Healthcare compliance leadership requires choosing between the “hard” of stagnation and the “hard” of growth. This post by John R. Nocero and Andrea L. Bordonaro explores how to move beyond basic regulatory tasks toward strategic Revenue Integrity and Operational Excellence. 

Regulatory compliance leadership isn’t for the faint of heart. Every day, leaders in our field face a fundamental choice that dictates the future of their organizations and their careers. It’s a choice between two distinct types of “hard.” 

One path leads to a plateau of administrative burden, while the other leads to a breakthrough in operational excellence. To move the needle on key compliance metrics, you must decide which challenges you’re willing to embrace. 

The Big Job of Regulatory Change Management 

Regulatory change rarely lives in one department. It touches:  

• Compliance  
• Revenue cycle  
• Legal 
• Clinical operations  
• IT 
• Quality 

Someone must translate regulatory language into operational tasks that those teams can execute. That translation step is where many organizations struggle. Well, guess what? You’re the translation step. 

Someone must translate regulatory language into operational tasks that those teams can execute. That translation step is where many organizations struggle. Well, guess what? You’re the translation step. 

Pick the Hard Work and Then Do It 

The compliance professional’s goal is to move metrics. Period. Whether it’s an outcome of no findings during a state inspection, ensuring everyone is signed off on education and training modules, or the weekly operational numbers posted for the entire organization to see, it’s your responsibility You know the work needs to happen. The challenge is getting the organization aligned around it. And that’s hard. 

Your organization’s leaders trust you to handle it, and they probably see you as capable of doing more. This visibility is an advantage, especially if you want to move up in the organization. But be aware, because corporate and everyone else is watching, looking for cracks in the armor or making you out as the target.  

Our advice? Choose your hard. Here’s how.  

Choose Your Hard: Two Options  

We all want an easier professional life. Less stress from daily meetings. More happiness from the validation of receiving praise from a job well done. Fewer complications from multiple people coming to your door every day to solve problems that aren’t yours.  

Here’s the truth nobody likes to admit: There’s no easy path. There’s only a choice between hard options. So, choose wisely.  

As we see it, you have two options: 

Option 1: Keep Doing What You’re Doing: The Administrative Burden of Stagnation 

This isn’t difficult. You’re basically choosing to do the same things you’ve been doing in the same manner. Keep leading the daily morning compliance meeting in the same style. Keep walking through the units waving and shimmying around but not really being authoritative or looking for issues. Talking to employees but not finding anything out, just basically wasting time. 

And please, avoid the hard conversations around people constantly interrupting you with their problems instead of doing what you get paid to do.  

This is hard, but not for the reason you think. This is hard because, well, we know you, you’re busy, but not productive. You are seen, but you aren’t really doing anything. You think you’re managing, but you’re really just walking around. 

You Get Credit for Moving the Needle, Not for Inertia 

You also think you should be promoted and moved up for doing what you’re supposed to do.  

Here’s the hard truth. You don’t get credit for the things you’re supposed to do. If you’re supposed to lead orientation, write policies, make presentations, all that is in your job description. It’s a basic function of your job. You’re not getting additional credit for that. You get credit for moving the needle, not stagnation.  

This version will feel easy in the moment. But over time, it becomes a cycle. Anxiety creeps in. Stress builds quietly. Communication gets messy. You start telling yourself little lies to stay comfortable. You get moments of happiness, but they don’t last because they’re built on escape, not stability. 

When a compliance department functions as a separate silo rather than a strategic partner, the friction is constant. You’re working hard, but you are not working toward a breakthrough. You are merely surviving the administrative weight of healthcare regulations. 

Option 2: Face Challenges Head-on: The Discipline of Operationalizing Compliance 

The alternative is the “hard” of growth. This involves the difficult work of Revenue Cycle Management (RCM) integration, fostering cross-functional alignment, and ensuring that compliance is viewed as a driver of healthcare quality and patient safety. 

It takes discipline to move beyond the checklist and into this strategy. It’s “hard” because it requires changing the culture of an organization, but it’s the only path that leads to: 

• Sustainable Revenue Integrity: Moving from reactive auditing to proactive prevention.
• Enhanced Patient Safety: Aligning regulatory requirements with frontline clinical care. 
• Professional Authority: Establishing compliance as a core pillar of the leadership team. 

Cut the noise. Reduce the dopamine overload. Sit with discomfort instead of running from it. Say the hard things. Build better habits. Run different meetings. If your boss is giving you a directive that you have to go and talk to the director of nursing and get his or her staff to carry out a particular order, don’t walk up to them and go “Hey, boss, wants you to do this” and tell them exactly the same order that was told to you. That’s not changing. That’s parroting.  

You need to do that a bit differently, such as “boss wants your team to do XYZ. Do you know how to do this? Does your team know how to do this? What are the gaps? What can I do for you right now?” 

The Hard Path Is Uncomfortable but Pays Off Over Time 

See the difference? It’s subtle, but effective. Basketball fans can think of it as the difference between telling your basketball team to run the triangle offense and perfecting the triple-post with all your front court repeatedly until it’s second nature, creating multiple scoring options based on defensive reactions. When you repeatedly do the hard thing, it pays off over the long term. 

This hard path is uncomfortable, and at first, it feels worse, not better. It’s hard to sit in the discomfort. But over time, something starts to change. Your brain slows down. Your emotions stabilize. You stop needing constant stimulation just to feel okay.  

And one day somewhere down the line, you realize: You’re not chasing happiness anymore or trying to be the part. You don’t need to wear a three-piece suit to the corporate board meeting. You can wear a Roman Reigns OTC crewneck. You don’t have to pretend to be the part. You are the part. And you are just experiencing it. 

Choosing the Tough Option Compounds the Benefits 

The tricky part about Option 2 is that it doesn’t feel like it’s working at first. That’s where most people quit. Option 2 is harder. But it compounds. It’s the difference between escaping your life and actually building one you don’t need to escape from.  

Be a long gamer because taking the “easy” path now often becomes the hardest life later. And the hard path now? That’s the one that sets you free. 

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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The post The Compliance Leadership Paradox: Why You Must Choose Your Hard  first appeared on YouCompli.

It amazes us how many healthcare facilities don’t always store records appropriately. Check that. People don’t store records properly.  

Just this week, I was in a colleague’s office. Literally, it looked like Staples puked up aisle 3. I asked her what everything was, because you couldn’t make heads or tails of any of it. She explained that it was patient records that she didn’t know what to do with.  

I asked her, “Well, what does the process say to do?”  

“Process?” she said. Nice girl, means well, greener than a pepper tree.  

After helping her re-organize everything, I was motivated to put together some ideas to help others in her situation. Here are some record retention best practices in the event you have hoarded up some claptrap and now have to figure out what to do with it.  

