helps establish consistency as long as they are used by all of those who perform a task. 

Here’s an example:  The nursing facility survey process is one that has been notorious for inconsistency and subjective assessment. Providers have complained for years about the fact that survey results can vary widely based on the surveyor. Over the course of 2018 and 2019, CMS rolled out an updated survey process. The new process included updated tools and automated certain elements in an effort to increase the overall level of consistency in the process. While it is still too early to ascertain definitively that this process is more consistent, we have heard favorable information from state survey agencies who believe that the process is leading them toward more consistent determinations. 

Another example is nursing facility level of care. Using the right tools can reduce reliance on subjective decision-making or eliminate the ability of individuals to “override” determinations by substituting their own judgment.  

Tools and technology can be of limited value where judgment calls ultimately have to be made especially where they can appear to be very subjective. Employee performance management is an area where different supervisors can see the exact same behavior or results and come to completely different conclusions. Tools like behavioral anchors can help but not eliminate this challenge.

In these situations, organizations can work to “calibrate” assessments. This can be achieved a couple of different ways. One well-trained person’s assessments can stand as the standard against which other assessments are evaluated and people are trained until their determinations are similar. Another way to do this is to hold “calibration” meetings in which assessors gather to discuss their evaluations and identify variables that need to be hashed out among the group in order to come to similar conclusions with similar inputs.  

Achieving consistency takes ongoing effort. It’s not something that you can just set and forget. Managers need to continuously monitor results by setting up reports and reviewing these regularly. Technology can assist here but this can also be done with Excel spreadsheets. 

Measure and track error rates. It’s all the better if these can be tracked at the agency, team and individual levels. It will aid you in being able to identify outliers and to troubleshoot problems. When mistakes happen, figure out why they happen at the root cause level and correct those root causes.  

When consistency and accuracy come together perfectly, you could be 100% accurate. While that may be a stretch goal, you can set incremental goals along the way to 100%. The consequences of working in human services is that errors have a direct impact on people’s lives – some profoundly so. Standards should be high.

As you set ambitious goals for your team, make sure you tie these goals to your organization’s mission and/or your strategic plan. Explain why it is important. Create a clear line of sight for each individual from their individual goals and responsibilities to those of the organization as a whole. Everyone should understand how they contribute to mission accomplishment. 

Your processes build reliability and gain in confidence with internal and external stakeholders as accuracy and consistency improve. But you are not an ACE yet. Efficiency is up next. 

When Debbie and I were in the state agency, we wanted to reduce turnaround times for some of our common transactions. We started to measure transaction processing times and put up boards to track those times and formulated plans to bring those turnaround times down. That seems like a good plan if those times are important (and they were because people’s lives or providers’ livelihoods were at stake) – but – how important was it to be fast, if we weren’t doing it accurately? If people got the wrong answer, or if a process had to be re-done, had we gained anything? We realized that it didn’t matter if it was fast if we got it wrong –we couldn’t sacrifice accuracy for speed. While all of the elements of ACE are important, the others don’t matter without accuracy. Accuracy is the first element of “ACE”.

According to the Oxford dictionary, “Accuracy” is defined as:  “the quality or state of being correct or precise”. The sub-definition reads “the degree to which the result of a measurement, calculation or specification conforms to the correct value or a standard”. 

If your agency or organization is performing any type of repetitive task you need to have some type of standard against which you are measuring. We have written before about our previous experience managing restaurants – accuracy means that the customer’s order is made correctly:  according to the standard of how the customer ordered it and according to the proper recipe. Accuracy in Medicaid eligibility means that the determination of eligibility was made correctly according to the policy standards. If you are performing survey oversight visits, the visit documentation should clearly capture what is being observed and determinations of compliance are made against the regulatory standard.  

The word “accuracy” conjures up the notion that one is either accurate or one is wrong.  That accuracy is either black or it’s white. Some things are straightforward – the sandwich gets two pickles, it’s got two pickles, eligibility threshold is $X, individual has less than $X dollars, you provided 10 units of service, you submitted a claim for 10 units of service. Other things have some gray area – does the setting promote community integration, does the individual need X hours a week of personal care, does the individual meet nursing facility level of care, is the care plan increase warranted, etc. Those shades of gray may be found in how regulations are interpreted, how documentation is interpreted, how decisions are made using the information that is at hand, among other things. These are all common in the LTSS world.  

