Burnout, Boundaries, and Compliance
Corporate Compliance, Leadership

Building Employee Engagement

Through Meaningful Healthcare Compliance Training

Written by Misty Kelly, OHCC, HPOC with contributions from Nancie Lee Cummins, CFE, CHA, CIFHA, OHCC, CHCM, CHCO CORCM, CRAS and Joy Rose, MSA, RHIA, CCS, CHA, CHPS   

This article was developed through collaboration with AIHC Education Volunteer Committee compliance professionals who shared practical experiences and lessons learned related to employee engagement and compliance education.

Several years ago, our organization deployed annual compliance training through a learning management system. Completion rates were acceptable; however, employees frequently waited until the deadline to complete their assignments, and retention of key concepts remained difficult to assess. The experience reinforced an important lesson: compliance training should not simply be focused on completion. It should focus on understanding and application. 

Training can satisfy a requirement without changing behavior. A completed module or passing quiz may document participation but does not necessarily demonstrate that an employee understands the expectation, recognizes when it applies, or can incorporate it into daily decision making. 

Begin With the “Why”

Organizations use a variety of methods to deliver compliance education, including annual LMS (learning management system) assignments, in-person presentations, newsletters, microlearning modules, department meetings, and one-on-one coaching. What resonates with one workforce member may not be as effective with another. Compliance professionals should remain flexible and willing to adjust their approach based on employee needs and organizational culture.

Nancie Cummins noted, “I have found individual training has helped the most. You can go through a format that meets Compliance plan criteria and have individuals interact to answer their specific needs. This way, you can address the compliance requirements while still allowing individuals to engage directly, ask questions, and receive guidance that is specific to their role and needs.”

While individualized training may not always be practical on a large scale, the underlying principle remains important: employees are more engaged when training is relevant to their role and allows opportunities for interaction, questions, and clarification. Even when one-on-one training is not feasible, larger sessions can incorporate opportunities for questions, discussion, and role-specific examples.

One Size Does Not Fit All

The challenge for compliance professionals is determining which methods will resonate most effectively with their workforce. There is no single correct approach. What works well in one organization may not work in another, and a method that was successful last year may be less effective today. Organizational cultures evolve, workforce demographics change, and training needs shift. Compliance professionals must remain attentive to those changes and be willing to adjust the format, timing, and level of interaction. 

The concept that compliance programs are not one-size-fits-all also applies to training platforms and methods. My overall goal with this article is to provide practical information to help guide new compliance professionals and offer new perspectives to seasoned professionals. 

Compliance education should not be limited to annual training. Whether education is delivered through a formal module, an ad hoc session, targeted remediation, or a Compliance & Ethics Week activity, employees should understand why the information matters. Whenever possible, connect the training to one or more of the following: 

  • Patient care and safety
  • The employee’s individual role
  • Organizational integrity
  • Operational effectiveness
  • Reputation and trust
  • Prevention of avoidable compliance problems
  • Other organizational-specific priorities

Employees are more likely to retain and apply information when they can see its relevance to their work. 

“Employees are frequently completing a checkbox without understanding the ‘why’ behind what they are doing.” – Joy Rose. Joy Rose’s observation reflects a common challenge. Employees are more likely to engage when expectations are connected to their daily responsibilities and the organization’s broader mission. Meaningful engagement requires a clear connection between the requirement, the employee’s role, and the consequence the requirement is intended to prevent. 

Choose Methods That Encourage Participation

LMS platforms can be effective tools for delivering and tracking education. However, even the most sophisticated platform will struggle to engage employees if content is repetitive, not role or industry-specific, or lacks practical relevance.

Compliance professionals should avoid designing education solely around their own preferred learning style. A format that feels clear and engaging to the person developing the training may not connect with every employee. Varying the delivery method can improve accessibility and help sustain attention, but variety should have a purpose. The selected method should support the learning objective, the complexity of the topic, and the needs of the intended audience. 

In recent years, I have focused on redesigning annual and targeted training to connect employees with organizational policies and reinforce applicable regulatory requirements. This required more than transferring existing content into a new format. We reconsidered how information was presented, where interaction could be added, and how employees could be directed back to the policies and procedures governing their work. Working with our information technology team, we used an AI-enabled platform to develop modules incorporating videos and interactive quizzes. Employee participation improved, and the experience reinforced an important point: strong content is essential, but presentation, relevance, and interaction influence whether employees remain engaged with that content. Technology did not replace the need for compliance oversight. It gave us another way to deliver information in a more engaging format.

For brief reinforcement

  • Microlearning and short refreshers
  • Short quizzes
  • Email, newsletter, or intranet reminders
  • Workflow posts explaining the purpose behind a task

For interaction and clarification

  • Live or department-specific sessions
  • One-on-one coaching when individualized support is needed
  • Department visits and informal question and answer sessions

For practical application 

  • Real-world scenarios
  • Role-specific instruction
  • Sample documents and guided exercises
  • Targeted education following audit or inspection findings

For engagement and visibility

  • Videos and visually engaging presentations
  • Gamification
  • Modest incentives, when appropriate

The method should never overshadow the message. Select the format based on what employees need to understand or do differently after the training.

Use Real-World Scenarios Responsibly

Employees in our organization have responded positively to real-world scenarios. In a post-training survey, 32% of respondents requested additional scenario-based education. Scenarios can help employees translate policy language into practical decisions and understand how a requirement applies in daily work. 

Compliance professionals must nevertheless use internal examples carefully. Remove or alter identifying details, avoid information that could permit re-identification, and focus on the scenario purpose or decision rather than the individuals involved. Not every internal matter is appropriate for broad education. When used responsibly, de-identified incidents, near-misses, and recurring questions can become valuable learning opportunities. 

Make Creativity Serve the Learning Objective

A well-chosen theme can also help create visibility and momentum around an annual campaign. Our organization has used travel, Olympic, superhero, and scavenger-hunt themes to refresh the employee experience. When feasible, simple décor, intranet content, photographs, and internal announcements can keep the campaign visible.

A theme, however, should support the learning objective rather than compete with it. Creative presentation may attract attention, but the content must remain relevant, accurate, accessible, and connected to employees’ responsibilities.

Leadership Sets the Tone

Training is less likely to influence daily behavior if leadership treats it as an annual assignment or does not reinforce expectations afterward. Leadership involvement should include visible support, sufficient employee time, operational follow-through, and reinforcement within departments. Leadership buy-in is often one of the most significant factors in influencing the success of a compliance program. 

In a recent post-training survey conducted within our organization, 36% of respondents identified leadership encouragement as a motivating factor in completing their assigned training. 

This year, our organization took a different approach by asking senior leaders to complete the training before it was deployed across the organization. As a result, leaders were able to provide feedback on the learner experience, answer employee questions based on firsthand knowledge, and reinforce the importance of the training from an informed perspective. Employees are more likely to engage when leaders demonstrate that compliance education is a priority rather than simply another assigned task.

Reinforce Learning Throughout the Year

Annual training alone cannot carry the entire compliance education program. There must be reinforcement and other trainings throughout the year. Employees may revert to prior habits when a workflow changes, particularly if the new process is not reinforced or if employees do not understand why the change occurred. Here are suggested reinforcement methods to consider:

  • Brief department touchpoints
  • Compliance newsletters or compliance content in the company newsletter
  • Periodic reminders via email or Teams messaging
  • Short quizzes
  • Leadership talking points
  • Workflow-specific coaching
  • New-hire reinforcement
  • Targeted education following audit or inspection findings

Measuring What Matters

Completion rates remain necessary for monitoring assigned education, but they answer only one question: Did the employee complete the training? They do not establish whether the employee understood the content, retained it, or applied it correctly. A more meaningful evaluation may include:

  • Knowledge checks that require application, not simple recall
  • Post-training surveys regarding relevance, clarity, and preferred formats
  • Targeted audits or observations of the affected process
  • Trends in repeat findings, recurring questions, and reported concerns
  • Discussions with department leaders about whether expectations are being followed

Follow-up education when results identify gaps

No single measure will provide a complete answer. Compliance professionals should consider multiple indicators and allow sufficient time for the expected behavior or process change to become observable. When results do not improve, the appropriate response may not be more training. The organization may need to examine the policy, workflow, available resources, competing priorities, or leadership reinforcement. 

Meaningful compliance training is not defined by completion certificates, attendance records, or annual deadlines. Those elements document activity, but effectiveness is demonstrated through understanding, application, and behavior. 

There is no universal formula for employee engagement. Each organization must consider its workforce, culture, risks, resources, and learning objectives. The most successful approach may combine formal training, practical scenarios, leadership reinforcement, ongoing communication, and opportunities for employees to ask questions and provide feedback. 

Our responsibility as compliance professionals is not simply to deliver information. It is to help employees recognize why the information matters and how it applies to the decisions they make every day. When employees understand the purpose behind an expectation and view Compliance as a trusted resource, training becomes more than a requirement. It becomes part of how the organization protects its patients, its workforce, and its integrity. 

About the Author

Misty Kelly, OHCC, HPOC, serves as Compliance & Privacy Officer for InnovaCare Health and has more than 23 years of experience in healthcare compliance, privacy, auditing, regulatory affairs, and risk management. She serves as a volunteer on the AIHC Education Committee. This article was written in collaboration with the following AIHC Education Committee Members: Nancie Lee Cummins, CFE, CHA, CIFHA, OHCC, CHCM, CHCO CORCM, CRAS and Joy Rose, MSA, RHIA, CCS, CHA, CHPS

Copyright © 2026 American Institute of Healthcare Compliance All Rights Reserved 

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Burnout, Boundaries, and Compliance
Leadership, Quality

Beyond Inspection Day

Building a Culture of Continuous Clinic Readiness 

Written by Misty Kelly, OHCC, HPOC with Corliss Collins, BSHIM, RHIT, CRCR, CCA; Nancie Lee Cummins, CFE, CHA, CIFHA, OHCC, CHCM, CHCO CORCM, CRAS; Joy Rose, MSA, RHIA, CCS, CHA, CHPS; and Lorianne Sainsbury-Wong, Esq. 

