Rachel Young – Regulatory Compliance Director

47 years old; Married, no children; Reports to the CMIO; Employed for 15 years with a multi-practice enterprise; Started as a family practice nurse; Masters in informatics/nursing


Rachel feels like she is stuck in the middle; providers don’t come to work to fulfill regulatory requirements, but the data is important for measuring quality and is required by their practice. It’s a constant struggle between what is required for reporting and what the practice deems important for clinical care.


“It is very difficult to get providers to keep track of and care about quality measures. I want them to understand that quality measures do benefit their patients and the practice.”

“I wish I could be sure no patients are falling through the cracks.”

“How do I get everybody to agree and support our initiatives?”

“I feel there is a lot of weight on my shoulders.”

Short-Term Goals

  • Get input on what needs to be measured to meet goals.
  • Help physicians understand the importance of documentation in the EHR and the impact on quality.
  • Get data on MIPS and make sure the organization isn’t penalized.
  • Finish submissions before deadline.
  • Get stroke accreditation/recognition.
  • Reduce the number of reports that have to be generated to do submissions.
  • Find a way to make providers care about their quality measures.
  • Stop working on weekends.

Long-Term Goals

  • If the adversarial culture continues, find another job where I can be helpful.
  • Reduce turnover in my group.
  • Streamline processes for tracking at-risk patients, focusing on more accurate data and improving patient care.
  • Achieve a higher title in the organization in order to be able to exert more influence on staff.

Typical Problems Faced on the Job

  • Cannot just call people and get something worked out; have to use email.
  • Change happens so slowly.
  • CDC requirements differ from quality reporting requirements.
  • State policy is sending people home without the services or the oversight to be safe.
  • Programs keep changing, and I can’t keep up.
  • Frustrating to wait for minutes for a report to finish, only to have it time out.
  • Too difficult to get all the data needed in one place.
  • Constantly interrupted.

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