What does it take to instill an accuracy mindset in your team? You and your team have to know what accurate looks like and how to achieve it. You must consider all the elements of an accurate decision or action. What rules are there; what policies or procedures must be followed; are there caps, limits, minimums, etc. that must be applied?

Creating process flows, decision trees, job aides, etc. can help to minimize the gray areas, improving accuracy. Automation in processes reliant on data entry can improve accuracy by eliminating human error, i.e. “typos”. 

Technology systems that use strong business rules or even algorithms can also help improve accuracy. Things as simple as checking digits in a phone number you enter, validating zip codes, checking for blank fields that are required in certain steps of the process, even spell checking notes and other documentation, allow you to use technology in pursuit of accuracy. More sophisticated systems might flag outliers, like high cost care plans, unusual variations in recorded assets or income, extreme changes in assessment scores, etc. for additional review to catch other errors.

Achieving accuracy is critical to developing faith and confidence among your stakeholders – whether those are customers to your restaurant, people applying for Medicaid for long term care needs, or providers who rely on the survey process as a key measure of the quality of care that they provide.  But being accurate once doesn’t build that confidence, it’s getting it right every time. And that is Consistency. More on that next time.

Despite the fact that we never even met each other prior to 2014, Debbie and I discovered when we began working together that we have very similar business philosophies. It took us a while to clearly articulate them but we both knew pretty quickly when we met that we were on the same wavelength and that helped form the basis for a unique and special partnership ever since. 

The two key ingredients in Sage Squirrel’s “special sauce” are that we both believe firmly that compliance is the foundation for excellence, not actual excellence; and that it doesn’t matter how good your policies are if you can’t execute them effectively. This has morphed over time into our key principles:

  1. The need to go beyond compliance in all things, and
  2. The need to ensure that business operations are designed to ensure accuracy, consistency, and efficiency – what we call “ACE”. 

We’ve talked in this blog quite a bit about going beyond compliance so I thought I would do a little deeper dive into ACE. We have been talking a lot lately about quality improvement and performance management and ACE is foundational to doing both. And we assume that everyone wants their business operations to produce accurate and consistent results as efficiently as possible – that’s ACE.

When we talk about business operations, we are talking about the systemic combination of organizational structure, technology, and business process design that allows your agency or company to actually accomplish needed work. That work may be production of something, it may be the provision of services, assessments, or the processing of transactions such as enrollments or approvals of actions. Of course, this list is not exhaustive – it is meant to be illustrative of the fact that you may not always think that you have business operations but the reality is that all organizations actually DO something.  

I once carpooled with a gentleman who ran a small state agency. He was very resistant to the idea of performance or quality in his agency because, in his words, “Our job is to monitor (their) quality and compliance – we don’t perform anything”. Actually, his agency administered processes that were pretty similar in nature to those associated with nursing facility surveys. That type of monitoring activity is business operations just like producing widgets or processing applications is business operations. 

There is no one magic bullet that makes ACE happen. You can’t do it with technology alone; you may have a good form or other tool, but an overly bureaucratic process to get it completed; you may have high performing employees but an organizational structure that fosters impermeable silos rather than centers of excellence.  

We talked about this in one of our In a Nutshell briefs:  ACE is about more than just getting the task done. It is all about making sure it is the right task, done the right way, by the right person. That’s what can allow you to make the most of your resource and go beyond mere compliance in the pursuit of quality – that’s operational excellence. Some of the elements to achieving ACE include:

  • Get the right people in the right roles and equip them well with strong onboarding, training, and resources
  • Create accountability with well-defined expectations
  • Ensure business processes add value and are efficient and effective
  • Use technology as a tool to automate process elements wherever possible.

Over the next few weeks, we will come back and fill you in more on our thoughts on each element of ACE – accuracy, consistency, and efficiency. We would love to help you ACE your operations!  

There has been a flurry of activity with states filing Appendix K and 1135 waivers in an effort to ensure service continuity despite challenges associated with the COVID-19 pandemic. These waivers are all designed to create flexibilities for providers and state agencies. Examples include expanded use of remote technologies, allowing use of alternative settings, suspension of some screening (PASRR) and prior approval processes, streamlined certification for new providers and to allow existing providers to add alternative services, and waiving face to face assessments for initial or annual eligibility, and many others. 