What Records Do You Have? Archival or Data? 

First step, take an assessment of everything you have. Samples? Materials? Records?  

Archival storage should be for all original records, including source data and metadata, which are generated, recorded, calculated or transcribed at the time of an activity. This data allows full and complete reconstruction and evaluation of the activity.  

Data storage may be written, printed electronically, scanned image, photographic, or other form for later reference. Raw data obtained from measurement, testing, processing, direct observation or computer, and instrument printouts should be represented exactly as captured at its source without transformation, aggregation or calculation.  

Responsible Parties and Retention Periods 

All personnel should be responsible for handling, submitting or returning records to the archive in the same conditions in which they were found.  

Keep in mind that different items are governed by different regulations, so you need to check retention periods. The retention period begins when all work with samples or records is complete. Specified retention periods supersede any other retention requirements unless explicitly noted. 

Factors Influencing Retention Period Requirements 

• State and federal laws: State laws are the primary source for retention periods, which can range from three to over ten years. Federal laws, like those from CMS for Medicare, may also have specific requirements.  
• Patient age: Records for minors often require longer retention periods, usually extending past the age of majority.  
• Type of record: Different types of records can have different retention requirements. For instance, some states require longer retention for certain records like mammography images.  
• Legal and regulatory changes: Laws and regulations can change, so it’s important to stay updated on current requirements. 

Scope of Work in Healthcare Records Retention Process 

Generally, quality or project management takes the lead on records retention. The scope of work involves: 

• Archiving, filing, retaining, organizing and retrieving records 
• Maintaining security and integrity of records in archives if stored on-site 
• Collecting and cataloging records, including: 
• Assigning archival numbers 
• Preparing archive labels, updates to archival forms 
• Making copies of any supporting electronic data  
• Handling off-site storage as applicable.  

On-Site and Off-Site Record Storage Locations 

For healthcare records, you have two storage choices: on-site or off-site.  

If you store records on-site, storage must be access-controlled, and all records must be stored appropriately to ensure integrity and preservation, minimize deterioration and facilitate timely retrieval. All original paper records should be stored in secure, fireproof filing cabinets or appropriate containers, like folders, binders, weather-proof envelopes, cases or boxes. 

If you decide to store records off-site, make sure to use a qualified contractor specializing in off-site medical records storage. Quality should be involved in sending records off-site. All records should be assigned a unique number or other appropriate identifiers which your site must maintain.  

Records should be sent off-site appropriately grouped by record type. This is important because at some point, you might need to retrieve them. And you generally don’t have much notice to retrieve something. It’s generally an immediate need or within 24-48 hours, so if you don’t know where the records are or how they are organized, you won’t be able to produce them as you need to. That’s a problem.  

General Guidelines to Reduce Risk in Records Retention 

Healthcare record retention is governed by federal and state laws, requiring that records be kept for a specific period for patient access, legal protection, and compliance.  

Your organization should operate under the basic requirements for retaining records unless otherwise specified. Use these general guidelines to ensure your processes are set up for retention compliance: 

• Without a specified retention period, a minimum period of 10 years should be used.  
• Once the defined retention period is reached, samples and records may continue to be maintained, returned, transferred to the appropriate owner, or destroyed.  
• Do not destroy anything without appropriate approval from the functional owner.  
• Record destruction must be appropriately documented to denote the end of the life cycle. 

What’s Your Next Step? 

When you have these processes and practices in place, records retention will be a lot more efficient and a lot less stressful.  

Want more ideas for optimizing compliance and quality? You’ll find guidance in these popular articles. 

• Four Ways to Integrate Compliance with Safety/Quality Efforts 
• Best Practices for Better Training in Healthcare Compliance
• Integrate Self-Awareness into Healthcare Compliance Programs: 18 Tips  

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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Sign-up for our Weekly Newsletter

Schedule a quick overview

The post Hoarders Need Borders: Quality’s Role in Healthcare Record Storage  first appeared on YouCompli.

In this blog, learn how to go on offense following a regulatory compliance audit or inspection, so you’re well-prepared for the next one. Using sports training analogies, the authors present a better way to handle ongoing inspections and audits in healthcare systems.  

If you play us in basketball, we’re going to run the fast-break transition offense at you, and we will tell you right now; you don’t want to play us two on two. We know our biggest strength – namely that conditioning kills. Savage speed plus unlimited endurance equals an unstoppable force.  

The fast-break transition offense we use is inspired by the 1990 UNLV Running Rebels basketball team. This high-tempo strategy aims to score before the defense can get set. It involves pushing the ball down the court immediately after gaining possession and creating scoring opportunities through numerical advantages and defensive mismatches.  

You can apply the same strategies when managing audits and inspections.  

What Drives Healthcare Audits and Inspections? 

Audits and inspections are regular occurrences in healthcare systems. A number of factors influence how often and what kind. 

• Internal vs. External: Healthcare organizations conduct their own internal audits monthly, quarterly or annually. 
• Regulatory Bodies: Government agencies conduct their own audits, with the number depending on things like budget and staff. 
• Risk and Regulation: Frequency may increase if issues are discovered or when major changes are made to regulations. 
• Organization Size: Larger organizations often have more complex auditing needs, potentially driving more frequent audits. 
• Staff Turnover: High turnover can trigger more frequent audits to ensure consistency. 

What’s Your Playbook for Regulatory Inspections and Audits? 

Most healthcare systems have good reason to believe that a regulatory inspection, sponsor audit or other scrutiny could appear at any time, announced or unannounced. It’s accepted that the standard technique for managing these visits is ongoing vigilance.  

At her presentation on “How to Be Your Own Internal Monitor: A Guide to Monitoring Your Own Studies” at the ACRP 2025 conference, Ann-Marie Jacobson, CCRP, Senior Research Affairs Specialist at Tufts University School of Dental Medicine, said “Because of the unknowns about inspections and audits of in-progress or completed clinical trials, it is important to make sure that all study materials are always kept accurate, current, and explanative of the study activities to date.”

“You always need to be asking yourself, if the Food and Drug Administration (FDA), sponsor, or IRB came in right now and selected a current or recently closed study for examination, would everything be ready?”  

She explained that at her institution, study coordinators “regularly conduct audits of regulatory binders, subject folders, case report forms (CRFs), payment logs, and enrollment/screening logs. These are coordinators who are separate from the clinical team, to ensure that fresh perspectives are always present.” 

We don’t disagree with her, but we wouldn’t call that a fresh approach. Rather, we think that ongoing vigilance should be the standard in healthcare compliance, like a basketball team needs the fundamentals of solid shooting, dribbling and passing.  

Changing Audit Landscape Requires a New Game Plan 

The current healthcare audit landscape is shifting and shifting quickly. Back in late 2024 and even earlier this year, federal and state auditors would arrive and investigate one complaint at a time. They’d come in specifically for one reason or to investigate a particular incident, talk with a couple of staff members, and then summarize their findings and leave.  

