The Footprint of a Nursing Home Leader
Many of us promised our parents that we wouldn't ever put them in a nursing home. Reality is that more than 3 million Americans rely on services provided by nursing homes at some point during a year and 1.4 million of these reside in the Nation’s 15,800 nursing homes on any given day (Bonner, 2013). In my position as Vice President of Operations with a publically traded healthcare company, I support twelve nursing homes. One such nursing home is a 194-bed for-profit Center that provides post-acute, rehabilitative, skilled nursing, and short and long-term care services. This Center is located in Texas approximately 5 miles from the border of Mexico. In an effort to support the Centers’ mission to “Make a Difference – Every Day, Every Time,” there are six key objectives vital to success: 1. Culture: Maintain a productive and positive employee environment. 2. Care: Provide quality care so residents may achieve their optimum level of functioning thus living an improved quality of life. 3. Census: Anticipate community health needs and develop business partnerships that help improve market share. 4. Cash: Ensure timely and effective collections. 5. Cost: Control operation costs. 6. Compliance: Comply with regulatory requirements.
Strong leadership is essential for this Center to successfully reach its key objectives. While the leadership at this Center has a history of consistently attaining key objectives, over the course of the previous two years this Center has experienced increasingly greater difficulties at doing so. The goal of this paper is to provide an analysis of this Center’s leadership to include the organization strengths, weaknesses, opportunities, and threats.
Not all leaders are created equal! As Peter Drucker observed, “Only three things happen naturally in organizations: friction, confusion, and underperformance. Everything else requires leadership” (Kouzes, 2013, p. 5). Nowhere is this more pertinent than in a nursing home. To begin, the primary leader of this Center primarily practices an impoverished management style. In other words, this leader likes to delegate and then disappear. A leader with an impoverished managed style is not committed to either task accomplishment or maintenance, they essentially allow their team to do whatever it wishes and prefer to detach themselves from the team process (Clark, 2014). This leader tends to expend as little effort as possible on the job. For example, this leader filled an opening for a Clinical Marketing Liaison with a poor performing charge nurse with no sales or marketing experience. By doing so, the leader was able to avoid disciplinary action for the charge nurses’ poor performance, posting a job advertisement, and conducting candidate interviews. Furthermore, this leader did not provide the employee the coaching needed to ensure success in the liaison position. This leader’s practice of this style of management has created disharmony and disorganization in this Center. While once a successful leader, this leader and her previous supervisor developed an intense personal bond which contributed to this leader providing very little staff guidance and handing over complete decision making freedom to staff. Secondly, this leader cultivates a diversified workforce. In response to the changing demographic profile of the United States, there is an increasing presence of minorities in the workforce. Nursing homes, in particular, are facing issues on how to manage such a diverse workforce. Furthermore, nursing homes have a bureaucratic structure with limited diversity at the administrative level, yet significant diversity at the direct-care levels (Vinson, 2011). Diversity and inclusion are central to this Center’s quest to become the most respected nursing home in The Valley. Internally through training, the department heads are taught to be self-aware to support a work environment that lends to employees feeling safe in their expression. Externally, the Center adapts business strategy to the changing needs of a diverse market. In addition, this Center has made progress in conventional measurements of diversity. Women accounted for 83 percent of its total workforce in 2014 and minorities for 42 percent. Lastly, this leader values the opinion of the Center staff and utilizes employee satisfaction surveys to provide a clear means of communication. These surveys allow employees the chance to voice their concerns and ideas. This feedback helps this Center decrease turnover, increase morale and improve internal communication. Also, these surveys provide this Center with positive feedback and a clear understanding of what leadership is doing well. With the survey information, the Employee Recruitment and Retention Committee is able to develop action plans to decide how to be improve critical areas identified. Also, the survey outcomes and the action plans are shared with the Center staff so as to take a team approach in improving the critical areas.
