Kevin Coughlin

Kevin Coughlin didn't set out to turn Wisconsin's assisted-living system upside down. He just wanted to inject its regulatory process with a dose of common sense. But Coughlin's rational approach has, in fact, been both revolutionary and successful: He has managed to shift the old "gotcha" relationship between regulator and provider to a collaborative process that has translated into safer homes for the frail and elderly residents in the state's 2,700 assisted-living facilities.

Coughlin's innovations come at a key time: Assisted living is on a fast track. In several states — including Wisconsin — assisted-living beds will soon outnumber those in nursing homes. But along with the explosion in capacity, there has been an even bigger boom in complaints. "We were overseeing an industry that was young," says Coughlin, 46, who was a manager at an assisted-living facility before taking a job with the state in 1997. "The industry was growing very fast, but in some ways it wasn't doing such a good job."

Although states write the regs for assisted living, federal rules for nursing homes tend to drive the regulatory process: In many states — and this was true of Wisconsin — both types of facilities were licensed and managed by the same bureau, with the same supervisors and field representatives auditing them. Then, in 2003, things changed: Wisconsin's Bureau of Quality Assurance, part of the Department of Health and Family Services, set up an assisted-living section and put Coughlin in charge. He saw the move as an opportunity for a fresh start — for both the regulatory process and the industry.

Having worked on both sides, Coughlin is passionate in his belief in the assisted-living philosophy, and that belief drives the way he approaches regulation. A key part of assisted living, he points out, is a resident's right to autonomy, but autonomy poses safety risks. "Residents have a right to accept that risk," he says, "but it's a hard thing for a regulator to accept. We don't want anything to happen to a person. So we've got to find the right balance between making sure residents are safe and that their rights are protected."

Coughlin also thought a collaborative approach could dispell the general distrust between providers and regulators — if he could develop one. His first move was to set up regular forums where providers, regulators and consumer advocates could meet and hash out targeted problems.

What could be more ho-hum than bi-monthly forums? They may generate goodwill, but it comes slowly. Then Coughlin found something that tipped the balance. He had compiled a list of problems regulators saw on their rounds. Instead of reading the litany of woes to the forum, he turned each "grievance" into a story — an anonymous story with no names attached. People were shocked that such things were happening in Wisconsin. And at the next meeting, there was a new attitude. "Everyone felt we had important work to do and we should roll up our sleeves and get at it," he recalls.

Now, when there are forum meetings, Coughlin's regulators tell providers the problems they're seeing, and the industry brings in resources to attack the issues. With a more trusting atmosphere, Coughlin has been able to push through important reforms. One is a two-tiered survey process whereby good providers receive less attention and longer licenses. That frees up supervisors to go after problem providers to, as Coughlin puts it, "help them come into compliance and sustain it or help them choose a different profession."

Supervisors have been able to get away from issuing citations for minor infractions. Again, Coughlin went for the two-tiered approach, distinguishing between small, easy-to-fix problems, such as a tear in a room's wallpaper, and systemic ones, such as no fire-safety training for a facility's staff. Citations, plans of corrections, monetary fines and de-licensing are reserved for serious threats to health and safety.

Coughlin's reforms have borne fruit. While Wisconsin's assisted-living industry continues to expand, complaints are decreasing and, even more important, major deficiencies are declining. "Three of the worst problems we had been dealing with for years have come off the top 10 list," Coughlin reports, "and that's because providers are being proactive, and we're able to focus on those issues."

— Penelope Lemov
Photo by Michael Kienitz