Checklists provide structure and consistency, but they should not become the inspection itself. The true value of an inspection lies in validation, observation, and determining whether a process is actually working as intended. “A clinic cannot inspect its way into quality/compliance. Quality/Compliance has to be built into daily operations. Audit readiness should be a daily practice, not event based.”

Inspection Readiness Is Not an Event

Many organizations begin preparing for an inspection only after learning that a regulator, accrediting body, payer, auditor, or other external reviewer is scheduled to visit. Policies are reviewed, binders are updated, logs are checked, and staff receive last-minute reminders. While preparation is important, true readiness cannot be built in the days or weeks leading up to an inspection.

A successful clinic inspection program is not measured solely by how well a site prepares for a scheduled visit. It is measured by how consistently compliant processes are maintained when no inspection is expected. Organizations that embed compliance into daily operations are better positioned to respond when outside reviewers arrive because readiness has become part of the culture rather than an event on the calendar.

Corliss Collins noted, “A clinic cannot inspect its way into quality/compliance. Quality/Compliance has to be built into daily operations. Audit readiness should be a daily practice, not event based.” - This statement reflects one of the most important lessons I have learned through years of conducting clinic inspections: an inspection can evaluate readiness, but it cannot create it. Readiness is created through the work that occurs every day between inspections.

Define What Readiness Means in Your Organization

Before developing or enhancing an inspection program, compliance professionals should clearly define its purpose and scope.

This may seem obvious, but organizations vary considerably in how compliance responsibilities are assigned. In some organizations, Compliance oversees a broad range of operational, regulatory, privacy, safety, and accreditation functions. In others, responsibilities such as infection control, medication management, employee safety, credentialing, and medical records may be owned by separate departments.

Lorianne Sainsbury-Wong emphasized the need to understand “what you own and what you don’t own.” She explained that an observation may overlap with more than one department, but the organization’s structure and assigned responsibilities should guide how that concern is evaluated, communicated, and followed through.

The inspection scope should answer several basic questions:

  • What requirements will the inspection evaluate?
  • Which areas are owned by Compliance?
  • Which findings require collaboration with another department?
  • Can the clinic readily produce the records, documentation, and evidence upon request?
  • Who is responsible for correcting each type of deficiency?
  • How will corrective actions be documented, escalated, and validated?
  • What evidence will demonstrate that the correction was sustained?

A clearly defined scope prevents gaps, reduces duplication, and helps ensure the right department is accountable for the right process. Just as important, clinics need to understand what readiness looks like before Compliance arrives. Nancie Cummins stated, “A process needs to be in place for individuals to be able to follow guidelines. Some individuals have a background in compliance, and it may be easier. I have found most need guidelines for structure to be able to come up with an effective plan.”

In my experience, inspection success rarely comes from surprise. It comes from providing clear expectations, practical tools, and sufficient opportunity for clinics to assess themselves before the inspection occurs. I often describe our program as an open-book test. The purpose is not to surprise the clinic; it is to determine whether expectations have been understood, implemented, and maintained.

A Clean Clinic Does Not Always Mean a Compliant Clinic

Visible readiness is important. Clean exam rooms, organized records, current postings, and completed logs all contribute to a safe and professional environment. However, appearances do not always tell the whole story.

Corliss Collins captured this distinction well, “A clinic may have clean exam rooms, completed logs, and organized binders, but still have weak processes.”

A clinic can appear inspection-ready while still having significant gaps beneath the surface. Staff may be completing a task without understanding its purpose. A log may be present but completed inconsistently. A policy may be accessible but not reflected in actual practice. A correction may have been made after the prior inspection but never incorporated into the daily workflow.

Corliss Collins also noted that many clinics are prepared to “look inspection-ready,” but not necessarily prepared to “prove process control.” She identified recurring concerns such as policy-to-practice gaps, training-to-competency gaps, repeat findings, document-control problems, weak recordkeeping, siloed departments, and limited leadership support.

That is why meaningful inspections need to evaluate more than what is visible on inspection day.

Move Beyond Documents and Evaluate Process Effectiveness

Document review is an important part of the inspection process. Policies, logs, licenses, certifications, training records, and required postings provide evidence that key compliance activities have occurred.

However, the existence of a document does not necessarily demonstrate that the underlying process is effective. Consider the difference:

Inspection Element

Question to Ask

Documentation

Does the required record exist?

Implementation

Is the process actually being followed?

Knowledge

Can employees explain their responsibilities?

Effectiveness

Is the process producing its intended result?

Sustainability

Is the process being maintained between inspections?

This distinction appears frequently in actual clinic inspections. For example, a clinic may perform its required monthly crash cart review, but replacement pull-tag numbers may not be consistently documented. In that situation, activity is occurring, but the documentation does not fully demonstrate control of the process.

Similarly, a clinic may complete routine safety checks but be unable to produce the related monitoring log. The missing document does not automatically mean the activity never happened, but it does mean the organization cannot verify that the process was performed consistently or reviewed appropriately.

The same issue arises when required employee records are incomplete. During recent inspections, clinics generally demonstrated strong operational knowledge, yet findings still occurred because required consents or declination forms were not available.

These are often correctable findings, but they also illustrate a broader compliance principle:
If an organization cannot demonstrate that a required activity occurred, the strength of the underlying practice becomes more difficult to defend.

Corliss Collins mentioned, “There is a big difference between a checklist and an audit. Always investigate, vet, verify, and validate everything based on evidence. Do not confuse activity with effectiveness.” 

Checklists provide structure and consistency, but they should not become the inspection itself. The true value of an inspection lies in validation, observation, and determining whether a process is actually working as intended.

Readiness Extends Beyond Formal Regulatory Surveys

When people hear the phrase “clinic inspection,” they often think first about a governmental, licensing, certification, or accreditation review. Actual clinic readiness is much broader. Payer visits, managed care audits, credentialing reviews, complaint investigations, privacy inquiries, and other external evaluations may all expose weaknesses in daily operations.

Lorianne Sainsbury-Wong emphasized that these visits should be approached with the same level of care given to formal regulatory or accreditation surveys. She also made an important observation, “What they see, what they hear, what they observe” matters from the moment a visitor enters the facility.

That observation extends beyond inspection preparation. It includes whether required postings are visible, whether conversations protect patient privacy, whether staff know how to respond to questions, whether restricted areas are appropriately secured, and whether daily operations reflect the organization’s written expectations.

External reviewers do not experience a clinic through its policies alone. They experience it through its people, environment, documentation, and processes.

  • A balanced inspection model may include:
  • Routine self-audits
  • Scheduled educational or readiness activities
  • Focused reviews of higher-risk processes
  • Periodic unannounced validation
  • Timely feedback and corrective-action support
  • Follow-up monitoring to confirm sustained improvement

The combination provides both preparation and a realistic assessment of day-to-day readiness.

When Findings Repeat, Look Deeper

An isolated mistake may require a straightforward correction. A recurring finding demands a different conversation. When the same type of finding continues to appear, the question should not be limited to:

  • Why did this employee make a mistake?
  • The organization should also ask
    • Why did this process fail again?

Joy Rose noted that many compliance challenges are not rooted in a lack of knowledge, but in a failure to consistently execute established processes. That resonated with me because it mirrors what we frequently encounter during clinic inspections. Most clinics understand the expectations. The greater challenge is maintaining those expectations consistently between inspections.

Repeat findings may indicate:

  • An unclear or impractical workflow
  • Inadequate training or competency validation
  • Insufficient resources
  • Competing operational priorities
  • Unclear accountability
  • A lack of leadership reinforcement
  • Poor document control
  • A corrective action that addressed the immediate finding but not its cause

Recent inspection trends within our organization demonstrate why this matters. Many clinics performed extremely well, with 17 achieving scores of 95% or higher and three achieving perfect scores. However, lower-scoring clinics frequently showed evidence that a meaningful self-audit had not been completed.

Many deficiencies could have been identified and corrected before the onsite review. Documentation remained the most common category of findings, and the issues generally reflected inconsistent execution rather than an absence of guidance or resources. These results reinforce two important points:

  • First, the standards are attainable.
  • Second, providing information does not guarantee that it will be consistently applied.

Corrective action should therefore extend beyond fixing the immediate item. It should determine why the requirement was missed, who owns the ongoing process, and what evidence will demonstrate that the correction has become part of normal operations. Corliss Collins advised that compliance professionals should “implement root cause thinking early.” 

Keep Inspections Educational, Not Punitive

Inspections should never feel like a “gotcha” exercise. Employees who perceive inspections as punitive may become defensive, provide limited responses, or avoid asking questions. None of those reactions improve compliance.

A supportive approach does not mean lowering standards or overlooking deficiencies. It means conducting the review professionally, explaining the reason behind the requirement, acknowledging areas of strong performance, and helping the clinic understand what must happen next. An educational inspection should include:

  • Clear expectations
  • Objective observations supported by evidence
  • Recognition of areas that are working well
  • Explanation of identified risks
  • Specific corrective-action requirements
  • Access to appropriate tools and resources
  • Follow-up to confirm completion and sustainability

The site should leave the inspection understanding what needs to improve, why it matters, and who is responsible for the next step. Our clinic administrator survey provides helpful support for this approach. Their feedback was overwhelmingly positive. Respondents consistently described the inspection process as professional, supportive, educational, and valuable in helping them better understand compliance expectations.

Survey results reinforce that accountability and partnership can coexist within the same inspection program. Those results matter because a rigorous inspection and a positive experience are not mutually exclusive. Compliance can hold clinics accountable while still treating the people involved with professionalism and respect.

There is value in both announced and unannounced inspection activities. Scheduled reviews give clinics time to gather records, coordinate with supporting departments, complete thoughtful self-audits, and address questions before the inspection. Unannounced or “pop-in” inspections more closely reflect the conditions a clinic may face if an outside agency arrives without advance notice.

Our program evolved from scheduled inspections to pop-in reviews after clinics had received preparation tools, checklists, guidance, and ongoing education. The purpose was not to create anxiety or catch employees off guard. It was to determine whether established expectations were maintained under normal operating conditions. At the same time, an inspection should account for the realities of the clinical environment. Staff members are managing patient care, urgent operational needs, and competing responsibilities.