People are inspired by vision. They want to follow a leader who shows concerns and values that are important to them. A positive leader will inspire 100 percent effort from everybody (Rosenberg, 2008). I imagine that when you make a visit to this Center you will notice employees dressed casually, staff feeding stray cats in common areas and that the Center suffers from poor housekeeping and maintenance services. This Center is known for values that are focused on quality of care, whose norms accept a wide range of behaviors, and whose practices are informal and inconsistent. Yet another example can be found in this Center’s core value of attention to detail. The primary leader believes in the importance of providing quality care through utilizing quality products. To ensure quality products are in use, this Center’s leader has partnered with a medical supply company to develop a medical product formulary. The primary leader has only shared the importance of the use of this formulary to a few of the Center’s department heads. The organization’s followers have no idea that it is important for them to use products on this formulary. Since this leader lends to weak culture by providing very little guidance, Center staff are not always sure what they should do if they notice a product off-formulary in use during resident care. The Assistant Director of Nursing (ADON) noticed that the skin protectant cream being used by the nursing assistants was off-formulary. The ADON reported this to the Director of Nursing, who filled out a grievance report and sent it to the central supply department to notify them of the off-formulary skin purchase. The nursing assistants continued using the off-formulary skin protectant cream and with the use of this cream resident skin tear occurrence increased.
This Center builds on their strengths and oh, what a difference management makes! The Center reaps the benefits of long-tenured leadership. These leaders have a combined 26 years of experience with the Center. The Administrator is responsible for planning, organizing, directing, and managing the operations and the Director of Nursing assumes authority, responsibility, and accountability for the delivery of nursing services in the Center. A study conducted by researchers with the Department of Public Health found that the level of care quality at a nursing home can be predicted by turnover, and that Administrator and Director of Nursing turnover is more predictive of care quality than structural characteristics, such as facility size and location (Geletta, 2013). Additionally, the Center is unique in their ability to care for critically ill residents who require special, aggressive, goal-directed care during their stay. The nursing home population is appointed to account for many potentially unnecessary hospitalizations, with estimates of up to 67% (Graverholt, 2014). In 2014, this Center was able to reduce hospital admissions to 14.7%. As such, a reduction of hospital admissions among nursing home residents may potentially serve a dual benefit of improving care for residents, as well as reducing use and monetary cost of health care (Graverholt, 2014).
Although there are strengths that surround our Center, there are a few weaknesses that should be brought to the forefront. Over the past several decades, the role of the nursing home has changed dramatically. There is a global phenomenon of a numerical and structural aging of the population. It is estimated by the United Nations that the number of older people over 60 years around the world will grow by 2.8% annually in 2025-2030 and exceed the number of young people for the first time by 2050 (Wright, 2015). In preparation of this phenomenon, the most remarkable development in nursing homes has been alternatives to traditional nursing home care. The institutional nature of nursing homes has given way to a culture change movement, which aims to improve the quality of life of nursing home residents through person-centered care structures and processes (Sloane, 2014). Not all nursing homes, including this Center, have embraced culture change. The Center’s failure to embrace culture change lends to lower resident satisfaction rates. This is not ideal considering the nursing home industry anticipates reimbursement to be tied resident satisfaction as part of an incentive program called Pay-for-Performance. Another highlighted weakness of this Center is survey management. Nursing homes are required to comply with certain requirements in order to be eligible to receive payment under the Medicare or Medicaid programs. The survey process is used to determine if the nursing home is meeting specified standards and if funding is appropriate. As shown in Figure 1, this Center has experienced an increase in the number of deficiencies cited during the previous thirty-six months. In addition, the Center’s average number of deficiencies is considerable higher than the average in Texas and the United States during the same thirty-six month period. Positive outcomes with surveys are critical for reimbursement and overall marketing of a nursing home.
