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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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.

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Sign-up for our Weekly Newsletter

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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.

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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 Risk Visibility Isn’t Optional in Healthcare Compliance  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. 

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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.

Maintaining quality in compliance training is a constant challenge for healthcare organizations of all sizes. Any surge of regulatory changes necessitates prompt, effective training programs for staff, yet the process of developing and delivering quality learning can be daunting.  

Crafting tailored educational content takes significant time and effort, especially for regulatory topics, while coordinating group sessions can feel like herding cats. Simply populating a Learning Management System (LMS) with generic material often yields lackluster results and managing it all with spreadsheets and emails adds to the chaos.  

For example, one large California health system faced the daunting task of creating, delivering and completing training for pharmacy techs within a tight 10-day window following a new privacy waiver. And that’s just one of many examples happening weekly if not daily across all health systems. This scenario underscores the need for proactive compliance training that not only meets regulatory demands but also engages staff effectively.  

This article by learning and compliance experts explains how compliance teams can get on top of training programs and deliver quality results.  

Why Training Fails in Corporate Healthcare Settings and How to Fix It 

Training fails in corporate settings (including healthcare organizations) because people don’t know how to train. HR or Quality departments typically handle training, not actual teachers, according to Erika Stevens, MA, FACRP, director of clinical research experience and faculty lecturer for MS Clinical Research Management Track at Rutgers Health. She addressed this issue at the Association of Clinical Research Professionals 2024 Annual Conference.  

Stevens also made note of the need to incorporate engagement best practices into the training of clinical research professionals. “Clinical trials continue to be complex, even for those of us who have been involved in them for many years, and not just in terms of how do we involve the patients, but how do we prepare the professionals to engage them?” 

Exactly. Here’s how to raise the quality of regulatory compliance training in your healthcare organization. Read this article for insights, tips and training best practices. And BTW, one of the experts IS a teacher. 

Context Means Learning in Training Situations 

On a recent episode of the Art of Manliness podcast, Scott Young, author of Get Better at Anything: 12 Maxims for Mastery, shared three key factors for learning:  

• Seeing

• Doing

• Listening

A significant component of human learning lies in the ability to act on and interact with the surrounding environment. So, to a large extent, the ease of how we learn from others determines how quickly we can improve. 

To see and learn in the world of business, we need to group professionals together during orientation. Then keep them together through the duration of work, no matter their job titles, to practice team-building skills and to be accountable to the group as well as to themselves. 

Encourage Deliberate Practice in Compliance Training 

Secondly, mastery requires “doing” through deliberate practice, which refers to a special type of training that is purposeful and systematic.  

While regular practice might include mindless repetitions, deliberate practice requires focused attention and is conducted with the specific goal of improving performance.  

Progress requires constant adjustment based on not just the red stroke of a teacher’s pen but on the results of hands-on experience.  

Feedback Is Key Ingredient of Compliance Education 

Whatever a person’s role, they need to repeat tasks and hone skills time after time. Training becomes about taking any action and then making course corrections based on feedback.  

Why Feedback Is Needed 

• Helps people flex and grow into new skills, capabilities and roles 
• Creates more positive and productive relationships 
• Helps to reach goals and drive business value 

Speaking of feedback, let’s put this one on the managers. In our fast-paced clinical research world, being clear and brief is gold. No one has the time or the attention span (thanks, TikTok) for long-winded explanations. Keep it crisp. Use technology. 

Technology Teaches 

Tech solutions are being combined with basic education principles to transform compliance training workflow and tracking. To improve corporate training in any capacity, organizations should borrow from various education principles and utilize technology, such as: 

• Active Learning & Engagement: Encourage participation through interactive discussions, problem-solving exercises, and hands-on activities rather than passive lectures. 
• Storytelling for Retention: People remember stories better than raw data. Framing training within real-life scenarios and relatable experiences increases comprehension and recall. 
• Personalized & Adaptive Learning: Use blended learning models, microlearning and adaptive tech platforms to cater to individual learning speeds and styles. 
• Connection & Emotional Relevance: Foster an environment where employees see the “why” behind the training—how it benefits them personally and professionally. Make this clear. 
• Scenario-Based Learning: Instead of memorizing regulations, research staff can engage in simulated case studies where they troubleshoot real-world ethical dilemmas or protocol challenges. 
• Interactive Workshops: Hands-on practice with data collection tools, patient communication techniques, or other applications ensures skill mastery rather than theoretical understanding. 
• Mentorship & Continuous Learning: Pairing new employees with experienced mentors fosters on-the-job learning and reinforcement beyond initial training sessions. 

