Effective Governance, Leadership, and Management

 

Question 1: Achieving the right balance among what Drucker described as managing a business, managing work and workers, and managing the facility in community and society will vary from one facility to another. As the NHA of a nursing home, how would you decide which area should be given more emphasis than the others? (150 words minimum)

 

Question 2: You are the administrator of a skilled nursing facility. You open an envelope left in your mailbox and learn that your director of nursing (DON) is resigning, giving you one month’s notice. You have tried to persuade the DON to stay, but her decision is final. Employ the decision-making modelto address this situation. How would you respond? (150 words minimum)

 

Solid governance is the foundation to ensure that a nursing facility is managed with integrity. Even the Affordable Care Act puts new demands in this area on facilities that are certified to serve Medicare and Medicaid beneficiaries. Managing a nursing facility has been complex and will become more so in a rapidly changing health care environment. Hence, well-prepared leaders are needed as never before. This chapter furnishes essential knowledge and practical tools that will prove to be of benefit regardless of whether this is a person’s first exposure to management or whether the individual has had several prior courses in this area.

 

Governance and Corporate Compliance

 

Governance refers to stewardship of an organization’s resources. An organization’s material, financial, and human resources must be used to produce outcomes that benefit the organization’s stakeholders. A nursing home’s main stakeholders are its clients; the community at large; employees; regulators; other health care providers, such as hospitals; and third-party payers.

 

Nursing homes are required by law to have a governing body—referred to as the board of directors, board of trustees, or simply “board”—to oversee the organization and provide broad direction. The board bears ultimate authority and accountability for the organization’s affairs.

 

The Board’s Composition

 

Selection of board members should be guided by the ownership structure and by the organization’s mission. For example, the board of a publicly owned facility will include people who can best represent the organization’s charity mission. The board may include one or two city or county administrative and health officials, a representative of the local social services department, one or two community physicians who mainly serve Medicare and Medicaid clients, a public health nurse, and an official from the local hospital.

 

In privately owned corporations—both for-profit and nonprofit—the board generally includes some corporate officers, such as the corporation’s president or chief executive officer (CEO), the vice president of operations, the vice president of human resources, and the chief financial officer (CFO). In these organizations, it is often a mistake not to include representatives from the community and some local business leaders. Also, regardless of the type of ownership, the nursing home administrator (NHA) should be a member of the board.

 

Board members should be selected from among respected leaders in the community on the basis of their qualifications and character. The skills and social standing of potential board members should be carefully reviewed to help select people who can provide technical expertise in health care, finance, law, or public relations to the extent possible; represent the community and clients; and bring their own individual perspectives to the operation of the facility.

 

The Board’s Functions

 

In the public sector, the board will focus particularly on the facility’s charity mission while also ensuring that the facility remains financially viable. In the nonprofit sector, the special focus should be on meeting the health care needs of the community, which should include a charity function to justify the corporation’s tax-exempt status. In the for-profit sector, maximizing profits and creating value for the owners or shareholders are the main goals. Long-term care facilities operated by various religious organizations, which are private, nonprofit entities, may adhere to certain religious tenets, spiritual values, and moral commitments upheld by the sponsoring organizations.

 

The NHA reports to the board and looks to it for general direction. In effectively managed organizations, a close relationship based on trust, mutual commitment, communication, and professionalism exists between the board and the administrator. The main responsibilities of the board are summarized as follows:

 

•  Appoint a qualified administrator to manage the facility. Clarify performance expectations.

 

•  Periodically review the administrator’s performance, determine compensation, and make decisions about the administrator’s continuing employment.

 

•  Establish or review the mission and vision for the facility and assist the administrator in establishing a strategic plan that is periodically updated. Establish or approve major goals and objectives for the organization.

 

•  Establish broad policies that provide adequate guidelines to the administrator in making decisions pertaining to finance, budgets, quality of patient care, building and equipment, staffing, employee relations, and legal and ethical conduct.

 

•  Establish policies to protect patient rights.