Lorianne Sainsbury-Wong recommended: “Advance communication, planning, team collaboration efforts to maintain consistent messaging and reduce stress levels as many staff fear being put on the spot if questioned during an onsite inspection.”

The goal should be realistic validation without unnecessary intimidation. When arriving for a pop-in inspection, I remind staff that Compliance understands the process can feel stressful. We are not there to act as the police. We are there to help identify and correct vulnerabilities before an external regulator identifies them under far less forgiving circumstances.

Leadership and Operational Ownership Matter
The Compliance department may design the inspection process, perform the review, report deficiencies, and monitor corrective actions. It cannot single-handedly maintain readiness at every clinic. Readiness lives in daily operations.

Clinic and department leaders help determine whether self-audits are meaningful, whether required records are maintained, whether staff receive sufficient time and support, and whether corrective actions remain in place after the inspection closes. When expectations are repeatedly communicated but the same findings continue to appear, additional training may not be the only answer. The organization may need to examine whether leaders are reinforcing the requirements, reviewing completion, removing operational barriers, and holding the appropriate individuals accountable.

Lorianne Sainsbury-Wong emphasized the value of “Proactive communications, structured planning regulatory compliance oversight, and organizational alignment are essential components of effective inspection readiness. Leadership should focus on equipping team with clear guidance and consistent messaging so that inspections serve as an objective assessment of compliance, quality, and operational performance, not a disruptive event in daily work.”

That partnership is essential. Compliance provides oversight and an independent perspective. Operations own the daily processes. Supporting departments provide subject-matter expertise and maintain records within their areas. Leadership ensures identified risks receive the attention and resources necessary for sustainable correction. Continuous readiness depends on all of them.

Questions Every Compliance Professional Should Ask

Before concluding a clinic is inspection-ready, consider:

  • Are policies current, approved, and accessible?
  • Can staff explain the responsibilities?
  • Does documentation support actual practice?
  • Are self-audits identifying concerns before Compliance does?
  • Are corrective actions addressing root causes?
  • Would the clinic perform the same way tomorrow if an external inspector arrived unexpectedly?

The answers often reveal more about organizational readiness than any score or checklist alone.

Conclusion

Meaningful clinic inspections are not simply about finding deficiencies. They are about determining whether written expectations have become part of daily operations.

Organizations that embrace continuous readiness spend less time preparing for inspection day and more time maintaining effective processes. Employees understand their responsibilities, leaders reinforce expectations, and corrective actions become operational improvements rather than temporary fixes.

A strong inspection program provides structure, identifies risk, validates effectiveness, and creates opportunities for education. It also recognizes when a finding reflects more than an isolated mistake and requires a closer examination of leadership, workflow, resources, or accountability.

Ultimately, the best measure of readiness is not how a clinic performs while the inspector is standing in the building. It is how the clinic performs every day when no inspection is expected.

About the Author & Contributors

Misty Kelly, OHCC, HPOC, serves as Compliance & Privacy Officer for InnovaCare Health and has more than 23 years of experience in healthcare compliance, privacy, auditing, regulatory affairs, and risk management.

Misty serves as an AIHC Education Volunteer and project manager for this article. AIHC Education Volunteer contributors to help make this article happen are Corliss Collins, BSHIM, RHIT, CRCR, CCA; Nancie Lee Cummins, CFE, CHA, CIFHA, OHCC, CHCM, CHCO CORCM, CRAS; Joy Rose, MSA, RHIA, CCS, CHA, CHPS; and Lorianne Sainsbury-Wong, Esq.

Copyright © 2026 American Institute of Healthcare Compliance All Rights Reserved

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Burnout, Boundaries, and Compliance
Leadership

Beyond Burnout

Workforce Ethics as Enterprise Risk and the Compliance Cost of Moral Injury 

Written by Bertholette Pardieu, MPH, CCEP, OHCC 

Introduction 

Workforce ethics, moral injury, and sustainability have emerged as critical compliance, governance, and patient safety concerns across the healthcare industry. Persistent staffing shortages, increased demand for services, and constrained resources have shifted workforce wellbeing from a human resources issue to an enterprise risk with direct implications for regulatory compliance, quality of care, and organizational stability.

For healthcare compliance and ethics leaders, understanding the relationship between workforce ethics and system performance is essential. Ethical strain within the workforce undermines reporting mechanisms, weakens compliance controls, and increases the likelihood of patient safety events. Addressing these challenges requires structured, organization-wide strategies that are deliberately integrated into governance, ethics, and risk management frameworks rather than addressed through isolated or informal efforts.

The Ongoing Workforce Crisis in Healthcare

Healthcare professionals across clinical and administrative roles continue to face escalating pressures. Chronic staffing shortages, burnout, high turnover, and increasing productivity expectations have become widespread across healthcare settings. These pressures are often accompanied by ethical conflicts that arise when professionals are unable to provide the level of care they believe patients require due to systemic constraints such as limited staffing, time pressures, or resource scarcity.

When healthcare workers repeatedly encounter situations where organizational limitations conflict with professional values, moral distress develops. If unaddressed, moral distress can progress into moral injury, which manifests as emotional exhaustion, disengagement, loss of trust in leadership, and withdrawal from organizational values. These outcomes directly affect workforce stability and compromise compliance processes, quality oversight, and patient safety initiatives.

Why Workforce Ethics Matters to Compliance and Risk

From a compliance and risk management perspective, workforce instability creates cascading organizational risk. Burnout and disengagement increase the likelihood of patient safety events, documentation errors, incomplete reporting, and breakdowns in adherence to policies and procedures. A workforce under sustained ethical strain is also less likely to participate meaningfully in compliance training, reporting mechanisms, and quality improvement activities.

Regulators and accrediting bodies increasingly assess organizational culture, leadership responsiveness, and staff engagement as part of broader evaluations of compliance effectiveness. As a result, compliance programs that fail to account for workforce ethics risk overlooking a key driver of regulatory exposure and patient harm.

To address this risk, compliance leaders should formally incorporate workforce ethics and moral injury into compliance risk assessments. Indicators such as turnover trends, vacancy duration, overtime utilization, safety event patterns, and ethics reporting activity provide valuable insight into ethical strain and emerging compliance vulnerabilities. Presenting these risks to executive leadership and boards alongside traditional compliance risks reinforces accountability and ensures appropriate mitigation strategies are implemented.

Workforce Sustainability as an Enterprise Risk

Workforce sustainability reflects an organization’s ability to maintain a stable, engaged, and ethically supported workforce over time. It extends beyond recruitment and retention efforts and encompasses leadership accountability, governance oversight, and organizational culture. Persistent workforce instability leads to diminished productivity, loss of institutional knowledge, increased reliance on temporary staffing, and escalating recruitment and onboarding costs. These challenges create financial strain and operational disruption, reinforcing the need to integrate workforce sustainability into enterprise risk management and governance structures.

Treating workforce ethics as an enterprise risk enables organizations to assign risk ownership, monitor trends over time, and implement corrective actions before issues escalate into regulatory or patient safety events.

Ethical Obligations and Moral Injury in Healthcare Compliance

Healthcare compliance programs are grounded in ethical principles that emphasize integrity, accountability, transparency, and patient-centered care. Moral injury represents a significant ethical risk because it undermines the ability of healthcare professionals to uphold these principles consistently. Compliance and ethics leaders have an obligation to recognize moral injury as an organizational issue rather than an individual failing. Ethical standards and regulatory expectations require healthcare organizations to foster environments where ethical concerns can be raised without fear of retaliation and where leadership responds meaningfully to those concerns. When ethical distress is ignored or minimized, trust in reporting mechanisms erodes, weakening compliance effectiveness and increasing organizational risk.

To strengthen ethical oversight, compliance leaders should establish clear ethics escalation pathways that are distinct from human resources or disciplinary processes. Providing staff with trusted avenues to raise ethical concerns outside of traditional human resources channels reinforces psychological safety and supports early identification of systemic issues that may impact compliance and patient care.

Ethical Support Structures That Strengthen Compliance

Healthcare organizations are increasingly implementing structured mechanisms to address workforce ethics and moral injury. When designed intentionally, these supports function as preventive and detective controls within compliance and quality frameworks. Moral distress rounds provide facilitated opportunities for staff to discuss ethically challenging situations in psychologically safe settings. When formalized through policy, documented appropriately, and reviewed at an aggregate level, these sessions help identify systemic challenges, promote consistent and ethical decision making, and inform leadership responses aligned with organizational values and regulatory expectations.

Ethics consultation services support staff and leadership in navigating complex ethical dilemmas related to patient care, resource allocation, or conflicting obligations. These services promote thoughtful decision making, consistent documentation, and alignment with ethical and regulatory standards. Wellbeing and resilience initiatives also contribute to workforce sustainability when they are integrated with ethics, compliance, and quality efforts. Effective programs address structural drivers of distress such as workload, staffing models, and leadership support rather than placing responsibility solely on individual coping strategies.

The Role of Compliance and Ethics Leadership

Compliance and ethics leaders play a critical role in elevating workforce ethics and moral injury from individual experiences to enterprise risk indicators. This includes integrating workforce ethics into compliance risk assessments, monitoring trends related to turnover, reporting activity, and safety events, and embedding ethical workforce considerations into auditing and monitoring activities. By doing so, compliance programs can identify early warning signs of ethical strain before they result in patient harm or regulatory exposure.

Leadership accountability is essential to sustaining ethical workforce support. Compliance leaders should partner closely with human resources, clinical leadership, quality, and safety teams to ensure workforce ethics risks are addressed through coordinated and sustainable interventions rather than isolated initiatives. This collaboration supports alignment between operational realities and ethical expectations.

In addition, compliance and ethics leaders should ensure workforce ethics risks are elevated through formal governance channels. Regular reporting to executive leadership and boards should include workforce-related risk trends, mitigation efforts, and outcomes. Providing leadership with clear, actionable data reinforces accountability and supports informed decision making. By reinforcing non-retaliation protections, promoting psychological safety, and modeling transparency, compliance leaders help sustain trust in reporting mechanisms and ensure workforce ethics remains an organizational priority.