Up Your Compliance Training Game with Personalization 

Although employees may attend workshops, complete modules, or watch presentations, they may still fail to retain knowledge or apply it effectively. A common reason is lack of engagement. Traditional training methods (e.g., slide-heavy lectures or dense manuals) are passive, generic and uninspiring.  

Don’t use a “One-Size-Fits-All Approach” or ignore personalization. We need to apply core educational principles to compliance. Simple as that. 

Making all types of training engaging, interactive and personalized helps: 

• Boost retention 
• Enhance job performance 
• Foster a culture of continuous learning 

Applying education-based strategies can transform compliance training from a mundane task into a powerful tool for professional growth and organizational excellence.  

For ideas on how to up your compliance training game, reach out to the professionals at YouCompli. 

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 Best Practices for Better Training in Healthcare Compliance  first appeared on YouCompli.

Traditionally, many healthcare compliance programs have left the work of patient safety and quality to other departments. However, according to the Health and Human Services (HHS) Office of Inspector General (OIG), “Entities should incorporate patient safety/quality oversight into their compliance programs.”   

OIG’s recent emphasis on patient safety and quality is not necessarily a call for compliance programs to take over these efforts. Rather, it’s a reminder that a compliance program should be designed to address the significant risks health care organizations face, which includes patient safety and quality of care.  

How to Incorporate Quality and Safety into Compliance Practices 

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. 

1. Build a Strong Compliance Committee 

2. Provide Safe Reporting for Safety/Quality Concerns 

3. Get Your Governing Board Involved with Quality of Care 

4. Nurture Relationships with Quality and Safety Leaders 

Four Ways to Drive Greater Connection Between Compliance and Safety/Quality 

1. Build a Strong Compliance Committee 

Most mature compliance programs have a compliance committee in some form or fashion. To build stronger safety and quality representation, include individuals responsible for quality assurance and patient safety as members of the committee. 

A strong compliance committee should ensure that appropriate auditing and monitoring of patient safety and quality take place on a regular basis. The OIG goes as far as suggesting that “Compliance committees of entities directly furnishing patient care, particularly entities such as hospitals, long-term care facilities, and other entities providing residential care, should also assess staffing for nursing, therapy, and other clinical services to ensure that the entity has the appropriate quantity, quality, and composition of care providers.” 

2. Provide Safe Reporting for Safety and Quality Concerns 

Compliance programs establish lines of communication for reporting concerns, and anyone aware of patient safety or quality concerns must know how to report such incidents or issues. They must also have confidence they won’t face retaliation.  

Awareness of incidents involving safety or quality is often the first step in developing a correction plan, so it’s essential that those who report know how their information is protected. 

Steps have been taken at the federal level to encourage reporting and analysis of medical errors. The Patient Safety Act and Rule provide federal privilege and confidentiality protections for patient safety information called the Patient Safety Work Product (PSWP). PSWP includes data, reports, records, analyses and written or oral statements related to patient safety events.  

More about the types of protections at the federal level can be found here: https://www.hhs.gov/hipaa/for-professionals/patient-safety/index.html  

 

3. Get Your Governing Board Involved with Quality of Care 

Governing boards of healthcare entities have ultimate accountability for ensuring quality of care, and their involvement can also ultimately benefit compliance outcomes.  

There are many resources available to educate your board on their responsibilities related to quality. These include: 

• “Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors”
• “Driving for Quality in Acute Care: A Board of Directors Dashboard”
• “Driving for Quality in Long-Term Care: A Board of Directors Dashboard” 

Read and share these with board members to help them stay informed more easily.  

4. Nurture Relationships with Quality and Safety Leaders 

Compliance departments aren’t expected to take over the detailed, day-to-day management of quality and patient safety programs. However, it’s essential that compliance leaders develop productive working relationships with leaders and in-house experts within the organization’s quality and patient safety programs. 

