The National Association for Regulatory Administration’s past Board President Alfred C. Johnson shares the impacts of COVID on the regulatory community, pointing to lessons learned and lessons observed. He also explains how NARA’s Key Indicator System helps to increase the efficiency and effectiveness of a licensing process.
Johnson describes NARA as an international nonprofit trade association for regulators. “But a very unique thing that NARA does is that it does not solely think that regulators are the final solution or the solution. We believe in collaboration,” he explains. “When you think about our membership of more than 300 people and organizations, those members are not just regulators. They are founders. They are providers. They are research scientists. It runs the gamut of people who are really interested in our vision, which is consumer protection through prevention.”
Alfred C. Johnson: There are a couple of things. I would use the concept of lessons learned and lessons observed. So, some of the lessons learned were that—especially residential type programs from a regulatory administration perspective and emergency preparedness—we thought we had some good requirements and things in place. I don’t think anyone could have planned for what the pandemic brought; think of PPE. That concept was foreign to many entities. When you think of regulatory administration, you may have had an infection prevention control regulation, but it didn’t drill down into the concept of what PPE was. What would happen with visitors? What would happen if a staff member or a kid or a consumer became ill? So, a lessons learned from that was looking at it as people typically talk about emergency preparedness—an all hazards approach. The pandemic showed that there were some mission driven services they had to continue. And now as we saw what happened during the height of the pandemic, and now as a result, how can we learn from those lessons? How can we be better suited to meet the needs of those that need us the most? And obviously, there are parents and loved ones who are counting on the providers to stay in operation. So, that’s one of the pieces.
The other thing was the use of technology. What happened during the pandemic forced all of us to consider—even if you weren’t comfortable, or if it was the 10th thing on your list—man, I’ve got to figure out how to get this work done when we can’t either be face to face, or I need this information. And I’m doing it the old-fashioned way. I’m faxing information. I’m holding information on this thumb drive. And I’m doing all this data entry. And now I can’t have people either in the building doing the work because we can’t be right next to each other. It forced us to really examine technology. And it also forced us to increase our communication. So, if I’m in Kansas, and I hear someone in California, who’s figured out a way to make this work, I’m actually reaching out to them. Or if I know that GL Solutions, or another company is doing this, I’m reaching out. And I’m trying to figure it out. I have this need. You have this program. Can you get it off your shelf? Can you tailor it to ours? I think the pandemic has shown that we don’t have to be afraid of technology. You think of just doing your work of accepting applications, processing applications, communicating decisions to people. That’s one aspect. But also, you think of the provision of care, so even the use of cameras and different things and balancing the rights of people. That has shown to be an effective way to continue to make sure that people are taken care of. So, from the care side to the kind of administrative side, the pandemic has kind of helped usher in the further use or further advancement of technology.
Alfred C. Johnson: One of the things I can share with you is the concept that NARA has and that’s a NARA product. It’s called Key Indicator System. So, when you think about the entirety of regulatory oversight, if a person, an authority having jurisdiction, is going out to conduct a survey, a licensing visit, one could believe that I’m going to walk within this setting, and I’m going to spend days. I’m going to spend weeks because the regulation set may be 100 pages long. And I’m going to spend a week here, going through and making sure that this location is in compliance with the regulations. We know that that’s not realistic and there’s not enough resources to do that work—the burden that you put upon not only the authority, having jurisdiction to do that work, but also the burden that you put upon the provider to accommodate this request for this piece of paper. Let me look behind this door. Let me interview this staff member. Let me observe this child or this adult receiving care treatment and services. It’s just not realistic and it’s not cost effective.