Now, we’re hearing differently. Just this week at one of our collegial facilities, an investigator came in to investigate about 10 complaints in various areas, from documentation, to patient care and the like.  

To diligently investigate complaints of this type and volume, the auditor or inspector is probably going to be there on-site for a week or more. They will gobble up valuable conference room space, staff time and basically throw your whole operation into a tizzy due to the heightened emotional state.  

What’s your game plan for audit readiness now? 

Fast Break Offense for Compliance Audit Readiness 

How do you combat this? Well, if you use the key principles of a fast break offense, you will be prepared and conditioned. We’ve adapted these three techniques to the compliance game, to make champions of your team. 

1 – Push the Pace 

In basketball, coaches encourage players to maintain a fast pace and recognize when to initiate the first trigger. In an audit, this means anticipating what the auditor is going to ask and getting ahead of it before they bring it up.  

Pre-audit prep meetings and ongoing reviews of your events make this work, but you can’t just do a pre-audit meeting when an inspection is scheduled. You need to regularly schedule pre-audit meetings, so you’re always prepared.  

I know most organizations don’t do this. But we do. Which is why we have covered things so thoroughly that we can go quickly and get the auditor what they need and then move on to the next question.  

2 – Strength in Numbers 

In sports, we recognize numerical advantages, such as 2-on-1’s, 3-on-2’s or 4-on-3’s and then capitalize on these circumstances through drive-and-kick sequences. Drive the ball to the basket and when the defense collapses on the person with the ball, you kick the ball out to an open teammate to hit a jump shot.  

Within audits, scoring means answering auditors’ questions with the best players you have. You create a numerical advantage by bringing in multiple people to meet with the auditor at the same time and kicking facts around like you would move the ball to score.  

3 – Continuously Practice Good Habits Across the Team 

Lastly, you need elite conditioning habits in sports and in compliance. To run the fast break effectively, you can’t get tired. Imagine unleashing an endless barrage of offense and staying so diligent to this effort that teams know it’s coming and still can’t stop it.  

The team with the most dialed-in offense is usually the most capable, but you need to have players who can react “lag-free” or win their first three steps to capitalize on numerical advantage. The only way to get good at this is to continually work on it.  

Quality and compliance preach continuous improvement, but how often do you do make the effort? How often do you stay late at work, just because? How often do you run more meetings or make everything tighter?  

Chances are zero times, but I will tell you right now that we do. So, if you get into an audit with me, by Day 4, I am still working with a full gas tank, but the auditor isn’t because they went home and “Netflixed“ while I slept. Get your whole team committed to elite habits, and you are unstoppable.  

Prepare Your Compliance Program for the Win 

By reinforcing these principles and working on conditioning and decision making, teams can create more scoring opportunities. And just as a prepared team can force the defense into difficult situations, a well-prepared compliance team can “force” the auditor into zero-findings and more quality inspections.  

Download a PDF Version of the Tip Sheet

Create Compliance Scoring Opportunities 

If you’re interested in more ideas for building a strong compliance program, read these resources next. A strong compliance culture is the foundation of a strong program. 

10 Tips for Building a Compliance Culture in Healthcare 

Earning recognition as a value creator and establishing a healthy culture can be challenging. Yet as these 10 tips show, you can successfully shape culture to help the larger organization better manage and control risk. 

Healthcare Compliance Culture Means Doing the Right Thing at All Levels 

A culture of compliance isn’t just a platitude. It really does exist. Those organizations with a strong culture of compliance and an effective compliance program are the ones with engaged clinical and operational leaders. 

A Culture of Compliance Through Proactive Decision-making 

A culture of compliance is critical to effective regulatory change management. Find three steps to help your leaders make decisions more proactively.   

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

---

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Schedule a quick overview

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27 Ungated Resources for Compliance Leaders and Teams 

Compliance professionals sometimes feel undervalued in comparison to other functions in their organization. They think leaders and colleagues don’t really understand what they do.  

These resources will help. Packed with ideas, tips and recommendations, these pieces were written by professionals with many years of compliance experience. 

You can quickly skim for articles that relate to your needs and interests. Bookmark this page as a reference for future questions or projects.

Visit Now

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The post With Compliance Audits, The Best Defense is a Good Offense  first appeared on YouCompli.

You Can’t Manage What You Can’t See 

I get into the hospital about 5am every day. I go to intake and get the daily census sheet and report it out to the providers. I walk upstairs and I get my census sheets for all four units. I call in a fourth provider if needed. I review my e-mails.  

But at 7:30 am every day, I round. No exceptions. Weekday. Weekends. Holidays when I am supposed to be off. Doesn’t matter. I round. It has to be done, because I can’t manage what I can’t see.  

You Need to Manage Healthcare Risk 

So many times, compliance administrators and quality leaders sit in their office and manage through e-mail. Say they are too busy. Too many things to do. Yeah, too many meetings. But the truth is, you need to manage risk. 

Risk comes in many forms . Financial. Patient-related. But the biggest unforeseen risk to me is reputational. If you don’t have a reputation for offering the best patient care while keeping people safe and patients receiving benefits from treatment, you won’t be successful. You won’t make money. You won’t care for patients. You need to see it. Firsthand.  

You can’t manage what you can’t see. Here’s how I round.  

What We Look for During Compliance Rounding 

I walk onto the units through the front entrance and immediately talk to the charge nurse.  

• Do you have enough staff?  
• Is everyone listening to you?  
• How is your census?  
• Do you have any events to report?  
• What is the “temperature” of the unit?  

I then walk down the hall and look in everyone’s room. Are the doors locked? Any ligature risks? Any contraband – things like cups, extra linens, things that someone could harm themselves with? You can’t manage what you can’t see. I walk into each room and just look.  

• What is its condition?  
• Are there any screws loose?  
• What does the milieu look like? Is it calm?  
• Are patients interacting with each other?  
• Are they respectful?  

Then up to all the techs. Same questions, plus ones like these: 

• Have patients gotten showers?  
• Are you tired? Do you need to break?  
• What do observations look like? Are they up to date?  

I then walk through the nurse’s station to the sister units and do the same thing. Same questions. Then downstairs to the other two units. Same thing. Same questions.  

You can’t manage what you can’t see. It takes about 45 minutes total, and it’s the most important part of the day. We have cameras, and I could look at the cameras and do this. But so much would be missed. You need to get onto the units. Why? Because you can’t manage what you can’t see.  