Ethical Workforce Wellbeing and Safer Patient Care

Ethical workforce wellbeing is a critical driver of patient safety and compliance effectiveness. When healthcare professionals feel supported in navigating ethical challenges, they are more likely to report concerns, document accurately, and adhere to policies. Sustained ethical strain increases the risk of errors, underreporting, disengagement, and regulatory exposure.

Compliance leaders should treat ethical workforce wellbeing as an enterprise risk rather than an individual resilience issue.

Integrating workforce ethics indicators into compliance and patient safety monitoring allows organizations to identify systemic drivers of risk. Trusted reporting mechanisms, leadership accountability, and alignment of wellbeing initiatives with compliance and patient safety objectives ensure ethical workforce wellbeing functions as a protective control that supports safer patient care and long-term organizational sustainability.

Conclusion

Workforce ethics, moral injury, and sustainability represent one of the most significant risk areas facing healthcare organizations today. Staffing shortages, burnout, and ethical conflict threaten compliance effectiveness, patient safety, and financial performance. By integrating workforce ethics into compliance risk assessments, governance structures, and ethical support mechanisms, healthcare organizations can proactively address moral injury, support their workforce, protect patients, and strengthen long-term organizational resilience.

About the Author Bertholette Pardieu, MPH, CCEP, OHCC

Bertholette Pardieu, MPH, CCEP, OHCC is the Director of Risk Management and Corporate Compliance Officer at Broward Community and Family Health Centers, Inc., the largest Federally Qualified Health Center in Broward County. She has over a decade of experience leading enterprise-wide healthcare compliance, risk management, privacy, and governance programs across highly regulated environments, including FQHCs and Medicare and Medicaid systems. Her work focuses on integrating ethics, workforce sustainability, and patient safety into compliance and enterprise risk management frameworks. She regularly advises executive leadership and boards on regulatory strategy, organizational risk, and ethical governance. Bertholette earned her Office of Healthcare Compliance, Certified (OHCC) through the American Institute of Healthcare Compliance, a licensing/certification partner w/CMS.

References

Copyright © 2026 American Institute of Healthcare Compliance All Rights Reserved

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Burnout, Boundaries, and Compliance
Leadership

Burnout, Boundaries, and Compliance

Why Staff Wellness Is a Risk Management Issue 

Written By Dr. Stacey Atkins, PhD, MSW, LSW, CPC, CIGE 

This article, grounded in findings from the recent AIHC webinar presentation 'Burnout, Boundaries, and Compliance: Why Staff Wellness Is a Risk Management Issue,' explores how staff wellness programs can be embedded into organizational quality plans and compliance frameworks to proactively address workforce fatigue and prevent downstream risks.

In today’s healthcare environment, the intersection of staff wellness, regulatory compliance, and organizational quality has become impossible to ignore. As staff burnout reaches unprecedented levels, it is increasingly clear that wellness is not just a human resources concern, but a compliance and risk management imperative.

Understanding the Compliance Implications of Burnout

Burnout, defined by the World Health Organization as a syndrome resulting from chronic workplace stress that has not been successfully managed, presents real compliance risks. These risks include errors in clinical documentation, lapses in ethical judgment, and regulatory breaches. Healthcare organizations must recognize that failing to address burnout contributes to higher turnover, lower morale, increased patient safety incidents, and diminished organizational performance. These outcomes directly impact quality metrics and compliance reporting.

Embedding Staff Wellness into Quality Initiatives

A critical finding from Dr. Atkins presentation coupled with additional research identified the value of early detection—integrating wellness strategies at the onset of program design. Staff wellness plans must be embedded as part of quality improvement frameworks, not as optional extras. Organizations that build wellness into policy, practice, and compliance audits are more likely to see measurable improvements in documentation accuracy, patient satisfaction, and employee retention. Proactive wellness programs signal to staff that their well-being is prioritized and monitored, just like infection control or safety metrics.

Early Detection Is Essential

Early detection refers to the strategic implementation of burnout prevention strategies during the formative stages of a healthcare program or system process. Rather than responding to burnout reactively, early detection builds organizational resilience by identifying risk factors—such as understaffing, inadequate training, or high patient acuity—before they lead to harm. Embedding wellness at this early stage empowers staff and creates a feedback loop where staff input shapes policies, reducing the burden of moral distress and compassion fatigue.

Building a Compliance Culture That Prioritizes Wellness

Healthcare compliance leaders are in a unique position to advocate for systemic change. A culture of compliance that integrates wellness must address:

  1. clear policies on mental health support,
  2. confidential self-reporting pathways for burnout,
  3. regular staff wellness assessments, and
  4. accountability structures that enforce reasonable workloads and boundaries.

Wellness champions and wellness subcommittees can play a pivotal role in fostering peer support and resilience among teams.

Practical Steps for Implementation

To effectively embed wellness into compliance strategy, healthcare organizations should:

  • Incorporate staff wellness indicators into internal audits
  • Require burnout screening as part of risk assessments
  • Develop cross-functional wellness committees
  • Use anonymous staff feedback to refine wellness interventions
  • Align wellness initiatives with accreditation and CMS quality metrics

Conclusion

Burnout is a multifaceted risk that affects every level of a healthcare organization. By embedding wellness into compliance and quality frameworks from the start, organizations can create safer, more effective systems of care. Early detection, policy integration, and leadership advocacy are essential for ensuring that wellness is viewed not just as a benefit, but as a compliance requirement. The time for healthcare systems to act is now—staff wellness must be recognized as a foundational element of quality and risk management strategy.

About the Author

Dr. Stacey R. Atkins, PhD, MSW, LMSW, CPC, CIGE

Dr. Atkins is a Compliance Specialist working as a team member in the Education Department of the American Institute of Healthcare Compliance. Her career spans leadership roles with the Office of the State Inspector General, Department of Behavioral Health and Developmental Services, and HRSA, among others.

References

  • Agency for Healthcare Research and Quality. (2022). Patient Safety Primer: Burnout and Resilience. Retrieved from https://psnet.ahrq.gov
  • National Academy of Medicine. (2019). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press.
  • Shanafelt, T. D., & Noseworthy, J. H. (2017). Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings, 92(1), 129-146.
  • World Health Organization. (2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. Retrieved from https://www.who.int

Copyright © 2025 American Institute of Healthcare Compliance All Rights Reserved

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An Approach to Reduce Patient and Workforce Harm

Written by Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS  

This article emphasizes the need of healthcare institutions to focus on building a culture of safety through improving care of the workforce.  Read Part 1: Building a Culture of Patient Safety Starts with Reducing Staff Burnout posted December 3, 2024.

New Dashboard to Track Progress

On December 5, 2024, the National Action Alliance for Patient and Workforce Safety (NAA) at the U.S. Department of Health and Human Services (HHS) launched the National Healthcare Safety Dashboard, an online resource that aggregates hospital safety data from four primary measurement sources. Thus, the dashboard creates one comprehensive resource for understanding the current state of patient and workforce safety.

The Agency for Healthcare Research and Quality (AHRQ) works under the Department of Health and Human Services.  AHRQ sponsors the National Action Alliance for Patient and Workforce Safety and now offers a resource for national patient and workforce safety data dashboard. The goal of data collection is to improve safety of patients and your healthcare workforce.

The National Healthcare Safety Dashboard makes national safety data more transparent, allowing for a comprehensive understanding of healthcare safety by care setting, beginning with hospital care. It opens doors to information and best practices to empower healthcare provider organizations, patient advocates, policymakers, professional associations and others to monitor national safety progress and make informed decisions to improve safety nationwide.

The National Action Alliance goals, listed below, are intended to help all healthcare systems strengthen their patient and workforce safety outcomes.


1.  Advance Healthcare Organization Safety Strategies Using Safety Self-Assessments

  • Encourage healthcare organizations to perform safety self-assessments focused on the NAP’s foundational elements.
  • Support healthcare organizations in their efforts to enact safety strategies based on identified gaps.

2.  Empower the Patient's Voice in Safety Strategy

  • Allow patients and families to submit safety concerns into healthcare organization event reporting systems.
  • Encourage healthcare organizations to implement communication and resolution programs.
  • Engage patients and families in safety event reviews and in safety initiative planning.

3.  Support the Healthcare Workforce by Making Healthcare Safer by Design

  • Identify and address five high-priority safety engineering needs.

4.  Support the Healthcare Workforce by Strengthening Healthcare Safety Competencies

  • Ensure all healthcare team members, from administrators to clinical and non-clinical staff, receive training in fundamental safety competencies.

5.  Facilitate a Learning and Research Network

  • Encourage learning and sharing across network.
  • Spotlight change leaders.
  • Promote robust safety measurement locally and nationally.
  • Support research to address high-priority needs in patient and workforce safety.

The initial version of the dashboard offers access to hospital safety data and will expand to include other healthcare settings, such as ambulatory clinics and nursing homes.  The data sources listed on the Dashboard include:

Resources and Tools on Patient and Healthcare Workforce Safety

Resources are listed on the AHRQ website by type of harm. These tools and resources include active federally sponsored implementation initiatives and funding opportunities and can help you address safety needs that you identify in your safety self-assessment.

  • Diagnostic Safety
  • Falls
  • Hospital-Associated Infections
  • Maternal Safety
  • Medication Safety
  • Never Events
  • Opioid Safety
  • Pressure Ulcers
  • Readmissions
  • Sepsis
  • Surgical Safety
  • Transitions in Care
  • Venous Thromboembolism

The AHRQ recommended Self-Assessment Tool is an essential resource designed to help health care organizations evaluate their safety readiness, identify opportunities for improvement, and track progress over time. The 2024 updated version of the tool aligns with the recommendations in Safer Together: A National Action Plan to Advance Patient Safety (National Action Plan) and incorporates the latest insights and best practices from global safety initiatives.