All of these changes are rooted in reducing or eliminating regulatory requirements that are perceived to be obstacles or barriers to service access and/or provision. Many of these  emergency flexibilities are things that providers and/or other stakeholders have been complaining about for some time. In some ways, the long term care system has been facing a slow motion crisis for some time now. The pandemic is bringing demographic changes and workforce capacity issues to light in an urgent and dramatic fashion.

The American LTSS service delivery system is not prepared to meet the challenges associated with the rapidly growing numbers of people who will need some degree of long term services or supports, and the strains that will place on Medicaid as the largest payer source for LTSS. While states and their federal partners have been working to make changes that will aid in meeting those needs, those efforts have been incremental, nibbling around the edges of needed change and possibly constrained by cultures organized around compliance and risk mitigation. They are not keeping pace with the demographic changes and the workforce challenges that abound impacting LTSS system capacity and quality. 

Regulatory structures are major drivers of LTSS service delivery systems all over the country.  Disrupting these structures could be a way to introduce needed change to LTSS and what could be more disruptive than a global pandemic? Disruption is often a necessary element in transformative change. This disruption, while unplanned and definitely not welcome, may provide an opportunity that should not be wasted. While we would never want a pandemic in order to spark transformative change in LTSS service delivery and regulatory structure, there is an opportunity here for state and federal regulators and payers to give careful consideration to what they need and why they need it before just reinstating all of the previous requirements when things return to “normal”. 

While the pandemic is certainly not over (sadly), the flurry of emergency activity may be slowing down. In a perfect world, close consideration would have been given to the longer term consequences of the emergency measures (see our last blog entry), but the last few weeks has seen rapidly changing guidance that have varied widely across the country, so situations have been fluid and suggest that long term implications have been a secondary consideration. Now may be the time to look forward to what will happen on the other side of the pandemic.  

Telehealth has been a topic of strong interest for years now in terms of building system capacity and improving quality of care, but payment systems have been slow in places to take that up. Workforce challenges should drive us all to consider the role that informal caregivers play in supporting people and how systems can support and maximize their ability to do this. People are better off in systems of consistent care and support so why shouldn’t providers like adult day centers have the flexibility to provide blended support models? Improving the speed and ease of access to home and community based services in order to prevent costly or unnecessary nursing facility admissions has been a challenge for states attempting to “rebalance” their Medicaid spending.

I don’t know anyone who thinks that the world is ever going to be “normal” again – there will be a new normal as we adjust to the long term presence of the COVID-19 virus and its impacts on our health and livelihoods. The pandemic has been and will continue to be a significant disruption in every area of life including LTSS. It would be a shame to simply go back to “normal” without making the most of this disruption. State and federal agencies, providers and advocates can all consider what changes are actually beneficial to systems and working to make adjustments to capture that benefit for the long haul.  If there are regulations that are truly barriers to access, or prevent the use and support of informal caregivers, or make it difficult to use telehealth and other remote monitoring tools, then isn’t it time to look at them even once we are past this pandemic? Let’s not waste this crisis. There are lessons to be learned and disruption enough to fuel real change. 

Sharing a new In a Nutshell that goes along with yesterday’s blog entry on Responding and Not Reacting.

#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel

For the last two weeks I have tried to do my normal grocery shopping and have been forcefully reminded that things are most definitely not normal right now. Saturday, I went to five stores in two towns and was unable to buy what I needed to cook for the week. Sunday morning I went back out again – and ended up in a queue before the store opened. That was a first! People have clearly been taking the COVID-19 pandemic seriously, but some of the reaction is driven by mixed or mis-information, or the rapid nature in which information is evolving. 

We also see that seriousness in our interactions with providers and state agency staff in recent weeks as well. While there is always urgency in providing care and services to vulnerable populations, that urgency is ramped up to an unprecedented levels. We have been reading about Appendix K and 1135 waivers that states are submitting and we are both observing and participating in communications that are taking place between states and providers.

The difference between “responding” and “reacting” is subtle but clear. When one reacts, one is typically acting with little thought – it’s more like acting out of reflex, like a knee-jerk. A response takes more thought and consideration. Reactions happen quickly and usually don’t take longer term effects into consideration. Responses, because they are more thoughtful, can address the longer term and bigger picture issues.  

There’s a lot of reacting going on right now. The grocery stores are one of the clearest examples of that. People reacted and cleaned out the stores – the supply chain simply hasn’t had the capacity to ramp up in a meaningful way and stores are short of many of the basics of everyday living.  