Why In-Person Observation Is Valuable Compliance Practice 

There are three main reasons why I do rounding and in-person observation:  

1. Presence: I have to have a presence on the units. Staff need to see me and see me holding them accountable. They know I’m going to come by every day. Same time. They need to be ready. No questions. No excuses. Plus, it shows I care. I do care about every member of the staff. I want them to get used to seeing me on the floor. Pull me aside. Tell me things. That’s important.  
2. Safety: No one should feel unsafe here, so I’m always looking around for contraband or things that patients can use to harm themselves. Cups and linens as I said but there are things that sometimes make it up to the units. Like shoelaces for example. Now, you take it for granted. Loop, swoop, pull and tie your shoes. A self-harming patient can see that as something more. I look at the environment, too. A loose light or a loose screw can be thrown or even swallowed. You need to stay on top of it. If I see something, I tell my Plant Operations Director and put in a work order to have it fixed immediately.  
3. You can’t manage what you can’t see: This is the most important reason and the one I keep bolding. The only way to know what is going on is to be present. Management by walking around is a thing. When I changed a process a couple months ago, the staff was outraged. We can’t do this, that or the other. Then I walked the units. People on phones. Laughing. Looking calm. You ain’t stressed. That changed fast. Funny how that happened.  

Get Real-Time View of What’s Happening in Your Organization 

Only by being present can you get a real-time view of what’s done, what’s stuck and what is slipping through the cracks. Visibility is power. And I finished this round at 7:28. Two minutes to get upstairs, where they’re also expecting me.  

More Resources About Compliance and Risk 

Ready, Set, Go! Identifying Emerging Risks in Your Annual Compliance Workplan 

Before moving on from this year, it’s important to take time and get feedback from business partners to ensure an “outside-in” perspective is included in your 2026 plan. Compliance expert Jenny O’Brien, JD, MCHDS, CHC shares proven practices.  

The Why, What, Who, and When of Healthcare Risk Assessments   

Sharon Parsley, JD, MBA, CHC, CHRC discusses risk assessment from a “why, what who, and when” perspective. She also looks at ways that you, as an effective compliance officer, can lead this process with your colleagues. 

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

---

The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

---

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Schedule a quick overview

The post Risk Visibility Isn’t Optional in Healthcare Compliance  first appeared on YouCompli.

In every organization there is a moment where the quality department becomes either the trusted operational partner or the operational roadblock. The difference tween the two comes from how you communicate, assign responsibility and how you follow through. This blog explains how to adopt the OG style for more effective quality programs in healthcare. 

Comparing Two Styles of Quality Performance 

There are two guys – let’s call them Young Buck and OG. The Young Buck is probably 30, limitless energy, the one-man wrecking machine. You know that guy. Full of passion or some other nonsense. All gas and no brakes. Runs through the facility on a crusade to save the world. All alone. Takes on all the tasks but somehow, really accomplishes nothing except annoying everyone else on the team with his constant question of “Need anything?” 

OG is a bit different. Older. Works like he is 30 with the wisdom that comes from being 20 years older. Shaved head, salt-and-pepper beard. Dresses as he wants because he has the street cred and knowledge to back it up, so no one cares. Works as an individual contributor but has a connection to everyone on the leadership team. Can tell you about all their strengths. Kills every audit, understands the entire operation. Has paid his dues, knows who he is and does not chase anyone’s validation except his own. 

Operational Partner or Quality Roadblock? 

The OG knows a thing or two about operational improvements that matter. He goes beyond simple efficiency improvements such as how units are staffed or cost-cutting initiatives like slashing overtime because the team is over hours.  

The OG embraces the philosophy that all aspects of the organization work harmoniously to deliver maximum value to customers, while minimizing waste and variation in processes (Six Sigma, 2025). It’s simple execution like this, isn’t it?  

• The organization develops systems that promote problem-solving at all levels. 
• Best practices are the norm not the exception  
• Cultivate culture where improvement is habitual, not exceptional.  
• Discipline and consistency are staples that override passion and enthusiasm. 

The operational roadblock is not always the guy who says no, at least not in this scenario. What we are describing is far too common. This roadblock doesn’t know what he doesn’t know and is too focused on short-term results (his own) than on long-term gains (the team’s). He’s in favor of acting but instead of evolving his processes thoughtfully, he wants to make significant changes to the way an organization operates. What this does is create bottlenecks, upset the status quo and build employee resistance. 

OG or bottleneck? Take your choice:  

• Long-term investment or short-term expense?  
• Streamlined processes or maximized rework? 
• Improved quality control or weakened inventory management?  

Us, too. The difference is how you communicate, how you assign responsibility and how you follow through. 

Three Ways to Partner like a Pro 

Want to be more like the OG? Here are some tips for more effective quality operations: 

1 – Communication: Be clear. Be direct. Know what you want to say before you actually say it. Think it out and then say it. Don’t be monologuing at people like Carson on The Tonight Show. You don’t need people to necessarily like you. It helps but it helps more if they respect you. The only way to get that is to tell them what needs to be said, say it and then follow up when needed. 

2 – Responsibility: Assign tasks to people for things they can be responsible for and actually succeed in. Read that again. It is selected delegation. Holding people responsible for things that they cannot perform is a recipe for disaster. In cliched terms, hold your people accountable. 

3 – Follow Through: So simple it only takes one sentence. Do what you say you are going to do, how you said you’d do it, when you said, over and over again. Period. That’s it. All you need to do. 

OG Your Way to Effective Quality and Compliance 

You don’t need to “young buck” your way through quality and compliance. The only way to be the OG is to become respected, highly regarded, skilled and authentic in what you do. Your team and organization will thank you. 

Ready to Learn More? 

We’ve got more resources on quality and compliance in healthcare. Have a look at these three selections: 

White Paper: How Compliance Drives Healthcare Quality and Safety 

Effective compliance management directly supports quality care, operational efficiency, and financial stability. Read the white paper for practical ways to leverage compliance as a strategic asset, transforming regulatory obligations into opportunities for excellence in patient care and organizational success. 

Blog: Four Ways to Integrate Compliance with Safety/Quality Efforts 

How can your compliance program answer the OIG’s call and include patient safety and quality in your oversight efforts? This blog explores four practices to integrate safety/quality concerns into compliance practices. 

Blog: Building a Quality Education Program That’s Good Enough 

It’s essential that you build a quality education program that works. Doing that right means covering the basics well, not adding fancy bells and whistles. This blog explains what will lead to training sustainability for you and the organization.   

Download Tip Sheet Below

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

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Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

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• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA

The post Healthcare Quality Leadership: How to Be an Operational Partner, Not a Roadblock first appeared on YouCompli.

In this blog, experts offer the real scoop on audit readiness in healthcare. Learn the unfiltered truth about compliance audits and what audit etiquette means. Get essential tips on preparing for audits, the role of healthcare compliance auditors, and what to do (and what not do) during an audit.  

What Does Audit Readiness Mean? 