So, NARA has this research-based Key Indicator System. The Key Indicator System just says the purpose of that system is to increase the efficiency and the effectiveness of a licensing oversight process. So, you refocus on those areas that have the greatest impact on the quality of care and quality of life. If you have a 100-page regulation set, there are some structural things that may need to be put in place. The building may need to have smoke detectors, sprinklers, you name it. There could be some prescriptive things in place, such as you may have to do an assessment or an admission agreement or certain things like that. And then there’s some outcome based, such as, supervision, activity, programming, those types of things. You have to put those in, but they’re outcome based, because they’re very tailored to the needs of that person receiving the services. The Key Indicator System truly takes a scientific approach to look at your regulations. Look at what has the potential for the greatest impact upon the quality of life and quality of care. You do that; you get those regulation sets. You put that within your licensing system. And then that dictates when you go out to do a survey or a licensing visit. You’re looking for those key areas. So those key areas could be, for example, training, fire safety, first aid, infection prevention. Those are areas that you’re going to look for. You may look for something structural, such as accessible walkways or pathways or doorknobs. Those types of things. You don’t ignore blatant issues. So, if a person reports something to you, the food is cold, the food is too hot, you’re going to look into that. But this is a very scientific approach and has been shown to increase the efficiency and the effectiveness of a licensing process.
You combine the Key Indicator System with what we call a differential monitoring process that pulls all of this together. So, you’re not necessarily treating each and every provider. Not everyone’s going to get a two day, one day, week, whatever. Based upon the issues that that provider may have, the history, you conduct a survey accordingly. And it allows for a very effective process. We work with authorities having jurisdiction to help them evaluate their systems, and then to implement an effective system.
Alfred C. Johnson: Exactly. And it also takes away the mystery. Sometimes, as a provider, you’re waiting for your annual survey. And you’re wondering, what are they going to look at? When I mentioned the alignment, and I use the term marrying, but really the alignment of quality and regulatory compliance. If you are taking care of the people, and you’re there, there’s an alignment of you got to train, the building has to meet certain qualifications, and you got to meet the needs of the people receiving services there. It takes away the mystery because that information—when you think about the key indicators—and that survey process should be readily available to the provider. Not that they know when you’re coming. They know what you’re going to look at. But what you’re looking at has significant meaning to the people that are receiving the services so you should be able to carry on as you normally would.
Alfred C. Johnson: First of all, September 23 through the 26th, we have our conference in Minneapolis. This is again, that similar event that we had this past year in Indianapolis. But this Minneapolis conference is going to bring a collaborative group of folks from a lot of research that’s going on, within assisted living, oversight.
So, when you think about the changing, dynamic and demographics of who’s being served in assisted living, there’s research that’s going on now. And there’s research that will continue. And we’re hoping to have the seminar or the conference in September be one of the main events to kick off and help push more than just research that sits. I use a term. I call it virtual dust. We don’t want research to sit on a website, sit on a shelf to collect dust. We really want to look at the application of things, so those best practices. How do you care for people? How do you implement and use technology to not replace that, but to supplement and enhance that care treatment and services that are being provided. So, you’ll see some of that happening in September.
We also have some good work going on on our child care side. NARA is working with several states and federal entities on researching and looking at some standards there. So we’re hoping as that takes place, that that conference in September will be an opportunity to not only pull apart, whatever has been developed, but also look at the application or implementation concepts. So that’s a really big piece.
The other thing is that throughout the year, we will have webinars. And as we put out these webinars, these will be webinars centered around regulatory administration. They also will be centered around best practices. So from birth to the end of life. We have a good group of speakers and subject matter experts, national experts who are going to provide information. And not just again, that one on one, but we want to move past just talking to people, but talking with people and then connecting and figuring out how can we better serve our communities by exposure to evidence based practices, actual best practices, and highlighting things that are going well, within.
NARA also is participating in a national collaborative on the adult care side. It’s called quality assisted living collaborative. We are partnering with LeadingAge, NCAL, Argentum and ASHA to develop best practices and guidelines for assisted living. We just finished infection prevention and control that will be published in March. And then we’re going to start with emergency preparedness. And we’re working right now on some dementia training requirements. So that’s another significant piece of work that NARA is involved in.
Editor’s note: Answers edited for clarity and brevity. To hear the entire interview, listen to our interview with Alfred C. Johnson on our Talkin’ SaaS podcast.
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