Given how vulnerable older people and people with chronic health problems are to the novel coronavirus, it’s important that publicly funded services continue to ensure their health and safety. It’s incumbent upon state agencies and providers of services to older adults and people with disabilities to respond appropriately to this crisis – not just react. 

Some questions to help make sure you are responding and not reacting:

  • Can you state clearly what the problem is that you are trying to solve?
  • How will taking these steps help solve that problem?
  • Will these steps create other problems?
  • Do I know what the potential unintended consequences are?
  • Are there other ways to solve this problem?

Involving stakeholders in the identification of problems and solutions can mean better decisions. Communication and education are key to successful implementation. This is just like the actions that agencies take in approaching change management. The urgency around the pandemic doesn’t mean that you shouldn’t go through these steps. It does mean that they have to happen faster. This crisis is unlike anything we’ve ever experienced. But there is a likelihood that this will be the new normal for a more protracted period of time than it would be for a hurricane, or a flood, or a tornado, or a fire. Operations could be impacted for months. State and provider agencies will live with the consequences of what they do now for months. Responding rather than reacting reduces the likelihood that you will create more problems at the end of that time. 

I have an hour-plus drive each way to the office and I find that podcasts are both a great way to pass the time while educating and/or entertaining myself along the way. There’s not much rhyme or reason to what I listen to, topic-wise. It may be history or popular culture or true crime – or current events. One that I listened to recently caught my attention because it touched on things that Debbie and I have been talking about and working on for a number of years now and framed them in a slightly different way for me.  

The subject of the podcast was the role of “administrative burden” in policy making and policy outcomes. The premise was that policymakers make decisions about desired outcomes and shape administrative requirements to drive those outcomes. They provided Social Security as an example of how government eased administrative burdens because they wanted people to access and use the benefits; examples of how governments create administrative burdens as a deterrence to accessing or using benefits were Medicaid and SNAP benefits, and requirements around voting.

We have also seen and been frustrated by processes that are unnecessarily complicated, that don’t take advantage of available technology, or that completely shift the burden to individuals who just have to keep trying until they get it right. This is particularly troublesome when you are talking about a frail older person who needs supports to stay at home and avoid going to a nursing facility. These are highly unlikely to be fraudulent applications. The cost of those delays is the increased likelihood of nursing facility placement and the administrative costs with processing an application three times for an individual who has been eligible all along but couldn’t get the paperwork right. That’s not efficient or humane.

As the podcast went on, I began to consider that it might not be quite so black and white. Some of these administrative burdens may be seen as defensible. The risk of fraud is one of the reasons cited for the heavy administrative burdens associated with Medicaid that falls squarely on the applicant. However, there is little discussion about how expensive these administrative systems are to maintain and whether that expense is justified by the extent of risk that a non-eligible person may receive benefits, particularly in this day and age, where a lot of this information is already available in an automated format. 

While I have no doubt that there is some political context around some of these decisions, some of these practices are just rooted in the culture of government at all levels to minimize risk and ensure compliance. They tend to be self-sustaining once in place. Debbie and I can both think of multiple examples of individual employees who created administrative burden because they were concerned about the possibility of one bad actor slipping through the cracks, despite the fact that such instances are rare and the costs associated with the increased workload far exceeded the risk of the bad actor slipping through.  

I have every confidence that most people who administer programs targeted toward persons who are elderly and/or who have disabilities actually want people to access and use those benefits. Institutional placement is far more costly in most cases and quality of life may be superior when people can remain in their homes and communities. But bureaucrats are frequently products of the environments they grow up in and don’t always recognize that systems and processes are burdensome 

It’s true what they say: the first step to fixing a problem is recognizing that you have one. If people who are in the systems don’t understand the upstream and downstream impacts of what they are doing and the full measure of risks and costs, then they likely don’t recognize that there is a problem in need of fixing. They may even see adverse program outcomes and not recognize that they are contributing to that. For example – people going into nursing facilities because HCBS can’t be started quickly due to assorted administrative requirements.  It’s always easy to blame the OTHER requirements.  

We were both fast food managers once upon a time and understanding the customer experience was of paramount importance so we may have some heightened sensitivity. This was an area of focus for us while we were working in Indiana’s Division of Aging and they are continuing to work on related issues so we are hopeful that Indiana will work to streamline and simplify access to LTSS. Streamlining access to LTSS is one of the tenets of No Wrong Door systems so other states have been working on it as well. 