Let’s say a regulator shows up at your door tomorrow. What’s the first thing your team scrambles to find? Is it evidence of task completion? Maybe a list of applicable regs? Updated policies? How about proof of communication to stakeholders? We saw a post this week asking for a current audit preparedness playbook because so many organizations think they’re ready, until they aren’t. 

Raw Truth about Compliance Audits 

Here’s the raw, unfiltered truth; no organization is ever ready for an external auditor or inspector. Ever. If you were, no one would panic when the FDA shows up at the door unannounced, or the state shows up in your lobby. “The state showed up the other day, and I knew why they were coming so I wasn’t unprepared.”  

The truth is you do your best, and you also expect the worst because they’re an auditor or inspector. Duh. It’s what they do.  

It’s like when you hear a funny rattle in your car. You take it to the mechanic. You know he’s gonna find SOMETHING. That’s his job. If you didn’t hear the rattle, you wouldn’t have taken it to him. You’re just hoping it is a minor repair rather than a total overhaul. Same with your audit, your auditor, and the rattle in your compliance practices. 

What to Know About the Healthcare Compliance Auditor 

Auditing is a formal, independent way to investigate regulatory compliance of a system or process within an organization. In accordance with regulations or industry best practices, an auditor assesses the adherence, adequacy and absence of certain processes.  

What a Healthcare Compliance Auditor Does 

• Identifies errors, omissions and irregularities.  
• Investigates the intent of possible wrongdoings. 
• Provides information regarding auditing procedures.  
• Submits reports to investigating authorities. 

Okay, A Compliance Audit Is Scheduled – What to Do? 

Once you know an audit is coming, use these five steps to prepare your organization. 

1. Make sure you can have as many of your team members available for the audit as possible, in case the auditor wants to schedule interviews with them.  
2. Provide a few date options for the auditor to choose from. A regulatory body like CAP, CLIA or FDA does not have to give warning of an audit and can arrive unannounced, but most audits are not unannounced. You have time to prep. Use it.  
3. Ask for an audit agenda as soon as you can. Review it.  
4. Alert the team that an audit will occur. This allows time to prepare any project-specific documents that may not be complete.  
5. About a week out from the audit, do a facility walkthrough to make sure there is nothing out of place. Do it two days out and then the day before. Yes, this much. You have people in your office. They move things.  

Once you have these steps under control, preparation becomes a case of do’s and don’ts. In other words, audit etiquette. 

What Is Audit Etiquette? Best Practices for Compliance Behavior 

Audit etiquette covers all the best practices required to facilitate smooth external audits. These vary slightly based on the health system’s existing compliance processes and experience facilitating them.  

In most cases though, following these techniques for what to do and what to avoid will drive positive, less stressful outcomes.  

What to Do in a Compliance Audit 

• Do listen to an auditor’s question and think before responding.  
• Do answer only the question that is asked. Stop talking.  
• Do ask for clarification if you don’t understand the question.  
• Do answer only those questions relative to your job.  
• Do be honest and pleasant. 
• Do treat the auditor with respect and courtesy at all times.  
• Do dress in business casual attire. 
• Do prepare to talk to the auditor and anticipate questions. 
• Do have quality obtain copies of taped conversations. 
• Do provide well-ordered, clear documents. 
• Do understand your policies and procedures. 
• Do keep computers locked when away. 
• Do close security-controlled doors. 
• Do keep paperwork organized and out of sight when possible. 
• Do escort the auditor at all times while on the premises. 

What Not to Do in a Compliance Audit 

Don’t guess. Say you don’t know or that you need to consult an SOP or defer to someone who is more suitable to answer the question. If you want to consult an SOP, describe the procedure in general terms with the auditor and then walk them through the details. Just saying “I have to consult my SOP” gives the impression that you aren’t trained. 

Here are other things NOT to do in an audit:  

• Don’t try to answer for someone else. 
• Don’t answer for another department or specialty. 
• Don’t offer additional information. Again, stop talking.  
• Don’t elaborate – answer only what is asked. 
• Don’t use hedge words (examples: I think, usually, normally). 
• Don’t guess when asked a question. 
• Don’t sign anything without legal approval.  
• Don’t argue with the auditor or inspection. Clarify anything the auditor misunderstood.  
• Don’t be rude or disrespectful to the auditor. 
• Don’t huddle. 
• Don’t panic. 
• Don’t lie. 

Practice Compliance Audit Etiquette with Confidence 

Regulatory bodies will give a report prior to leaving the audit. Ensure you engage with the necessary teams to give sufficient responses and have a plan for any noted observations. The observations and responses in a report will generally be the first items looked at in the next audit. Make sure you stay on top of these action plans and complete the items you have committed to. 

Also remember that auditors may be experts or novices based on the type and scope of the audit being performed. Do not assume you are the smartest person in the room when communicating with an auditor. Understand that the inherent authority of the auditor is dictated by the interested party they are advising. Their ability to influence a decision (that may have a significant impact on your organization) is the foundation of a desired outcome for you. That’s one reason why we recommend practicing good audit etiquette. 

More Resources about Compliance and Audit Readiness 

• Three Strategies to Align Compliance with Revenue Cycle 
• Audit Expectations and Challenges 
• Healthcare Audit? Stay Ready. Don’t Get Ready. 
• How to Use TPE Plans for Compliance Auditing and Monitoring 

John R. Nocero, Ph.D., and Andrea L. Bordonaro, MAT, blog on LinkedIn as “The Q-Kids,” discussing everything related to clinical research education, inspiration, and professional connection. 

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

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The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

---

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The post Audit Readiness? How about Audit Etiquette?  first appeared on YouCompli.

With its emphasis on risk management, compliance training is pivotal in protecting both employees and organizations from legal and ethical pitfalls. By having a good understanding of compliance, employees help safeguard the company against lawsuits and reputational damage.  

In this practical blog, two experts – one in education and one in compliance – offer advice and analogies to improve your compliance education practices.   

Compliance orientation educates new staff members about company policies, procedures, and various regulations that govern their specific roles. Ongoing compliance training ensures that as regulations evolve, all employees are appropriately educated on implications and requirements. Read on to learn what it takes to consistently hit the mark with all your compliance education.  

Make Employees Fit to Perform with Training and Orientation 

Training and orientation requirements are very much like starting an exercise program. All too often, people want to try the double-split; train twice a day; and eat nothing but cucumbers, fish and broccoli for months on end, when you haven’t worked out since high school. Yo, since high school, bro – and you want to jump into the bodybuilding lifestyle like it’s the deep end of the pool? 

The most important thing really is to not think too hard on any of it because the basic point remains the same: Eat a lot of healthy food and train everything really hard. Eat more and do recovery stuff if you are under-recovering and eat less if you are getting fluffier than you would like. Then do it for years and years and years. 