Conclusion

Healthcare is not safe until it is safe for all.  As healthcare organizations implement these initiatives and work collectively across the NAA, the National Healthcare Safety Dashboard becomes an essential tool that allows the healthcare community to monitor progress and offers insights to guide further action.  Workforce safety recognizes the imperative to protect workforce members from physical harm so that they can deliver high-quality care, and recognizes the vital importance of psychological and emotional safety for engaging, communicating, and collaborating effectively to safely deliver patient care.

The National Healthcare Safety Dashboard is now live and accessible to the public:

About the Author and AIHC

The author, Joanne Byron, shares her clinical, consulting, auditing and educational experience by serving as the Board Chair and overseeing the AIHC Volunteer Education Committee. She is also a volunteer hospice nurse, hospice hands-on-care volunteer and End of Life Doula.

The American Institute of Healthcare Compliance (AIHCR) is a non-profit healthcare training organization and a licensing/certification partner with CMS. Please visit our online store listing current training and certification offerings.

Copyright © 2024 American Institute of Healthcare Compliance All Rights Reserved

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Building a Culture of Patient Safety Starts with Reducing Staff Burnout

Written by Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS

Patient safety directly relates to reducing mistakes. Increased job-related stress contributes to workforce burnout, a major contributing factor to unsafe practices. Unfortunately, our healthcare workforce faces unprecedented challenges: incidence of violence in the workplace, accelerated rates of burnout, and exposure to dangerous hazards.  This article emphasizes the need to improve patient safety and outcomes through reducing staff burnout.

Introduction

Providing a safe environment instills confidence not only to the patients we serve, but for our workforce as well.  According to the National Institutes of Health, a strong link exists between workforce wellness and patient safety.  When healthcare workers are physically and mentally well, they are more likely to have the ability to focus and deliver safe and quality patient care.  Therefore, we can conclude that a healthy workforce is necessary for a safe patient environment. 

A positive patient and workforce safety culture has been shown to significantly improve a number of patient outcomes, including lower rates of surgical site infections, falls, and medication errors, according to the Patient Safety Network. In addition to specific health outcomes, patients report having better experiences with their care when the culture of patient safety is strong.

Although most healthcare organizations agree on the importance of safety culture, research this year focused heavily on the psychological factors surrounding culture, such as psychological safety, how to support healthcare workforce staff after an adverse event, and burnout. This is a challenge in today’s world.

Work Overload as a Contributing Factor

Causes of work overload in healthcare include time constraints; alert or alarm fatigue; new and hard-to-use technology, including EHRs; and cognitive strain, which, according to the American Medical Association (AMA), directly or indirectly causes 87.1% of medical errors—even though most safety interventions focus on training clinicians, whose knowledge and skill is responsible for only 12.8% of medical errors.

Assaults, Violence Contribute to Burnout

The passion most healthcare workers have can be overridden by the threat of on-the-job violence. And this doesn’t even account for the threats encountered getting to and from work!

According to the Bureau of Labor Statistics, there is a 63% increase in the rate of injuries from violent attacks against medical professionals from 2011 to 2018. And, according to a report by the Centers for Disease Control (CDC) and the Bureau of Labor Statistics (BLS), it is reported that:

  • In 2020, health care and social assistance workers overall had an incidence rate of 10.3 (out of 10,000 full-time workers) for injuries resulting from assaults and violent acts by other persons.
  • The rate for nursing and personal care facility workers was 21.8 per 10,000 full time workers for injuries caused by assaults and violent acts by others.
    • This means that for every 10,000 full-time employees in nursing and personal care facilities, there were an average of 21.8 reported incidents of workplace violence.
  • Data obtained from nurses (RNs/LPNs) in a major population-based study showed a rate of physical assaults at 13.2 per 100 nurses per year and at a rate of 38.8 per 100 nurses per year for non-physical violent events (threat, sexual harassment, verbal abuse).

As you can see, it is difficult to work your best under these circumstances.  And even though some institutions may have a proper formal incident reporting system, there are still many incidents, especially in the forms of bullying, verbal abuse, and harassment that are never reported.

Most Vulnerable Workforce

The most vulnerable healthcare workers victimized are staff at emergency departments, especially nurses and paramedics, and staff directly involved with in-patient care.

What Patient Safety Is

When discussing “patient safety” in the context of this article, it may be helpful to quote definitions, examples and descriptions of what a safety culture is. 

According to the American Nurses Association, a culture of safety describes the core values and behaviors that come about when there is collective and continuous commitment by organizational leadership, managers, and healthcare workers to emphasize safety over competing goals.   The Joint Commission defines Safety Culture as the sum of what an organization is and does in the pursuit of safety.

From a global perspective, the World Health Organization states that patient safety is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum." Within the broader health system context, it is “a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur."

Is Burnout a Still Problem Now that COVID-19 is Behind Us?

The COVID pandemic is a major contributing factor to the overall burnout of health care workers. And, COVID continues to be a current infectious disease stressor to the healthcare workforce.  According to the Centers for Disease Control (CDC), “Health worker jobs in the U.S. involve demanding and sometimes dangerous duties, including exposure to infectious diseases and violence from patients and their families. The COVID-19 pandemic presented even more stressors. These included a surge of patients, longer working hours, and shortages of supplies and protective equipment. Health workers are reporting feeling fatigue, loss, and grief at levels higher than before the pandemic.”  The CDC reports:

Individuals who choose to work in healthcare often make personal sacrifices for their work. While the work can be rich with purpose and meaning, the demands on time and attention can be relentless to the point of being unhealthy for the healthcare worker.  Leadership’s approach and commitment to patient safety has a significant impact on your organization’s culture. If leaders do not prioritize or actively foster a culture of safety, it can negatively affect staff engagement and commitment to patient safety practices. Strong and supportive leadership is crucial for implementing and maintaining a culture that prioritizes patient safety.  Lack of support from upper management contributes to clinical staff burnout.

Burnout related to work stress is mainly seen as emotional exhaustion, depersonalization, and diminished sense of accomplishment.  This manifests itself with mental and physical exhaustion and is demonstrated as a lack of commitment, inadequate support, or insufficient prioritization of safety measures by leadership and staff. This can result in a higher likelihood of medical errors and adverse events occurring.

In healthcare organizations, patient and workforce safety culture are founded on how well teams work together, how supportive leadership and managers are of patient and workforce safety, how staff report events and near misses, and how teams and leaders respond to events. A weak organizational culture can also discourage staff from reporting incidents or speaking out about potential safety concerns further compromising patient safety.

Focusing efforts on a sound and sustained safety culture will lead to and support better outcomes in patient healthcare and safer working conditions for healthcare workers.

Address Patient Safety and Volunteer Staff Burnout

Don’t overlook the important role of your volunteers! Volunteers have a potential negative impact on patient care when these important members of your team experience high levels of burnout.  This can lead to decreased attention to detail, potential errors, and compromised quality of care due to exhaustion and reduced motivation. Although they are unpaid staff, they still require orientation and training.  When their importance is overlooked and minimized, it can contribute to burnout, making them more prone to mistakes, overlook important details, or have reduced responsiveness, potentially affecting patient safety.  Factors like unclear expectations, excessive workload, lack of support from leadership, inadequate training, and feeling undervalued can contribute to volunteer burnout. 

Emotional exhaustion, decreased engagement, increased absenteeism, irritability, and feeling overwhelmed are common signs of volunteer burnout. Implement systems to identify early signs of burnout in volunteers and provide necessary support or adjustments to their roles. Routine skills testing, annual HIPAA and compliance training should be included in your volunteer program.

Conclusion

The purpose of patient safety is to reduce risks, errors and harm that can occur to patients while receiving medical care, which is part of the huge patient quality emphasis currently stressed in the United States and globally. As the world faces evolving and new challenges, it can be difficult to provide an infrastructure to respond with consistent, effective practices deployed by a workforce that is properly equipped, financially and emotionally supported.

The most effective approach to envision the promotion of a patient safety culture is a multifaceted approach of interventions established at the top.  Additional reading and resources to review are:

About the Author and AIHC

The author, Joanne Byron, shares her clinical, consulting, auditing and educational experience by serving as the Board Chair and overseeing the AIHC Volunteer Education Committee.  She is also a volunteer hospice nurse, hospice hands-on-care volunteer and End of Life Doula. 

American Institute of Healthcare Compliance (AIHCR) is a non-profit healthcare training organization and a licensing/certification partner with CMS.  Please visit our online store listing current training and certification offerings.


Copyright © 2024 American Institute of Healthcare Compliance All Rights Reserved

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Leadership in a Value-Based Care (VBC) Environment

Part 1 in a Series of Leadership Articles on Value-Based Care

Written by Joanne Byron, LPN, BS, CCA, CIFHA, CHA, COCAS, CORCM, CHCO, OHCC, CMDP, ICDCT-CM/PCS

Edited by Julie Rickman, MBA, CHC, CHPC, CHCO   


This article is the first in a series sponsored by the American Institute of Healthcare Compliance (AIHC) Volunteer Education Committee. Part 1 is an overview of challenges many health care leaders face with shifting reimbursement.  Additional articles will focus on various specific areas, such as data analytics, and key performance indicators (KPIs).

Introduction

Reimbursement has been shifting to value-based reimbursement models over the past years, labeled Value-Based Care or VBC.   Value in healthcare is the measured improvement in a person’s health outcomes for the cost of achieving that improvement1. While some descriptions conflate value-based healthcare and cost reduction, quality improvement, or patient satisfaction, those important efforts are not the same as value, which focuses primarily on improving patient health outcomes.

Value-based care differs from the traditional fee-for-service approach, where physicians are paid based on the amount of healthcare services they provide because it ties the amount providers earn for their services to the results they deliver for their patients, such as the quality, equity, and cost of care.

Healthcare executives are challenged with finding resources, talent and motivation to lead the workforce in a direction to improve both patient outcomes and reimbursement, in addition to dealing with a shortage of physicians and nurses to staff facilities.  The cost of providing quality care services is soaring, creating a challenge for healthcare C-Suite executives.  It is now the “trend” for healthcare C-suite executives to promote an unwavering commitment to “value-based care” – but can it be achieved?  What type of change is being demanded of leadership?