 

•  Provide needed support to the administrator by procuring technical expertise when necessary and by committing adequate resources so that the facility can be effectively managed and an acceptable level of patient care can be delivered.

 

•  Oversee the facility’s operations and outputs. Because of its legal accountability, the board must ensure the facility’s compliance with quality standards, financial goals, and legal and ethical expectations.

 

Although the board has the primary responsibility for the functions just outlined, the NHA should be actively involved in developing policies, mission and vision, and strategic direction for the facility. As a general rule, the board exercises due vigilance, but without undue interference with the NHA’s job. How much autonomy the NHA is given to make independent decisions, however, depends on his or her level of skills and experience. The NHA must keep the board updated and informed on substantive operational matters, such as quality issues, deficiencies cited on survey inspections, any legal issues, any negative publicity, budgetary compliance, need for resources, and staffing-related issues.

 

Role of the Nursing Home Administrator

 

The NHA acts as the agent of the board and is responsible for the day-to-day management of the nursing facility. In managing the facility, the NHA must provide leadership and direction to the department heads. The NHA also has the primary operational responsibility for human resource management, marketing and public relations, budgetary compliance and financial management, and quality and productivity management.

 

Corporate Compliance

 

Accountability to the various stakeholders is the essence of corporate compliance. Compliance with the various laws and regulations is a very basic expectation. The Affordable Care Act adds two main requirements for certified nursing facilities (Farhat, 2013): (1) they must institute effective compliance and ethics programs, and (2) in case of a facility closure, they must provide a written notice at least 60 days prior to closure. Governance efforts, however, must go beyond the legal and regulatory realm to incorporate standards of ethics and to “do what is right.” The organization’s officers must govern with integrity. They must be vigilant, and they must voluntarily take corrective steps before issues turn into major legal and ethical dilemmas.

 

An effective corporate compliance program must satisfy seven conditions (Boyle et al., 2001; P. Willging, personal communication, January 5, 2009):

 

  1.  Compliance standards and procedures to be followed by the employees must be developed. Although legal compliance is critical, of equal importance are dealings with clients and associates. For example, standards should emphasize the importance of forthright advertising and full disclosure, the requirement for honest assessments of patient conditions and needs, and the imperative of treating both residents and associates with dignity and respect.

 

  2.  A high-level corporate officer—such as the vice president of human resources or the vice president of operations—must be assigned to administer and oversee the program. The corporate compliance officer must have direct access to the company’s CEO.

 

  3.  Effective lines of communication must be established and assured. Managers must be open and honest in conveying the company’s expectations to the associates. Associates must feel comfortable in both questioning and informing management on issues that may be of concern to them.

 

  4.  All associates must be trained so they become familiar with corporate standards. Associates must also understand the procedures to follow when violations of the standards are observed.

 

  5.  An internal review and audit protocol must be implemented. Establishing standards of behavior, communication, and training are not sufficient to ensure that the system is working. Verification procedures are a must. Such procedures should spot check not just the adherence to standards of conduct but also associates’ belief that standards are being adhered to. It is also important to verify whether the associates feel that violations of acceptable behavior can be reported without fear of retribution. For example, a hotline or toll-free phone number can be instituted to facilitate confidential reporting of violations.

 

  6.  Protocols must be established to investigate all allegations of violations. If a violation is found, disciplinary action must be taken. Depending on the perceived severity of the apparent violation, consultation with legal counsel may be necessary. Legal counsel can help ensure that contemplated disciplinary action will not violate any federal or state laws, or a union contract.

 

  7.  After a violation is detected, all reasonable steps to respond to and prevent further violations must be instituted.

 

The Effective Administrator

 

Effective NHAs come in all shapes and sizes; the only thing they may have in common is the ability to get things done (Drucker, 1985). The NHA should function as the general manager of a nursing facility. As discussed later, the NHA must have both leadership and management skills. According to Drucker (1974), an effective manager must find the right balance among three domains:

 

•  Managing the business aspect

 

•  Managing work and workers

 

•  Managing the organization in community and society

 

A balance among the three is necessary because “a decision or action that satisfies a need in one of these functions by weakening performance in another weakens the whole enterprise” (Drucker, 1974, p. 398). Thus, effective management becomes a skillful juggling act; it requires expertise in various management disciplines.