Fresh eyes are one of the best ways to spot these kinds of issues. People who haven’t been around the system for a long time are among the quickest to see things. Soliciting input from those fresh eyes can open your eyes to how your systems are experienced by users, both providers and consumers. That input may come from new hires, consumer advocates, or consultants – including the squirrelly ones! 

Administrative burdens aren’t limited to state and federal programs. Any organization can create administrative barriers or obstacles that impact people that work there or people that they serve. There are some ways that you can learn about those issues and address them. Invite those fresh eyes, be open to feedback from people who bring you concerns about complicated procedures and don’t let your processes get stale. Sometimes “we’ve always done it this way” is why things get more complicated than they need to be. Institute ongoing review and validation to ensure that your procedures are always accurate, consistent and efficient.  

When I took my first management job, I recognized that I was taking responsibility for the job performance of other people. It had became my job to achieve outcomes based on the work of other people. I had to figure out how to keep people motivated to do good work, motivate them to do better work in many cases, or move them out if they were unable or unwilling to do so. If I was a tyrant about the moving out part, then I probably wasn’t going to be very good at the motivating part, so I learned on the job how to manage myself in order to manage others. I learned on the job how to care about the people that I worked with because caring about them meant that I could see them as individuals and learn how to tailor my approach to their individual needs. I got training along the way, but that training built on my understanding and ownership of my role as a manager and the acceptance of increasing levels of responsibility for my own and others’ job performance. 

I’ve been reading lately about the idea of “radical candor”. It looks like this is being presented like a new idea, but it feels like it is just a re-packaging of common sense ideas for managing people. Of course, the book by this title was published in early 2017 so it’s still on the hot list and that’s why the idea is getting a lot of buzz right now.  

The premise of the book is that managers should “challenge directly” while also “caring personally”. Doing these things at the same time results in radical candor. Doing one without the other results in either “ruinous empathy” or “obnoxious aggression” and doing without either of them becomes “manipulative insincerity”. I’m sure we all recognize bosses from our past lives in one of these four phenotypes!

People who read a book and then say, “now I’m practicing radical candor” are most likely not doing that. I have observed people who said that they were bringing radical candor to their work (because they had just read the book and were inspired), but the observed experience was manipulative insincerity, because candor is hard. 

Managers have tough jobs. One of the hardest things managers have to do is give feedback and coach when they are trying to help improve performance or facing the need to move someone out of a role that they aren’t performing well in. It requires self-awareness, personal vulnerability, emotional intelligence, and the willingness to say difficult but honest things to people. It takes courage to say difficult things that are potentially going to impact a person’s livelihood, and it takes the ability to manage your own reaction and allow them to process what they are being told with devolving into “flight or fight” yourself. It requires practice and the acceptance that sometimes you are going to get it wrong.

Debbie was telling me recently about how she trained new managers. Relying on an adage that has stuck with her, she told them to ask themselves three things when they were considering feedback to their teams:  Is it kind? Is it true? Is it necessary? If the answer was “yes” to two out of three, then it was OK to say it. In fact, as a manager, they were obligated to say it, both the kind things and the necessary things. I had seen numerous examples of how Debbie applied this to her work as a manager and leader, but I had never heard the thought process behind it. Turns out these are a distillation of some ancient wisdom, all fully in the public domain now.

I saw one of the people who worked for Debbie flower into an effective manager because she had been given the tools and support to actively manage her team into both high performance and high engagement. This person started from the point of caring about her team – she just needed some tools to channel that caring into productive management. If you start from caring and learn how to do candor well, the result may be radical candor. If you didn’t “care personally” before you read the book, you aren’t going to after you’ve read it either – you may be candid, but it won’t be radical and it won’t lead to magical management results.  

In full disclaimer, I have to admit that I haven’t read the book – now I’m going to have to. We need more good managers in public service and in LTSS – these are people who do care and who may just need some training, tools and support to turn that caring into effective management. The book is identified on the website as having “launched a management revolution…” Per my last post, investing in management skills is a good thing and there is value in candor – I just wish it wasn’t seen as something radical! 

Sharing a new In a Nutshell on what we call ACE – when it comes to critical business process it’s all about accuracy, consistency, and efficiency.


#BeyondCompliance, #LTSSTransformation, #OperationalEffectiveness, #SageSquirrel