Understanding the Leadership Challenge

Value-based care and changes in reimbursement is the focus of government and commercial insurance payers as our population is aging and due to an increase in poverty, contributing to Social Determinants of Health (SDOH). Improving a patient’s health outcomes relative to the cost of care is an aspiration embraced by stakeholders across the healthcare system, including patients, providers, health plans, employers, and government organizations1. But healthcare providers haven’t been able to successfully reduce cost, even with the massive number of hospital mergers and acquisition of physician practices over the past few decades.

The result?  The government is reforming healthcare into a new health ecosystem.

Issues leadership faces in 2023-20242 are:

  • Confronting affordability and disrupting costs by shifting to VBC
  • Automating or digitizing healthcare (AI)
  • Rethinking risk
  • Solving clinical workforce shortages
  • Delivering cost-effective quality care
  • Implementing SDOH screening tools

Positive Take-Aways

Shifting reimbursement from quantity to quality has many positives.  Expectations of physicians to see more patients to gain bonuses has led to dissatisfaction.  This was especially true when Health Maintenance Organizations (HMOs) were popular, back in the 1980s.  Physicians were penalized for ordering too many tests or seeing too many patients.  The financial incentive was do less, make more money, resulting in questionable outcomes, at best.

A huge positive impact with value-based healthcare is that it connects clinicians to their purpose as healers, supports their professionalism, and can be a powerful mechanism to counter clinician burnout. When done “right,” value-based healthcare’s focus for better health outcomes aligns clinicians with their patients. That alignment is the essence of empathy.

Moving to a system of value-based care requires that physicians and physicians-in-training view their role differently within the larger care team, such as what constitutes an effective care solution, and about the importance of measuring the health outcomes that matter most to patients. This learning should begin during medical school.

By improving patients’ health outcomes, value-based care reduces the compounding complexity and disease progression that drive the need for more care.  This produces a down-stream positive effect both on the cost of healthcare and patient outcomes.

Measured health outcomes demonstrate a clinicians’ ability to achieve results with patients and families and drive improvement in the results that matter most. The problem, what is being measured, and how?

The Centers for Medicare and Medicaid (CMS)

The Centers for Medicare & Medicaid Services (CMS) has been leading the way to actually reform the healthcare system in the United States for years.  Through financial incentives and other methods, the goal of the government’s value-based care programs is to hold providers more accountable for improving patient outcomes while also giving them greater flexibility to deliver the right care at the right time. 

According to CMS, “Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for.”  CMS states that value-based programs also support the government’s three-part aim to achieve the following:

  • Better care for individuals;
  • Better health for populations; and
  • Lower cost.

One CMS example is the voluntary Medicare Shared Savings Program, which allows providers to form groups called accountable care organizations (ACOs). ACOs can earn financial rewards by taking responsibility for caring for a defined group of Medicare beneficiaries and improving the care they receive, largely through better coordination of services.  What does the evidence show?

According to the Commonwealth Fund3, evidence has shown ACOs have produced savings while at least maintaining quality of care, but not necessarily improving health disparities.  ACOs in the Medicare Shared Savings Program, Medicare’s largest voluntary ACO model, serving predominately patients of color, were found to perform worse on quality measures than ACOs with fewer patients of color. They were also more likely to exit the program. These outcomes may reflect longstanding quality disparities and possibly a lack of administrative and financial resources to address disparities in ACOs serving predominately patients of color. However, some experts believe that ACOs have the potential to promote equity through population-based payments, so long as equity is explicitly considered in payment design.  The Commonwealth Fund also states that ACO benchmarking methodologies, which are used to set savings targets, have been controversial because they may discourage participation by adversely impacting certain ACOs. Well-performing ACOs may be penalized over time as they are held to increasingly high savings targets; at some point, these ACOs may be unable to cut costs any further or generate more savings3.

Taking Leadership Challenges Head-On!

Collaboration and cooperation are key -- not only from the top-down within your own organization, but realizing your organization may need to rely on additional resources.  Start by identifying the common needs of a patient segment.  The goal is to create care teams designed to deliver care that provides a comprehensive solution for patients or families. When the goal of care shifts from treating to solving patients’ needs, care teams can both address the clinical needs of patients and begin to address the nonclinical needs that, when left unmet, undermine patients’ health.

Get the Board of Directors Involved

Provide training on the topic of reimbursement and the shift to VBC. C-suite executives along with the board of directors should first gain a solid understanding of why your organization should plan to shift from fee-for-service and accept more risk under VBC.  

Executive support is required to obtain not only support, but approve the financial means required to be invested in technology and new systems needed in the VBC environment. This includes how physicians will be compensated differently under a VBC model and a shift in incentives.  Get physician leaders involved quickly to help develop a transition plan to obtain physician buy-in for a successful transition.  Risk must be shared between the physicians and their employer because VBC models are at-risk contracts.

Understanding Your Costs

The first and most important factor for organizations to understand is your cost structure. You should know how much it costs for you to deliver a unit of care. And, in light of implementing Artificial Intelligence (AI) technology now or in the near future, cost is a critical factor. It’s important to evaluate how necessary upgrades and a new approach to your operations may need to be made to ensure quality care standards are being met while staying within the negotiated price points.

Knowing the parameters of what your costs are is crucial as you begin to negotiate with insurance companies on a reimbursement strategy. This knowledge is also crucial as you begin to develop your service lines and determine how payments are going to be apportioned among providers in a value-based program.

Getting to your true costs means initiating a detailed, thorough cost accounting program.  If you can’t readily determine your costs for providing various services, you may need to enhance your internal accounting structure on both the clinical and administrative side of the organization.

Understand Your Current and Historical Data – focus on data analytics

Data analytics is the science of analyzing raw data to make conclusions about that information. Data analytics can help a business optimize its performance, perform more efficiently, maximize profit, or make more strategically-guided decisions.  There are three types of analytics that businesses can use to drive their decision making:

  • Descriptive analytics, which tell what has already happened;
  • Predictive analytics, which show us what could happen; and
  • Prescriptive analytics, which inform us what should happen in the future.

Without a strategy that includes sophisticated analytics, it will be challenging to predict proper coverage for quality disease management across the continuum. By analyzing patient data, healthcare providers can lower readmission rates, reduce errors, and better identify at-risk populations.  When utilizing social determinants of health (SDOH) Z codes, you can identify environmental and social factors which impact your organization. 

Comprehensive benchmarking and actual performance in areas such as post-acute care, emergency department utilization, and inpatient care, can guide healthcare organizations to higher-quality care while predicting profitability and VBC contract performance.

Insights gleaned from data analytics can support a provider’s most impactful and strategically prioritized clinical interventions.

Data will also allow you to track your own success and use this information in contract negotiations.  Measurement of results allows teams to know they are succeeding. Measuring health outcomes also provides the data needed to improve care and efficiency while lowering cost.

The Elephant in the Room

While transitioning to a value-based care strategy sounds like an answer to providing better quality care for patients while allowing providers to truly focus on the patients they care for (and, hopefully, reduce or avoid clinician burn-out), the current staffing shortage in the medical profession does not lend itself to easily address this solution. Studies have shown that a primary cause of burnout among healthcare providers is the administrative burden required to carefully document and report on all aspects of patient care. Getting behind in documentation can lead to sloppy, inconsistent reports regarding patient progress, and the stress of burdensome documentation requirements has led to providers exiting the profession.

The impacts of a reduced workforce are being felt across the continuum of care, and patients suffer as a result. Attempting to realign physicians with their calling to truly help a patient’s health and well-being may be an attractive solution to combatting burn-out, but decreased staffing places pressure on existing staff to handle more patients. Without an infusion of more staff, it seems difficult to envision that a value-based care model could truly exist and succeed under current circumstances.  Organizations should carefully evaluate where and how they can take steps toward a VBC model while still addressing the administrative burdens placed on a reduced level of staffing.

Conclusion

Most of us can agree that the fee-for-service reimbursement model lacks focus on truly patient-focused care and best outcomes. The solution for most organizations to achieve a smoother transition to a VBC model will involve advancement into the Artificial Intelligence (AI) arena. 

Although AI is becoming more wide-spread, until additional safety and security measures are developed, the timing may not meet demand for the sophisticated AI needed to meet the government’s reshaping our health care system.  This could force health care institutions into utilizing AI too quickly.  Unless our private sector healthcare system can change to improve patient outcomes, the government will continue to try and solve the problem for us.

References

1 National Library of Medicine article “Defining and Implementing Value-Based Health Care: A Strategy Framework”

2 PWC – Next in health services 2023

3 The Commonwealth Fund Commission on a National Public Health System

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Part 2:   Solutions to Leading the Younger Generation

Written by the AIHC Volunteer Education Committee   


Please read Part 1: Challenges of Leading the Younger Generation. According to members of AIHC, the retention rate of younger generation employees has become a critical challenge.  This Part 2 article focuses on exploring why younger generation employees struggle in the workplace, why retaining these employees is important and potential solutions to attract and retain the younger generation.

Common complaints from older generations about millennials in the workplace are that they're whiny, entitled, and require too much nurturing. With that being said, millennials do desire engagement from their employers. However, leaders shouldn't mistake this for being too needy.  

Perhaps we can improve the hiring and retention of the younger generation by putting our bias aside for just a moment to gain a better understanding of the issue.

Generation Y and Z Personnel in the Healthcare Setting

What are Generations Y and Z?

According to an article by Beresford Research, the definitions below are based on analysis by the Pew Research Center.  Generation X is anyone born between the years 1965 and 1980, but what about Y and Z?

  • Generation Y (millennials) were born between 1981 and 1996; 
  • Generation Z are people born between 1997 and 2012.

Generation Z, also known as the post-millennial generation or iGeneration, is the first generation to grow up fully immersed in a world dominated by technology, social media, and constant connectivity.

Insight to Why Millennials Struggle in the Workplace

As Generation Z enters the workforce, they are bringing their unique perspectives and expectations.  We need to take time to see their world through their eyes so we can improve how we manage our workforce, and perhaps even learn something from this generation.

What are the characteristics of millennials and Gen Z in the workplace?