 

Managing the Business Aspect

 

Here, the term business is used in the sense of economic performance (Drucker, 1974), which applies to all ownership types. The essence of business management lies in using resources in a manner that adds value (i.e., worth as perceived by the facility’s key stakeholders). The added value that society expects from a nursing facility is affordable patient care that meets certain generally agreed-upon standards of quality. Even though what is “affordable” and what constitutes “agreed-upon standards of quality” are not clearly defined, taken together these terms mean that a nursing facility must satisfy the patients, their families, and the payers. Because the payers include those who pay the facility directly on a private-pay basis as well as government payers—mainly Medicare and Medicaid—who pay indirectly out of taxes levied on citizens, society as a whole has expectations that nursing facilities achieve the twin goals of affordability and quality.

 

Managing Work and Workers

 

One of the essential functions of management is to make work productive (Drucker, 1974). Productivity incorporates quality as a major output that results from the use of resources over which management has control. Productivity maximizes quality for each unit of resources used in delivering health care. In simple words, the facility must improve quality while reducing costs.

 

To make work productive, managers must first understand what work needs to be done and how to organize it (The entire Part III of this book is devoted to understanding and organizing various tasks necessary for effective delivery of services). Direct hands-on patient care, as well as support services, are essential for achieving and maintaining quality standards.

 

A second and often a more difficult task in achieving productivity is building a cooperative spirit among the workers through leadership and motivation. The challenge for the effective NHA lies in creating a workplace environment in which each person contributes his or her best efforts toward organizational goals. The effective NHA understands that if work and workers are mismanaged, organizational performance will suffer no matter how good the NHA may be in managing the business side of the operation (Drucker, 1974).

 

First, the organization must offer rewards—wages, benefits, and opportunities for individual development and growth—that are at least commensurate with what the associates bring to the organization. The organization can do several additional things to create work environments in which exemplary associates would flourish, find satisfaction, and boost their self-esteem (Kelley, 1998):

 

•  Remove roadblocks to productivity by shielding associates from excessive bureaucratic demands that may interfere with getting real work done. Workers must fill out papers and reports and attend meetings, but such demands can be overdone.

 

•  Associates should be left alone to do their jobs and should be kept free of constant interruptions from administration. Facility administrators can “keep their fingers on the pulse” but also promote self-management because most workers want to manage themselves.

 

•  Participative management is fine, but most workers want to be involved only in decisions that affect them. Above all, exemplary workers are not interested in knowing the trivia about their boss’s jobs or their personal lives.

 

•  Although associates want to manage themselves, the NHA must make sure that the various departments’ efforts come together. An important aspect of administrative responsibility is to fill any chasms between departments and to promote interdependencies that will enhance the value of the services delivered.

 

•  People are interested in knowing what outcomes their efforts have produced. Similarly, the value added by the synergistic use of interdependencies should be disclosed to associates to promote ongoing cooperation between departments.

 

Managing the Facility in Community and Society

 

In Drucker’s words, “None of our institutions exists by itself and is an end in itself. Every one is an organ of society and exists for the sake of society … Institutions must be part of the community … Mismanaging social impacts eventually will destroy society’s support for the enterprise and with it the enterprise as well” (Drucker, 1974, pp. 41–43). From this perspective, the effective administrator must frequently evaluate whether the facility is making positive strides in connecting with the community and whether it is adequately discharging its responsibility toward society. The latter requires a constant striving to seek excellence in caregiving and upholding the highest standards of ethics.