One way to develop productive working relationships is to better understand what quality and safety leaders do. A good resource for learning more about the standards, goals and language often used by quality and safety leaders is the Institute for Healthcare Improvement or IHI (https://www.ihi.org/).  

This organization offers both introductory, intermediate and advance learning opportunities for those who want to become better-versed in quality and patient safety topics. The IHI Open School (https://www.ihi.org/education/ihi-open-school) is a great place to start. And for those looking for more formal recognition, the IHI offers certifications, such as the Certified Professional in Patient Safety (CPPS). 

Compliance, Quality and Safety — Together for Common Good 

The call for compliance programs to become more involved in an organization’s patient safety and quality efforts is getting louder from agencies such as the OIG. It’s also smart business practice.  

In summary, this blog has covered four ways to begin the process: 

• Considerations for your compliance committee 
• Ensuring confidentiality of incident reports 
• Involving the governing board  
• Broaden understanding of what safety/quality leaders do 

With these practices in your toolkit, you’ll be on the path to a stronger, more effective compliance program.  

And to help with overall regulatory analysis and operations, learn more about how YouCompli compliance software can support your mission. The tools include capabilities to easily map and track responsibilities across functions.  

CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.   

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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 Four Ways to Integrate Compliance with Safety/Quality Efforts  first appeared on YouCompli.

The HHS OIG recently issued its first Industry Segment-Specific Compliance Program Guidance, or ICPG, with many more expected.  This first ICPG covers Skilled Nursing Facilities and Nursing Facilities.  

Let’s review some of the highlights. 

1. Quality of Care and Quality of Life 

For decades, the OIG and other government enforcement agencies have emphasized the importance of the quality of care and quality of life for nursing facility residents.   

When a nursing facility submits a claim to Medicare or Medicaid for reimbursement, it certifies the services were provided in compliance with all applicable statutes, regulations, and rules. If a nursing facility does not provide care consistent with professional standards of quality, or in an environment that promotes quality of life, claims for reimbursement may be considered false.   

The ICPG provides the following examples of quality and related safety concerns that can lead to submission of false claims:  

• providing medically unnecessary or grossly substandard services 
• housing residents in unacceptable or dangerous living conditions 
• failing to provide residents with activities 
• failing to provide residents with needed psychiatric care 

2. Billing Requirements 

The ICPG states, “Ensuring compliance with Medicare and Medicaid billing requirements should be a core function of nursing facility compliance program operations.” 

The OIG expects nursing facilities to be proactive in their oversight of billing compliance. This includes conducting regular reviews to ensure billing and coding practices are current and accurate, as well as performing regular internal billing and coding audits. Even if an entity makes an isolated billing error, that entity still has an obligation to repay the overpayment to avoid False Claims Act liability. 

The ICPG specifically addresses the following risk areas associated with billing requirements: 

• SNF Prospective Payment System (PPS)  
• Value-Based Payment Models and Programs 
•  Medicare Advantage and Medicaid Managed Care  
• Medicare Part D  
• Medicare Health Plan Enrollment for Nursing Facility Residents 

Interestingly, the ICPG for nursing facilities also refers readers to a supplement on understanding reimbursement for nursing facilities, which can be viewed at https://oig.hhs.gov/documents/compliance/10039/nf-icpg-supplement.pdf. 

3. Anti-Kickback Risks 

The OIG’s General Compliance Program Guidance (GCPG) highlighted some of the risks associated with the Federal Anti-Kickback Statute (AKS) in the healthcare industry. The nursing facility ICPG provides many helpful and specific AKS risks to unique to nursing facilities. Among the specific risks highlighted by the OIG are: 

• Free (or Below Fair Market Value) Goods and Services  
• Discounts 
• Arrangements for Services and Supplies  
• Long-Term Care Pharmacy and Consultant Pharmacist Arrangements  
• Hospital Arrangements  
• Hospice Arrangements  
• Care Coordination and Value-Based Care Arrangements  
• Joint Ventures 

The ICPG emphasizes that all referral relationships call for vigilance under the Federal AKS. The discussions in the ICPG not only highlight several risk areas for nursing facilities under this law, but it also provides excellent recommendations for mitigating those risks. OIG also stresses that nursing facilities should scrutinize the listed risk areas as part of their risk assessment, internal review, and monitoring processes. 

CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.   

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The post Breaking Down the OIG’s First Industry-Specific Guidance  first appeared on YouCompli.

On December 11, Juan Soto signed a 15-year, $765 million contract with the New York Mets. It’s the largest free agent contract in Major League Baseball – and sports – history. The Mets outbid several teams, including the Los Angeles Dodgers and New York Yankees, for Soto’s services.  

The Pittsburgh Pirates, once one of MLB’s most successful teams, were not among those teams. They do not have the revenue to support such a signing. To compete against teams with larger revenue bases, they must build a solid minor league system, stock it with promising young players, hire the right coaching staff to develop those players, and cross their fingers that they avoid injuries and develop into competent ballplayers.  

Healthcare systems in today’s landscape are no different. The larger systems, such as the Mayo Clinic and Cleveland Clinic, have probably 50 people lining up for every open job they post. A 60-bed behavioral health system in Canton, Ohio can’t attract the top talent like its larger counterparts, but is still expected to compete with them. 

Still, like smaller-market baseball teams, it’s possible for smaller healthcare systems to compete. To do so, you need to ask yourself two questions – who are you and what are you measuring? 

Who are You? 

For real – what type of organization are you? If you are a smaller healthcare system, don’t build an education program that is more suited for the larger organizations. A smaller healthcare system requires smaller components in their program, but greater details.  

For example, the smaller health system in Canton gets a nurse right out of school. She’s likely not an RN but an LPN, has three months of experience rather than three years, and is enthusiastic about her career rather than jaded. What do you do? For starters, you paint with a broad brush and expose her to every role and responsibility on the floor. You train her to be a mental health technician, teach her to see patients in their rooms, and show her how to capture data on an iPad. You let her sit at the nurses’ station and document assessments in the computer. You train her to go into the medication room and hand out medication as required. And you also train her in the kitchen to pass out meals. Why? Well, for starters, you are a small organization, facing staffing issues and call-offs every day. The more skills you give her, the greater flexibility that you have with your workforce every day. She becomes a Swiss army knife, able to go into any role with relative ease.  

This is important, because you are creating sustainability. You aren’t able to compete with the big boys; you don’t have the revenue, talent or experience. You need to ensure that you keep the lights on every day. The only way to do it is creating a nimble workforce with a skillset that allows talents to be plug and play – able to go on any floor and in any job and succeed.  

What are You Doing? 

Easy: making money. You are not trying to make money for ONE year, you are trying to make money for the next TEN years and beyond. That requires playing the long game, creating metrics to measure important tasks and skills, and getting better at them.  

This means looking at every department: figuring out what is important to them, measuring it, defining metrics, and setting expectations to get better over time. For example, in the quality department, we measure things like quality checks and quality assurance. We also look at hospital specifics, such as the number of incidents we had over a month, the number of falls and hospital-acquired infections and the number of charts reviewed. Each metric is assigned a quality metric, and everything is tracked. If a fall does occur, then it is quality’s job to collaborate with nursing leadership to figure out what happened, plant operations’ job to assess floor conditions and ensure safety, etc. If you do this month over month for each department, then you have a year’s worth of data to assess where you are good, where you need work, and the skills you can build on.  

You also want to take into account feedback from both staff and patients. Outcome-inspired surveys are key here. Ask your patients about their length of stay, how service was, if they like their food, how were they treated, etc. Ask staff about their conditions in the workplace, their co-workers or staff, etc. Ask these questions on a 1-10 scale, so you can again measure month over month.  

You do this long-enough, you will know where you are good and where you need work.  

As painful as this is to admit, the Pirates are a feeder system for the Yankees. They develop players and the Yankees come in, pay them more money, and take them away. But that doesn’t mean the Pirates do not have a sustainable team, with a chance to win. They do, with the right strategy.  

Healthcare systems are the same. You may be smaller, but you are more nimble than larger organizations. You may have less experienced employees, but they are more enthusiastic. Use this to your advantage and create a culture where people want to be, and you will succeed.  

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 Sunrise Vista in Canton, 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 Plug and Play: You are Not Bought, You are Built  first appeared on YouCompli.