We’ve found that there seems to be several common threads that identify millennials’ reasons for leaving a job.  According to the February 19, 2023, article from the Insider “Welcome to Generation Quit,” Generation Z bore the brunt of early 2020 layoffs and job losses and now Generation Z is suffering from lack of mentorship, tenure and stability at a pivotal point in their careers. 

CNBC reports that Generation Z and millennials want to work on their own terms and “are particularly eager to leave some public-facing industries, including health care, retail and education,” according to the Deloitte Global 2022 Gen Z and millennial survey.

The table below is a simplistic comparison between millennials and Gen Z:

Millennials

Generation Z

Want to work toward a purpose

Are motivated by money and job security

More interested in on-going conversations about performance than annual reviews

Require more frequent feedback on their performance

Interest in collaboration and teamwork

Driven by individual performance and competition


One comment made during an AIHC Volunteer Education Committee Meeting is that it is understandable that younger people change jobs frequently.  “Staying at a job 30+ years and retiring with a pension is no longer a guarantee as it was for older generations – this is seen by younger generations as a lack of employer loyalty and commitment and it has resulted in their lack of motivation to want to stay.  Younger generations have seen their parents be forced into retirement or downsized during a merger or acquisition.  Their loyalty lies within themselves and not to a greedy corporation that demonstrates time and time again how unimportant their employees are.”

This may seem “shocking” to seasoned, dedicated management, but it is important to view the optics from the younger generation’s point of view if we are to tackle the problem.

Potential Solutions

Understanding how millennials think, what motivates them in the workplace and what keeps them happy long term is the best way to attract and retain this generation of workers.  Implementing even some of the solutions below will help create a better-balanced workforce, help reduce stress even for your more “seasoned” workaholics and perhaps reduce workforce burnout!

Workplace Environment is Too Rigid or “Robotic”

Work Burnout - 84% of millennials in the workplace who participated in a survey conducted by Deloitte said they’ve felt the effects of burnout at their current job. The top causes were unrealistic expectations for deadlines, lack of recognition, and working too many hours on the weekend. Work cultures that don’t protect their team members from the effects of burnout are likely to see low employee retention rates, poor performance, lack of engagement, and other issues that negatively impact an organization.

  • Notice when a team member is struggling at work and reach out. Leaders who get to know their employees realize when someone is lagging, feeling fatigued, or acting differently than they usually do.
  • Don’t allow PTO to be taken as a “pay-out” – make PTO mandatory each year.

When possible, consider . . .

  • Providing mentorship during the on-boarding / probationary period;
  • Being open to flexible job options like remote work, telecommuting, and generous family leave;
  • Initiating honest conversations around team members’ needs;
    • For example, during one-on-ones, ask team members what you can do to make them feel more engaged and motivated at work.
    • Additionally, brainstorm ideas with them about job perks, benefits, and work terms.
  • Why and when a worker must be in the office;
    • Offer varied shifts where operationally feasible or modified hybrid work schedules;
    • Consider a 4-day work week (everyone on your workforce will benefit and reduce potential burnout);
  • Improving communications and provide reasoning to employees (be more transparent).

Lack of Opportunity for Growth - They’re looking to work with and learn from executives who are constantly seeking to answer the question: “What is leadership, and how do we build a culture of leaders?”

  • According to Gallup, millennials want jobs to be development opportunities, so offer to work on a career development plan that keeps them on track to achieve important milestones as they grow with the company.
  • Help millennials in the workplace set challenging objectives and key performance indicators that push them out of their comfort zone.

Feeling of Being Disengaged and Underappreciated - Not receiving recognition or appreciation for hard work and dedication is one of the top reasons millennials leave their jobs.

  • Be specific about the “what,” “why,” and “how” when showing gratitude and recognition. Let people know the exact ways they help the business thrive.
  • While sharing gratitude is one of the easiest and most effective ways to give employee recognition, researchers from Harvard Business Review found 37% of managers toss positive reinforcement like employee awards or words of affirmation to the side.

Another Company Offers Them a Better Job - Gallup’s study on millennials in the workplace indicates that 60% of those in Generation Y would be open to new job opportunities. 36% of these people plan on finding a job with a new company within the next 12 months.

So many millennials want to leave their current employer due to a lack of engagement tactics and attraction and retention strategies. It’s safe to say that based on these findings, millennials aren’t interested in remaining with companies that don’t tend to their need to feel engaged at work.

So, consider . . .

  • Working to build a strong relationship with employees. This requires time and effort on leaders’ part, but without this investment, team members will feel no reason to be loyal to a business that doesn’t seem to care about them on a professional and personal level.
  • Being intentional about creating a team that people love being a part of. Developing this sense of belonging, fun, excitement, inspiration, and engagement will help group members look forward to work every day.

Know Your Employee Retention Rate

What is a good employee retention rate? You may be surprised at the result!

In general (not health care specific), employee retention rates of 90% or higher are considered good, meaning a company should aim for an average employee turnover rate of 10% or less.

  • National Hospital Turnover Rate - According to Healthcare Finance News, the national hospital turnover rate is 25.9%.  In the past five years, the average hospital turned over 100.5% of its workforce, which is also reported by Becker’s in the Hospital CFO Report of January 3, 2023.

Calculate Your Talent Acquisition Cost

Cost-per-hire - To calculate the cost-per-hire, divide the total recruitment time spent over a given period by the number of new hires.

  • Your recruitment processes have costs associated with them, and you should always be measuring the return-on-investment (ROI) to decide if you’re overspending or underinvesting. When you understand this and can look at trends over time, your organization is in a much better position to adjust course when things aren’t working.

Retention Rate - Employee retention rate calculations provide a point of reference when determining how your organization compares to others.

  • Retention rate is often calculated on an annual basis, dividing the number of employees with one year or more of service by the number of staff in those positions one year ago. Several different formulas can calculate employee retention rate, but a basic formula you can easily use is:
  • (# of employees at the end of a set time period / # of employees at the start of a set time period) x 100 = retention rate percentage.

Summing it all up!

Healthcare providers need to adjust leadership styles to engage the younger generations, which can be a healthy approach to avoid burnout of your workforce in general. 

The younger generations are tech-savvy – which is needed in the ever-evolving technology advancements of medicine, cybersecurity and computer systems required in healthcare.

The healthcare industry has strict compliance requirements that must be met to ensure patient safety, quality of care and confidentiality. As the youngest generation in the workforce, Gen Z may lack experience working in healthcare, which could lead to compliance issues. They may not be familiar with the intricacies of healthcare regulations and more importantly, may not understand the importance of adhering to them.  Healthcare organizations and providers can help bridge this gap by providing proper training and education to Gen Z workers and ensure that Gen Z workers have the knowledge and skills necessary to provide high-quality care while adhering to compliance requirements. But the willingness to understand and respect authority and established processes must be present.

It must be a symbiotic relationship - We need the younger generation in our workforce – the youth is our future - we can’t abandon them and they can benefit from our experience and expertise.

This article is written by the Volunteer Education Committee of the American Institute of Healthcare Compliance (AIHC), a non-profit 501(c)(3) organization.  AIHC appreciates the dedication and expertise of this highly educated group of health care compliance professionals.

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Burnout, Boundaries, and Compliance
Leadership

Part 1: Challenges of Leading the Younger Generation

Written by: A. Michi McClure, J.D., an AIHC member and Volunteer on the CEU Education Committee   


This Part 1 of a 2-part series addressing how healthcare originations can gain a better understanding to successfully hire and retain the younger generation. Please read Part 2 Solutions to Leading the Younger Generation.

Generation Y (Gen Y born between 1981 and 1996) is a diverse and multicultural generation, and they value inclusivity and social justice. They are highly educated and career-oriented, with a strong desire for flexibility, work-life balance, and personal fulfillment. This generation is also known for their entrepreneurial spirit, creativity, and ability to adapt to change quickly. They have a strong sense of individuality and are comfortable expressing themselves through various forms of digital media.

In terms of social and political views, Gen Y tends to be more progressive and open-minded than previous generations. They are concerned about issues such as climate change, racial and gender equality, and mental health, and they are vocal in advocating for change.

With many of our current healthcare leaders considered Millennials, and healthcare laws and regulations having been written by those considered Gen X and older, what impact does Gen Y have on Healthcare Compliance?

Gen Y and Authority

Gen Y is often characterized as having a more skeptical and independent attitude toward authority compared to previous generations. This may be due in part to their exposure to a wide range of information sources through the internet and social media, which has allowed them to question traditional sources of authority and seek out alternative perspectives. As Gen Y enters the workforce, they are bringing their unique perspectives and expectations to various industries, including healthcare.

Gen Y and Technology

Gen Y is the first generation to grow up in a world where technology is ubiquitous, and they are known for being tech-savvy and comfortable using digital tools to manage their own healthcare. However, the increasing reliance on healthcare technology creates several challenges and issues for the healthcare industry as a whole where Gen Y represents not only the future leaders in this industry but also future customers.

This generation has grown up in a digital age and is accustomed to on-demand services and instant access to information. As such, they have different expectations when it comes to healthcare delivery compared to previous generations. They expect healthcare providers to offer online and mobile services, such as virtual consultations, telemedicine, and appointment scheduling through apps and other digital platforms. Gen Y values convenience and flexibility, and they want to be able to access healthcare services from anywhere, at any time.

To capture this population as patients, healthcare is finding itself increasingly investing in digital tools and platforms that allow patients to access healthcare services from their smartphones or computers and creating a larger environment to create data breaches and cyber-attacks.

If digital healthcare platforms or apps are not adequately secured, patient data could be compromised, leading to compliance issues and negative consequences for patients. This has been illustrated by several startups in the digital healthcare space where proprietary medical records were not adequately tested before its use causing the unauthorized disclosure of thousands of patient records.

Gen Y and Social Media

Generation Y (Gen Y) is known for being social media savvy, having grown up with social media as a primary form of communication. While this skill can be beneficial in many industries, it also creates challenges for Gen Y workers in healthcare. Social media presents several compliance challenges for healthcare providers. For example, healthcare workers must adhere to strict regulations surrounding patient privacy and confidentiality. Posting about work-related matters on social media could lead to a breach of patient confidentiality, violating compliance requirements, and potentially harming patients.