There are many external forces or opportunities that influence and affect our organization. For example, nationally, Texas ranks 49th for Medicaid reimbursement rates. The state's average nursing home rate is about $123 a day, and the average cost of care for nursing home providers is about $145 to $150 a day, according to the Texas Association of Homes and Services for the Aging (Lee, 2011). On October 1, 2013, the Texas Health and Human Services Commission implemented a new program called Upper Payment Limit Supplemental Payment Program. The Program allows non-state government-owned entities, such as hospital districts, to hold the licenses of nursing facilities to allow the State to claim federal matching funds under Medicaid up to what Medicare would pay for a similar service. In August of 2014, this Center went through a Change of Ownership making the owner of record a non-state government-owned hospital district. To date, on average the Center has received approximately $40 per resident per day in addition to their average Medicaid rate. This additional money allows for Center earnings to be reinvested into the Center in the form of but not limited to equipment, programs, and technology. Today, over 5 million Americans are living with Alzheimer’s disease, including an estimated 200,000 under the age of 65. By 2050, up to 16 million will have the disease (Alzheimer’s Association, 2014). To keep up with the growing need and demand, this Center has a 28-bed female secured unit to protect and care for confused or wandering residents with a diagnosis of Alzheimer’s disease or similar dementia. This secured unit is consistently occupied at 100% with a waiting list. The Center often denies admission of potential male residents seeking a secured unit due to not having appropriate accommodations. With this said, the Center and the community it serves could benefit from the installation of a male secured unit.
Action must be taken to identify and overcome organizational threats. One such threat facing this Center is the August 2014 Sunset Advisory Committee proposal asking lawmakers to pass a law requiring the Texas Department of Aging and Disability Services to revoke the license of any nursing home with three or more of the most serious offenses over a two-year period. With the Center’s history of a high number of deficiencies and that number being considerable higher than the average in Texas and the United States the Center faces a greater risk of closure. Lawmakers are expected to consider this issue during the 2015 legislative session. In the meantime, the Center and its’ allies hope to influence legislatures through lobbying with the assistance and support of advocacy groups. Another threat facing the Center is the March 1, 2015 transition to Star Plus Medicaid which replaces the current fee for services payment structure. Texas Medicaid is following through with this transition with the goal of reducing nursing homes costs. In an effort to reduce costs the State will move residents who are high functioning into lower cost care environments by not granting medical necessity which is required to be approved for nursing home Medicaid. This effort will decrease the occupancy of nursing homes.
Successful operations at this Center rely on the strengths of the primary leader. To begin, most people prefer to work with likeable people! This leader successfully influences followers through the trait theory of leadership by displaying the qualities of likeability. If someone is liked, his colleagues will seek out every little bit of confidence he has to offer (Casciaro, 2005). This leader’s likeability bridges gaps that might not otherwise be intact between diverse groups found in border towns such as where this Center is located. The positive work relationships this leader’s likeability produces is crucial to the Center’s success as it helps create a positive and productive work environment. Secondly, this leader exhibits strength in decision making through the participative theory of leadership. This leader utilizes strategies such as listing pros and cons or creating a timeline to assist in the decision making process. Then, the leader shares this information with her leadership team and finalizes the decision based on consensus. By implementing these set processes this leader is able to avoid hasty, indecisive decisions. Most importantly, this approach to decision making is successful in this Center because there are plenty of leadership team members who possess the personality traits associated with leadership. Lastly, this leader successfully navigates the role theory through minimizing the primary leadership duties. The Director of Nursing assumes many roles normally assigned to the primary leader. For example, the job description of the primary leader states that the leader is to act as the Center’s Abuse Coordinator and complete and any Plan of Correction related to negative regulatory survey outcomes but the primary leader expects the Director of Nursing to complete these job tasks. In summary, the primary leader has sent this role to the Director of Nursing and the Director of Nursing has received the role.