What Compliance Training and Physical Training Have in Common 

A full employee training program should promote a comprehensive understanding of regulatory compliance and safety, along with continuing education and professional development. Then do it for years and years and years – just like physical training.  

Initial training is the introduction to an employee’s duties, with some sort of competency assessment, if needed. Ongoing courses are typically basic information that employees must complete to finish any job-related training. 

Why Do Orientation Programs Fail? Isn’t it Obvious?  

We’ve explained why training and education for new employees are similar to phys ed programs. So, much like your exercise program, why doesn’t your compliance orientation strategy always work? There are multiple reasons why programs fail. Do any of these sound similar? 

1. Too Much, Too Fast 

Your orientation plan gets done because you have to do one. As we’ve talked about before, these sessions are often “death by PowerPoint” and didactic lectures, and newcomers have no idea what’s going on. There’s so much information being thrown at them rather than interacting that after several days in a classroom, new employees feel like they’re drinking from a fire hose instead of being onboarded appropriately.  

2. Where’s My Stuff? 

We shouldn’t have to say this reason, but it’s true. Sometimes the employee doesn’t even have a defined workspace or workstation when they arrive. Once, when we got to work, the laptop we were supposed to have was still in use by the person we were replacing. We were like, well, how am I supposed to learn then if they’re still working on the computer that I’m going to use? HR was like, just watch them over their shoulder and do that they do.  

All of that left us feeling extremely disillusioned. If you didn’t even plan for us to be there, not to mention, if you can’t provide the basic work equipment, we’ll spend more time trying to find it than actually being productive.  

3. Poor Coordination 

Lastly, a lot of great ideas exist only on paper but are never fully implemented effectively on the ground. For example, you want all the leadership team to present during orientation, but you didn’t really check everyone’s schedule for orientation week.  

Now you have a huge gap in the day when the Director of Healthcare Informatics is supposed to teach, but they’re meeting with the VP of Corporate Compliance regarding consenting best practices. You didn’t know that because you didn’t check, and now you have a lull in the agenda, or you scramble to have other presenters move up, giving them very little time in their work schedule to be ready to present.  

Don’t do this. It’s a knee-jerk reaction that makes you look horribly disorganized, to the point where the employee says, “Why do I want to work here again?” 

What to Do Instead for Strong Compliance Training: Three Tips 

1. Concretely define responsibilities.  

In other words, who is doing what. These duties have to be set in stone. For example, the hiring manager will be responsible for ensuring appropriate training and competency assessments of staff; ensuring all essential staff are trained on appropriate Standard Operating Procedures (SOPs) before performing any work; providing notifications to appropriate departments that a new employee is starting; creating and maintaining job descriptions and ensuring all direct reports are current on all training requirements. We’ve actually seen some hiring managers become responsible for identifying and conducting appropriate competency testing for their employees.  

Yes, you need to get this specific. Otherwise, this won’t work.  

2. Have the organization prepared for their arrival. 

We can’t stress this one enough. For example, before a new employee starts, HR should work with all relevant departments to make sure they’re set up on all applicable electronic systems, such as an Outlook e-mail set up. IT or a reasonable designee needs to be responsible for ensuring the computer set-up is completed; an ID badge is already created, and all applicable accounts are accessible and ready before the employee starts.  

It’s a little thing but it goes a long way.  

3. Make sure the training program is ready. 

Ensure all required training is sent to applicable systems for the new employee, so they don’t have to fumble around for it. Ensure all your presenters are ready, and the orientation schedule is adhered to. If it can’t be for whatever reason, think of additional training tasks you can add, such as a facility tour, Q&A with new employees, department-specific training, or shadowing opportunities.  

This keeps new employees eager to learn, while your experienced employees are still involved in onboarding.  

Don’t Take Shortcuts with Compliance Education

Many people take shortcuts with their exercise programs such as doing half-reps or taking fancy, expensive fat burners. Don’t do the same with your compliance training program, such as giving a few presentations and having them sign off on some SOPs and then tossing them into the fire of a busy shift.  

During the first week of employment, your job is to build comfort and confidence within your employees so they can perform the job. Always remember that some things can be covered in a manual, but it takes time on the floors or at your desk for new employees to pick up the ins and outs.  

Develop the Muscle of Knowledge: Optimize Compliance Training 

By actively committing to effective compliance training, health systems mitigate risks and protect their reputation while empowering employees to uphold the highest standards of conduct.  

Reach out for ideas on how to standardize, track and measure compliance education for your organization.  

And in the meantime, if you’d like to learn a little more on your own, we recommend these resources: 

• Building a Quality Education Program That’s Good Enough 

• Best Practices for Better Training in Healthcare Compliance 

• Best Practices for Documenting Compliance Training in Healthcare 

• Five Strategies for Aligning Human Behavior With Your Compliance Program 

John R. Nocero, Ph.D., and Andrea L. Bordonaro, MAT, blog on LinkedIn as “The Q-Kids,” discussing everything related to clinical research education, inspiration, and professional connection. 

Andrea has taught first grade in Willoughby, Ohio for 27 years in the same classroom that she attended school as a child. She earned a Bachelor of Science in elementary education with a minor in language arts from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

John builds and fixes quality departments, while currently thriving as the Administrator & Director of Quality, Risk Management and Compliance at River Vista, a behavioral hospital in Columbus, Ohio.

---

The Q-Kids – John R Nocero and Andrea L Bordonaro – are experts at everything quality, regulatory, education training and compliance and love sharing their knowledge on YouCompli.

Follow them on LinkedIn – for more quality content or send them a message – they’d love to hear from you.

---

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Schedule a quick overview

• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA

The post Three Tips for Strong Compliance Education Practices  first appeared on YouCompli.

This blog explains how to make healthcare quality education programs more effective through focused efforts. It’s about quality, not quantity. Focus on the fundamentals: establish clear policies, learn from past inspections, and create education programs that meet both regulatory requirements and employee development needs. 

As the authors dive into how compliance can enhance quality initiatives through education, they also explain why training need not be complicated. The blog makes its point with a fascinating tale of the value of knowing exactly where to focus your “chalk mark,” if you will. 

Make Your (Chalk) Mark — Why You Need to QC Your QA 

Sometimes people want to make their quality practices so hard. No, it’s true.  

Before you even implement your program, you study the Seven Elements, your competitors, your competitor’s competitors, and so forth, when really, it’s easier to implement and course correct. It’s overkill. 

No wonder people have no real idea what quality is. Every week when we present during new employee orientations, I always ask, what is quality? The most common answer is, doing it right. According to what? The requirements. Which requirements? There are many. Well, all of them? No. 

Yes, quality is hard. 

Measuring Your Quality Programs Too Much? 

You also make measuring your quality program so hard. Tracking is ongoing, anticipatory and retrospective to identify how organizations are performing, including where and why facility performance is at risk or failed to meet standards.  

