The final wave of Centers for Medicare & Medicaid Services regulations were all scheduled to go into effect November 2019. While CMS has attempted to lighten our load, the effort is a little late.
Facilities have been actively building their compliance and QAPI programs for two years in anticipation of November 2019. Regardless of the changes in the regulations, CMS is looking for nursing homes to develop, implement and maintain an effective compliance program.
Many of the lessons that I have learned over the years have come from my experience working with over a dozen corporate integrity agreements (CIA) — including my own. A CIA is a mandated compliance program that is usually part of a settlement agreement with the Office of Inspector General. You can think of it as the mother of all compliance programs! While it might feel like another burdensome regulation, a compliance program can be a functional tool to objectively learn about your operation. I wanted to share some common features I have seen from my clients that have been successful in implementing a compliance program.
Rome wasn’t built in a day: As nursing home operators, we are always dealing with the “crisis de jour.” We have to quickly assess, fix and move to the next problem. Building an effective compliance program is really a shift in culture, and change takes time. A 2009 study by Phillippa Lally, Ph.D., a health psychology researcher at UCL, found that on average it takes 66 days for a habit to become ingrained.
Sometimes it took 254 days for a new habit to become second nature. If we multiply that by the number of staff, consultants, residents, etc. it can become very overwhelming and enough to throw your hands up in the air and say “NEVER!”
It is all about baby steps. The typical CIA is for a five-year term. There is a reason for that. I have found that the first two years of developing a compliance program is just about figuring it out. It’s about determining who should be your compliance officer, how will the committee work, what are the organization risk areas, how you will gather your data, etc. Set realistic goals so you can feel success. Success breeds more success.
DON’T Fake It till You Make It: A robust compliance program is not the size of the dusty policy book in the administrator’s office. Sure, policies are necessary but it is more about the culture then the binder.
Setting up complex systems that no one knows about will not work if the Office of Inspector General comes knocking. A successful compliance program is based on transparency and an organization committed to internal audits, monitoring, self-correction and enforcement. Your staff needs to feel safe with bringing concerns to management and encouraged to “see something – say something.”
Top down before bottom up: The commitment to a compliance program comes from the top of the organization. There needs to be buy-in from the top — that includes both emotional and financial investment.
The successful organizations are those that devote resources that enables staff to succeed. What does that really mean? It could mean investment in technology to help with data or training, but it’s more about being involved. A CIA requires regular training and reporting to the board of directors. Members of the leadership cannot claim “but I didn’t know.” From my experience, when there is a strong message from the top then there is empowerment and success from the bottom up.
Know thyself: In long-term care we tend to be reactive versus proactive. I believe a big part of this is that we don’t have the proper tools to be proactive. With the high staff turnover and regulatory environment, having a handle on your potential risk and data can be very complicated. When facilities have a functioning compliance committee who objectively evaluate risk areas and question trends, it allows the facility to find issues before they become a crisis to really know what’s happening in your facility. While there are elements that need to be included in a compliance program, the OIG wants to see you making the program “yours.”
But why? We have all experienced a child asking “why” a million times until they get to where they want to be. I believe a hallmark to a successful compliance program is always asking why. In our QAPI process we are always developing performance improvement plans based on root cause analysis of our issues. But I encourage you to go one step further.
WHY were we successful? WHY did our survey go well last year? WHY were our falls with injury decreased this quarter? Why did we have an increase in referrals? I encourage the compliance committee to question success as well as risk.
It’s a team sport: This is a process that requires participation from all members of the team. Use your resources including the OIG website, existing CIAs, networking and consultants, but the key to success is empowering your team to be transparent and ask the right questions. Slow and steady wins this race!
Tamar Abell is the CEO of TBA Consulting Group.