Steven Littlehale

The best way for our industry to NOT move forward is to conduct a series of “brainstorming” sessions where we agree to “think outside the box.” This has been my observation over the last two decades of working tirelessly with talented, creative, and mission-driven clinicians, owners, and operators. 

It has been reinforced over the last several months of grappling with COVID-19’s wake of destruction, during which I participated in a series of “think tank,” “long-range visioning” meetings. 

Have you noticed this irony in the meetings you have attended? They usually begin with “These are unprecedented times,” then segue into “There are no wrong answers at this meeting.” Typically the word “strategic” is used, and before COVID-19, you or other attendees might go crazy with multicolored sticky notes, markers and paper mounted on the walls. The meeting concludes, and you get a sinking feeling in your gut. Your first thought is it’s the carbohydrates you ate (even though you promised yourself you wouldn’t). Then it hits you: Instead of brainstorming and thinking outside the box, you’ve actually defined the box! 

Anything outside our current regulatory or reimbursement environment has been “put in the parking lot,” and what’s left is a “new” idea that sounds vaguely like what we’ve been doing all along. Existing compliance standards and current trends in nursing home litigation spell doom to any shade of color outside today’s Crayola box and definitions of normative practice. 

Sadly, that Crayola box is the same box we were handed when we started working in this industry. Yes, QIs became QI/QM and then QMs. MDS became 2.0 and then 3.0. RUG changed its extension a handful of times. But none of these changes was truly innovative. While I concede that the Patient Driven Payment Model was an authentic swap-out of crayons (and thank goodness for that), and some new crayons are now in the box as ownership structures have changed and we make prettier pictures with data and technology) our original box of crayons is still mostly untouched. 

What squelches innovation and diminishes our creativity? I hypothesize that it is our highly regulated environment. Our most creative “brain trust” gets co-opted into responding to government or state regulations that are sometimes drafted to satisfy a policy and not a resident care delivery priority. The penalties for “one false move” are so great, who would ever take the risk and think outside the box? 

Let me be clear: I am not denigrating the incredible creativity that nursing home staff at all levels have demonstrated in response to the endless challenges since COVID-19 entered our buildings. I am specifically referring to defining who we are five to 10 years from now, and how we will get there.

Are we relying on the same governmental entities that stifle our creativity to innovate on our behalf? CMS’s Innovation Center, born out of the ACA, is where I see creativity — albeit at times burdened by bureaucracy. Are we waiting for CMS to tell us what we will look like five to 10 years from now? I fear that creativity from regulators just means thicker borders around our box.

We also can’t simply look back or cling to what we know—this is not sustainable. Can you authentically advocate for the continuation of our industry as it is when you silently declare “but I’ll never go there”? Can you defend the commingling of short- and long-stay patients and residents without mentioning long-standing reimbursement systems created decades ago?

What is the solution? Albert Einstein said,  “If at first the idea is not absurd, then there is no hope for it.” Visioning for the future does not require abandoning the past, but it does require giving up the crayon box entirely and rethinking how to color the years to come. 

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.