You attempt to quantify your quality program by: 

• Collecting and analyzing data 
• Measuring processes and systems for effectiveness and efficiency 
• Identifying undesirable patterns or trends 
• Making changes that improve performance and safety 
• Reducing risk of safety events and demonstration of best practices 

What about this level of preparation? Also no. It’s overkill. 

Overloading Quality Training 

Hear us out – we’re not saying the above is wrong, but it’s way too much right now. It’s like giving someone vanilla ice cream, savory peanut butter topping, fluffy marshmallow, hot fudge, chocolate sprinkles and Reese’s Pieces candy. There’s time for that, but it’s not the standard. Vanilla ice cream works just fine most days, and when you just give someone ice cream, suddenly everyone has a ball.  

You probably already have a quality training program; otherwise, you wouldn’t be reading this article. What people don’t think about is training with employees who have TikTok attention spans. (Put down your phone. We know you just picked it up.)  

You don’t need all of this. You need less. You need to QC your QA. That is, quality check your quality assurance. Where is the real value of the training? 

QA + QC = QM 

Before we go on, let’s clarify what these acronyms mean to better understand how they work together for quality management (QM). 

Successful quality management requires both QA and QC. Both work together to ensure repeatable outcomes and quality patient care. 

Where to Start Improving your Healthcare Quality Training 

Don’t overcomplicate your quality agenda. More doesn’t always mean better. Build a quality education program that works. That means covering the basics well, instead of piling on secondary content and details. 

To improve quality training, start by prioritizing policies. It’s essential to blend mandatory policies and regulations (the “need-to-haves”) with employee requirements and skill development (the “want-to-haves”).  

Also review recent inspection reports from auditors, inspectors or regulators to identify areas of deficiency and opportunities for enhancement.  

By focusing on these fundamentals — establishing clear policies, learning from past audits, and designing educational programs that address both regulatory demands and employee competency— you foster a more effective and compliant quality training initiative that ultimately enhances patient care. 

$10,000 Chalk Mark Illustrates the Value of Focus 

You’ve heard the old story of the engineer who charged $10,000 for fixing a machine — $1 for turning a screw and $9,999 for knowing which screw to turn. According to Ramirez (2025), this isn’t just a fable. The story is real — and the man behind it was Charles Proteus Steinmetz (1865–1923), one of the most brilliant, yet often overlooked, engineers in history.  

In the early 1920s, Henry Ford, the king of industrial mass production, found himself facing a major crisis. At his famed River Rouge Plant in Michigan, a massive, custom-built generator — critical to keeping the entire factory running — broke down. Ford’s best engineers tried everything to fix it. They disassembled parts, checked wiring, replaced components — but no one could figure out the root cause. 

He called Steinmetz, who arrived asking for a notebook, pen and cot. He sat by the machine for two days. After 48 hours of meticulous study, Steinmetz asked for a ladder, tape measure and a piece of chalk. Climbing carefully up the side of the massive generator, he measured a specific point, then marked it with a simple “X.” Turning to the exhausted engineering team, he said, “Take off this panel, unwind the coil from this exact point, and remove 16 turns of wire.”  

Skeptical but desperate, the team obeyed. Moments later, the generator roared back to life — as strong and steady as the day it was installed. A few days later, Ford received an invoice from Steinmetz: Total Due: $10,000 

Shocked by the steep cost, Ford requested an itemized bill. Steinmetz replied with legendary precision: 

• Making chalk mark: $1 
• Knowing where to put it: $9,999 

Our point is, know where to put your chalk marks. Where should you focus quality education to fire up the generator and keep compliance running correctly? 

Chalk It Up to Experience 

We can take our QC data and use it to maintain and improve education programs. We generally make our “chalk marks” in one of three categories. These are areas where focused attention has the best return for quality programs:  

Where to Use Quality Control for Quality Assessments: 

• Teacher education: Use QC programs to assess a teacher’s knowledge, skills, attitudes and values to predict their suitability. Also include systematic reviews like self-evaluations, external evaluations and learner assessments.   

• Quality management: This refers to policies and systems to maintain and improve the quality of education and research. Quality management can help clarify responsibilities, work processes and improve transparency.  

• Curriculum development: QC in curriculum development ensures that actual results are close to desired results. In academia, this includes student outcomes, such as how well students perform at different grade levels, and what they can do when they graduate. Data is collected in a variety of ways, including scatter diagrams and control charts.   

The goal is to pinpoint areas for improvement that will deliver a big impact on your investments in quality programs.  

Use QA-QC Synergy to Master Quality Training 

Steinmetz’s story isn’t just a quaint historical anecdote — it’s a powerful reminder about the real value of expertise, experience and deep knowledge. Steinmetz’s chalk mark wasn’t just about turning a screw. It was the result of decades of learning, endless experimentation, and a mind capable of visualizing forces that others couldn’t even detect. 

We understand the balance is delicate, because decision-makers always prioritize long-term system improvements (through QA) over short-term fixes or validations (through QC). But when you need a QC approach, you cannot use QA.  

You need a reactive approach to identifying defects, which involves inspection, testing and verification of the product or result to ensure it meets the specified standards. QC is about detecting and fixing defects after the process has occurred.  

You know you have a training program. How are you teaching it? Where should the chalk mark go? In today’s world, when information seems abundant and skills are often commoditized, the story of Steinmetz reminds us that true mastery is rare — and priceless.  

Think of your quality programs in the same way, as needing assessments to identify gaps, deficiencies, or areas for improvement. Then use your mastery to bring focus to quality education.  

More Resources about Quality and Compliance 

• Building a Quality Education Program That’s Good Enough 

• Healthcare Compliance Is Everyone’s Business: Legal, HR, Quality 

• QA-QC-QM – Quality Education for an Effective Quality Management Program 

John R. Nocero, Ph.D., and Andrea L. Bordonaro, MAT, blog on LinkedIn as “The Q-Kids,” discussing everything related to clinical research education, inspiration, and professional connection. 

John is the Director of Quality at River Vista in Columbus, Ohio. He has worked in clinical research since 2003 and is inspired by the Irish professional wrestler Becky Lynch, whose personal and professional story centers on achievement, tenacity, grit, and overcoming adversity.  