While it is likely a leader intends to bring their best game each day, leaders do have weaknesses. First, to be effective the Center’s leader must consider the contingency theory and initiate structure to ensure task completion and goal attainment. Failure to initiate structure could result in a negative Center outcome. For example, the business office is responsible for obtaining prior authorization for rehabilitation services covered under Medicare Part B. Members of the management meet with the contracted rehabilitation provider weekly to discuss admission, discharge and change in rehabilitation services. Despite these weekly meetings, the leader failed to ensure the prior authorizations were obtained when a change in business office staff occurred. This failure resulted in a significant loss of revenue. Next, an opportunity lies in this leader’s ability to implement the theory of behavior modification or affect a change in staff behavior which is not consistent with the expectations of the organization. The Center has a history of poor housekeeping services to include sight of waste, debris, clutter and spills. Failure to maintain effective housekeeping services has resulted in resident complaints and accidents. Lastly, this leader fails to be effective at the Situational Leadership Theory by not being the coach and leader needed to develop staff on individual skill areas. A good example of this weakness lies in the ten quality measures affecting the Centers for Medicare and Medicaid Services quality measure star rating which reflects how well the Center cares for residents’ needs. Currently, the Center’s quality measures star rating is considered low or at a 3 on a 1 to 5 rating. In the future, the industry expects this star rating to affect reimbursement through a program called Pay-for-Performance which links quality to payment. Thus, at a 3 star rating the Center can expect to receive a lower reimbursement versus the reimbursement of a 4 or 5 star rated Center. Despite on-going leadership training, this leader has failed to appropriately diagnose clinical management shortcomings in order to provide effective coaching to drive the star rating.
Vast opportunities for growth are emerging at the same time that the pool of high-performing talent capable of seizing those opportunities is shrinking. Those who can stay ahead of the rapid pace of change, anticipate talent needs, and take the lead in developing innovative strategies for the future will likely be tomorrow’s winners (Wilverding, 2008). For future success of the leader and organization, I have developed recommendations consistent with leadership and organization weaknesses. To begin, in order to build each department and department manager to become the leader of the services they provide I recommend the leader assess each using provided organization tools and the Situation Leadership Theory. This assessment will provide the leader with the readiness level of the department and followers with regards to department tasks, functions, and objectives. With this information the leader will be able to diagnose what stage the department and follower is in prior to actually coaching or leading to be successful in a task or responsibility. Following completion of this assessment, I recommend the leader initiate structure by implementing a development plan to strengthen the department and follower to ensure task completion and goal attainment. In addition, the leader should be consistent with follow-up by developing a development plan review schedule. To further motivate desired behaviors this leader should recognize changing behaviors through reward and punishment power. My second recommendation involves the leader practicing customer-focused leadership through continuous resident satisfaction surveys. These surveys will ensure leadership is provided a realistic view of what is happening day-to-day. Each week 15 to 20 residents should be surveyed through five to ten questions derived from grievance trends and negative regulatory outcomes. A tracking tool should be used to compile results by unit for easy trend identification. Following survey completion, the Center leader will conduct a review of each survey and develop and implement an action plan with pertinent Center followers in a team-effort approach. Survey outcomes, both negative and positive, should be shared with all Center followers, and the Quality Assurance Committee to ensure awareness and a team-effort approach to arrive at solutions to identified issues. These satisfaction surveys will provide the feedback to assist in improving quality of care which will lead to an increase in resident satisfaction, as well as provide followers tools to achieve goals. The ultimate goal of this recommendation is for the Administrator to engage the Theory Y by adopting the participative management style. By providing the followers with a pleasant working environment, a leader makes it possible for them to learn new things, be creative, accept responsibility and become successful (Grace, 2015).
Being responsible for the success of a competitive, unpredictable organization involves a significant amount of responsibility. Thus, a leader should practice excellence every day by taking responsibility for organizational strengths, opportunities, weaknesses, threats, themselves and their behavior. After all, organizational excellence begins with the leader!

References
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Figure 1. Line graph showing average number of health deficiencies cited by year.