Gen Y workers must also be mindful of the impact their social media presence could have on their professional reputation. Social media is often public, and healthcare providers must maintain a professional image to build trust with patients and colleagues. Posting inappropriate or unprofessional content could damage their professional reputation and impact their career prospects.

On the other hand, social media can be a valuable tool for healthcare providers to engage with patients and promote health education. By using social media to share educational content, answer patient questions, and promote healthy behaviors, healthcare providers can reach a broader audience and improve patient outcomes.

Overall, social media savviness can be both a strength and a challenge for Gen Y workers in healthcare. While social media can be a powerful tool for patient engagement and education, it also presents significant compliance risks and potential damage to professional reputations. Healthcare providers should work with Gen Y workers to navigate these challenges and develop appropriate policies and training to ensure that social media is used in a way that benefits patients while complying with regulations and protecting patient privacy.

Gen Y is Moving Fast and Breaking Things

As Gen Y enters the workforce, they bring with them a desire for efficiency and a focus on streamlining processes. While this can be beneficial in many industries, it creates a challenge for Gen Y workers in healthcare, where compliance with regulations is critical.

In healthcare, compliance with regulations is crucial to ensure patient safety and confidentiality. However, this can sometimes conflict with the desire for efficiency and streamlining processes. For example, taking shortcuts or skipping steps in a process could compromise patient safety or violate compliance requirements.

To address this challenge, Gen Y workers in healthcare must balance efficiency with compliance. They must find ways to streamline processes while adhering to regulations and maintaining patient safety and confidentiality. This requires a deep understanding of healthcare regulations and a commitment to following them, even if it means sacrificing some efficiency.

Finding the right balance between efficiency and compliance can be challenging. It requires collaboration between Gen Y workers and more experienced healthcare providers to identify areas where processes can be streamlined without compromising compliance. Additionally, it requires ongoing education and training to ensure that Gen Y workers understand the importance of compliance and the potential consequences of non-compliance.

By finding the right balance, healthcare providers and Gen Y workers can improve patient outcomes while ensuring that patient safety and confidentiality are protected. This requires ongoing collaboration, education, and training to ensure that Gen Y workers understand the importance of compliance and the role they play in maintaining it.

Gen Y and Adherence to Policy and Procedure

Gen Y workers bring a fresh perspective and new ideas to the healthcare industry, and they often have a different approach to work than previous generations. One challenge that Gen Y workers face in healthcare is the need to adhere to policies and procedures.

Compliance in healthcare requires strict adherence to policies and procedures to ensure patient safety and confidentiality. However, Gen Y workers may have a more relaxed approach to work and may not always follow established policies and procedures as closely as older generations.

To address this challenge, healthcare providers must prioritize education and training, and maybe that training and education is not delivered in the same way it was delivered to previous generations. Perhaps we put less emphasis on the “what” and more on the “why.”  The expectation should be that healthcare proficiency will take time. Gen Y is going to ask questions; we who are more senior should embrace that. Leaders must create an environment where new hires feel encouraged to learn which includes making mistakes, while fostering a culture of compliance within the workplace. Set clear expectations for behavior, consequences for non-compliance, and communication should include feedback.

Adherence to policies and procedures is critical in healthcare, and we create a win-win when healthcare providers leverage the strengths of Gen Y workers while maintaining patient safety and confidentiality.

Gen Y and Communication Modes

Gen Y's preference for communicating via email and text messages has had a significant impact on the delivery of healthcare and the compliance surrounding such modes of communication. Simply put, Gen Y expects their healthcare providers to use digital tools to communicate with them.

One of the key benefits of using email and text messaging in healthcare is the ability to improve communication between patients and healthcare providers. With the rise of telehealth services, patients can easily connect with their providers through email or text messaging, regardless of their physical location. This can be particularly beneficial for patients who live in remote areas or have mobility issues.

Using email and text messaging also allows for more efficient communication between patients and healthcare providers. Patients can quickly and easily communicate their healthcare concerns, ask questions, or request prescription refills, without having to wait on hold or schedule an appointment. This can save both patients and healthcare providers time and resources.

The potential downsides to using email and text messaging in healthcare are not only with regard to privacy and security, but also in miscommunication or misunderstanding between patients and providers. Healthcare providers must be diligent in ensuring that their messages are clear and concise, and that patients understand any instructions or advice provided.

Conclusion

As the healthcare industry continues to evolve, it will be important for healthcare providers to adapt to the unique needs and preferences of this emerging generation of patients. Please read Part 2: Solutions to Leading the Younger Generation written by the AIHC Volunteer Education Committee (which includes Michi McClure)

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Quality
Leadership, Quality

Leadership & Building a Culture of Safety

Written by: Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, COCAS, CORCM, OHCC, ICDCT-CM/PCS   



Serving as Part 3 in our Leadership Series, this article is based on one of the lessons from a new course being offered by the American Institute of Healthcare Compliance in April, 2023 entitled “Quality, RCA and the 8D Approach”.  

Leadership must gradually change the culture so that the need to report and do something about a safety issue outweighs the fear of being punished.  Senior leaders, C-Suite executives, unit leaders, physicians, nurses, and all other staff must be held to the same standards.

Sentinel Event Alerts are published for Joint Commission-accredited organizations and interested health care professionals.  Sentinel Event Alert identifies specific types of sentinel and adverse events and high-risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences.

Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives. The Joint Commission urges organization to route Sentinel Event Alert issues to appropriate staff within your organization.

In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors.

Competent and thoughtful leaders contribute to improvements in safety and organizational culture.  The Joint Commission accreditation manual glossary defines a leader as: “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization's governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.”

Leaders understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.  James Reason compared these flaws – latent hazards and weaknesses – to holes in Swiss cheese. These latent hazards and weaknesses must be identified and solutions found to prevent errors from reaching the patient and causing harm.

  • Examples of latent hazards and weaknesses include poor design, lack of supervision, and manufacturing or maintenance defects.

The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.

In addition, through the results of its safety initiatives, The Joint Commission Center for Transforming Healthcare has found inadequate safety culture to be a significant contributing factor to adverse outcomes. Inadequate leadership can contribute to adverse events in various ways, including but not limited to these examples:

  • Insufficient support of patient safety event reporting;
  • Lack of feedback or response to staff and others who report safety vulnerabilities;
  • Allowing intimidation of staff who report events; and
  • Refusing to consistently prioritize and implement safety recommendations.

In essence, a leader who is committed to prioritizing and making patient safety visible through every day actions is a critical part of creating a true culture of safety. Leaders must commit to creating and maintaining a culture of safety; this commitment is just as critical as the time and resources devoted to revenue and financial stability, system integration, and productivity.

Maintaining a safety culture requires leaders to consistently and visibly support and promote everyday safety measures. Culture is a product of what is done on a consistent daily basis. Hospital team members measure an organization’s commitment to culture by what leaders do, rather than what they say should be done.

Leaders can build safety cultures by readily and willingly participating with care team members in initiatives designed to develop and emulate safety culture characteristics.  Effective leaders who deliberately engage in strategies and tactics to strengthen their organization’s safety culture see safety issues as problems with organizational systems, not their employees.  They also view adverse events and close calls (“near misses”) as providing “information-rich” data for learning and systems improvement. 

Individuals within the organization respect and are wary of operational hazards, have a collective mindfulness that people and equipment will sometimes fail, defer to expertise rather than hierarchy in decision making, and develop defenses and contingency plans to cope with failures. These concepts stem from the extensive research of James Reason on the psychology of human error. Among Reason’s description of the main elements of a safety culture are:

Just culture – people are encouraged, even rewarded, for providing essential safety related information, but clear lines are drawn between human error and at-risk or reckless behaviors.

Reporting culture – people report their errors and near-misses.

Learning culture – the willingness and the competence to draw the right conclusions from safety information systems, and the will to implement major reforms when their need is indicated.

In an organization with a strong safety culture, individuals within the organization treat each other and their patients with dignity and respect. The organization is characterized by staff who are productive, engaged, learning, and collaborative.  Having care team members who gain joy and meaning through their work has been found to have an important role in establishing and maintaining a safe culture.

When team members know that their well-being is a priority, they are able to be meaningfully engaged in their work, to be more satisfied, less likely to experience burnout, and to deliver more effective and safer care.

Leaders who encourage transparency in response to reports of adverse events, close calls and unsafe conditions, and who have established processes that ensure follow-up to ensure reports are not lost or ignored (or perceived to be lost or ignored), help mitigate intimidating behaviors because transparency of action itself discourages such behavior.

On the opposite end of the spectrum, intimidating and unsettling behaviors causing emotional harm, including the use of inappropriate words and actions or inactions, has a detrimental impact on patient safety and should not occur in a safety culture. This includes terminating, punishing or failing to support a health care team member who makes an error (the “second victim”).

Unfortunately, as attention to the need for a culture of safety in hospitals has increased, “so have concomitant reports of retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies,” according to a National Association for Healthcare Quality report.

Intimidation has included overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities. Survey results released by the

Institute for Safe Medication Practices (ISMP) show that disrespectful behavior remains a problem in the health care workplace. Most respondents reported experiences with negative comments about colleagues, reluctance or refusal to answer questions or return calls, condescending language or demeaning comments, impatience with questions or hanging up the phone, and a reluctance to follow safety practices or work collaboratively.

Conclusion

Building a safety culture must be implemented using a top-down approach. In a safety culture, health care organization leaders are ultimately responsible for developing highly reliable systems. In turn, staff members are personally responsible for what is considered largely under their control, making good choices when working within these systems.

By building trust and encouraging reporting, leaders empower an organization’s most valuable resource – its people – to be always vigilant for hazards in the face of varying conditions.

  1. Joint Commission Sentinel Events
  2. Sentinel Event Alert: Issue 57   https://www.jointcommission.org/en-us/knowledge-library/newsletters/sentinel-event-alert/issue-57
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