Andrea has taught first grade in Willoughby, Ohio for 25 years. She earned a Bachelor of Science in elementary education from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

Download our Latest Whitepaper

Sign-up for our Weekly Newsletter

Schedule a quick overview

• One Compliance Pro’s Regulatory Change Management Process    by Amy Laufmann, MBA
• Five ways to show how healthcare Compliance delivers value by Jerry Shafran
• Revenue Cycle Management Compliance: Ensuring… by Maya Turner, CPMA, CPCO, CFPC, CPC, CPC-I, AAPC
• Three Strategies to Align Compliance with Revenue Cycle  by CJ Wolf, MD
• 12 key metrics for compliance officers looking to… by Kenneth Zeko, JD, CHC
• Mitigating Conflicts of Interest that Drive Profit… by Susan Thomas
• How the Three Lines Model Strengthens Healthcare Compliance by Kenneth Zeko, JD, CHC
• Transforming Compliance to a Department of Yes  by Lisa Herota, RHIA, CHC, CHPS, CCS Compliance & Privacy Officer
• New Regulation– Now What? Step-by-Step Guide to… by Amy Laufmann, MBA
• Navigating Compliance Responsibility: A Foundation… by Amy Laufmann, MBA

The post Elevate Healthcare Quality Training: Focus, Not Filler  first appeared on YouCompli.

Without a good employee education program, your quality program can suffer. And without a good quality program, patient care can suffer. Compliance can partner with quality to mitigate legal and reputational risks through good education practices. 

This expert-written blog explains how to improve quality education programs and prepare employees to meet quality and compliance goals. To make the lesson stick, quality education is metaphorically compared to nail polish – an unlikely pairing but one that drives home the message brilliantly and memorably.  

Nail It Using These Timely Principles 

According to Wikipedia, nail polish is a lacquer applied to a human’s fingernails or toenails for various reasons, including suppressing cracking, looking and feeling your best, and highlighting your unique style.  

But there’s more to nail polish than a snappy color shade. When evaluating the quality of nail polish, good products should provide full coverage with fewer coats, have quality ingredients and protect your nails with shine.  

What does an educational program have to do with quality nail polish? Actually, several things. We compare quality management with this popular beauty regimen to reveal common principles to make your organization look and feel its best.  

• Full Coverage – Good for Nails and for Quality Education 
• Commit to Continuous Improvement in Education Program 
• Use Quality Ingredients for Quality Education and Quality Polish 
• Quality Training Covers and Protects, Like Good Polish 
• Make Quality Education Shine – Like Your Nails 

Self-Care – Good for Nails and Healthcare Organizations 

When people paint their nails, the result both looks and feels good. In fact, we can make a case that getting a manicure is a form of self-care.  Similarly, having a quality management program is a form of organizational self-care. Now, we would venture to guess that many businesses operate without a quality management program, and those businesses are obviously not concerned about future prosperity or being here 50 years from now. You probably are. It’s why you are reading this. And building a quality education program is part of a long-term strategy nurturing a more sustainable, resilient organization. 

High-quality nail polish should provide full coverage with fewer coats. Compliance and quality education programs should do the same. Comprehensive training should be designed to address the significant risks health care organizations face, which includes patient safety and quality of care.  

Commit to Continuous Improvement in Quality Training 

If you don’t have a continuous improvement program, you stagnate or you get worse, while your competitors who are focusing on quality get better.  

The main mission of quality is to standardize systems and processes, so the organization delivers repeatable, efficient outcomes and the highest quality of patient care. Without standard operating procedures (SOPs), a workforce operates as it sees fit without any form of documented control. Even worse is when all training is done by word of mouth. And when one of those trainers leaves, that essential training knowledge and skill go with them.  

Not sure how to organize a good, ongoing education program? We recommend you do what is doable, and you can read more about that in this article. Basically, it suggests that you simply identify the actions you can take and follow through on them.  

In developing your compliance education strategy, focus on the easiest opportunities first and establish reliable practices that don’t easily chip, like janky, low grade nail polish. This list could include training in reviewing data, handling incident reports, engaging in leadership meetings, and managing daily tasks.  

Acknowledge the situation, create a solid plan, prepare for unavoidable interruptions and make the most of your efforts. Commit to your training plan over time. Consistently show up and aim for gradual improvements. 

Use Quality Ingredients for Quality Education 

Good nail polish should resist chipping and fading for an extended period and add an extra layer of protection to what you do. The ingredients used in the lacquer play a role in delivering this result. 

Similarly, your education program should be based on solid ingredients for compliance-related training that doesn’t fade or chip. This is one of the ingredients of a quality management program, along with: 

• Written policies and procedures 
• Compliance program leadership and oversight 
• Effective lines of communication with compliance officer and disclosure programs 
• Enforcing standards with consequences and incentives 
• Risk assessments, auditing and monitoring, and responding to detected offensives   
• Development of corrective action initiatives 

These elements come directly from the Office of Inspector General of the US Department of Health and Human Services General Compliance Program Guidance (November 2023). The OIG’s stated purpose in issuing this information was to provide a reference guide for the healthcare compliance community and other healthcare stakeholders. It also covers other interesting information such as applicable laws and regulations, and compliance adaptations for large and small healthcare providers.  

Quality ingredients. Quality results. In both compliance and nail polish. 

Quality Training that Protects and Shines 

For quality nail care, you want a finish that adds shine and protects your nails. We recommend Color Street, which features patented technology with a base, color and topcoat all in one, while easily removable with polish remover. According to their web site, they are transforming the nail polish industry with salon-quality manicures in minutes, to have you looking and feeling your best, while rejuvenating nails and cuticles.  

For quality in training and education, you want the same end result. Your education program protects and shines when it is focused on the activities and risks of the organization. This training begins with learning about the role of the compliance officer, governing board, code of conduct and where to find information on compliance policies and procedures as well as non-retaliation provisions. 

Do we need to tell you again about the benefits of an effective education program and how it protects and makes your organization shine?  

Exactly.  

Make Compliance Education a Big, Shiny Deal 

Remember, while looks aren’t everything, the way you look is often part of any first impression that you give. Many people notice your face and hands initially, just as many employees will notice your onboarding and other educational programs first.  

Unkempt nails may lead people to think the rest of your life is just as messy. The same is true for educational programs. Lackadaisical training may lead people to think compliance isn’t that big a deal.  

Make a great impression and pay attention to the amount of care you give to your body and to your organization. A good compliance education program should provide full coverage with fewer sessions, draw on good ingredients, and protect your organization with confidence. 

Try the YouCompli system as a centralized hub for tracking compliance and quality processes throughout the areas of your organization. 

John R. Nocero, Ph.D., and Andrea L. Bordonaro, MAT, blog on LinkedIn as “The Q-Kids,” discussing everything related to clinical research education, inspiration, and professional connection. 

John is the Director of Quality at River Vista in Columbus, Ohio. He has worked in clinical research since 2003 and is inspired by the Irish professional wrestler Becky Lynch, whose personal and professional story centers on achievement, tenacity, grit, and overcoming adversity.  

Andrea has taught first grade in Willoughby, Ohio for 25 years. She earned a Bachelor of Science in elementary education from John Carroll University and a Master’s Degree in the Art of Teaching and Education from Marygrove College. 

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The post Polish Your Quality Education Program  first appeared on YouCompli.