 

Leadership

 

The Meaning and Purpose of Leadership

 

Leadership can be defined as influencing people to act for certain goals that represent the wants, needs, aspirations, and expectations of both leaders and followers (Burns, 1998). Although leadership can have many different meanings, Northouse (2001, p. 3) concluded that four main components are central:

 

•  Leadership is a process that requires continuity. It is also interactive and involves give and take between the leader and followers.

 

•  Good leadership affects the followers in a positive way. Leaders use their influence to direct people toward a common purpose.

 

•  Leadership occurs within a group or “people” context. Leadership finds its meaning in relation to other people. Hence, a genuine care and concern for those being led makes leadership effective.

 

•  Leadership involves goal attainment. Leaders direct their energies toward individuals who are trying to achieve something together.

 

The following words on leadership have been ascribed to the Chinese philosopher Lao Tse, who lived in the 5th century B.C.:

 

A leader is best when people barely know that he exists,

 

Not so good when people obey and acclaim him,

 

Worst when they despise him.

 

Fail to honor people, they fail to honor you.

 

But, of a good leader, who talks little,

 

When his work is done, his aim fulfilled,

 

They will say, “We did it ourselves.”

 

The entire process of leadership is people focused. Hence, the signs of outstanding leadership appear primarily among the followers. Are the followers reaching their potential? Are they learning? Are they devoted to serving? Do they achieve the desired results (DePree, 1998, p. 130)?

 

Leadership Attitudes and Styles

 

Much has been written about leadership styles that explains how leaders think and act when managing workers. Leaders’ behaviors emanate from their general attitudes and assumptions about workers. Leaders’ personal styles are also oriented in varying degrees toward relationships and tasks. Finally, leadership is situational.

 

Two-Model Theory

 

To explain management behavior, Douglas McGregor (1906–1964) proposed two models known as Theory X and Theory Y, which present two contrasting assumptions leaders make about workers. According to Theory X, leaders assume that:

 

•  Workers are lazy.

 

•  They dislike work and responsibility.

 

•  They will avoid work if not closely supervised.

 

•  They are indifferent to organizational needs and goals.

 

Traditional leadership was based on Theory X and focused on monitoring and controlling people in the organization in an effort to make them obey managers’ orders or face negative consequences. Theory X assumptions lead to task-oriented behaviors on the part of leaders, as opposed to relationship-oriented behaviors; such leaders will have a tendency to adopt a directive style (Figure 14–1). Directive leadership can be characterized as take-charge, one-directional, and single-handed decision making by the leader. Directive leadership involves giving orders, establishing goals and methods of evaluation, setting time lines, defining roles, and establishing methods and processes for achieving the organization’s goals (Northouse, 2001, p. 57).

 

In what McGregor called Theory Y, leaders have the opposite attitudes toward workers:

 

•  Workers want to take responsibility.

 

•  They like challenging work.

 

•  They desire opportunities for personal development.

 

•  They want to help achieve organizational goals.

 

Leaders who espouse a Theory Y perspective are likely to adopt relationship-oriented behaviors and will be inclined to use a participative or a delegative style of leadership (Figure 14–1). This relationship orientation results in supportive behaviors in which open communications, listening, praising, asking for input, and giving feedback are important (Northouse, 2001, p. 58). The main characteristic of the participative style is involving other people in decision making and giving their ideas due consideration. The leader may present ideas and invite feedback from workers or solicit new ideas from them. In the delegative style, leaders derive considerable satisfaction from giving decision-making responsibilities to their associates (Brody, 2000).

 

Two-Dimensional Model

 

In the mid-20th century, several independent research studies resulted in two-dimensional models of leadership comprising task orientation (also called production orientation, or initiating structure) on one end of a continuum and relationship orientation (also called person orientation, or consideration) at the other end. The main contribution of the two-dimensional theory has been in highlighting that leadership is not necessarily a dichotomous phenomenon, as suggested by Theory X and Theory Y. A leader could be oriented toward both tasks and people, albeit in various degrees, depending on the leader’s predominant attitude whether it is embedded in Theory X or Theory Y. Accordingly, Blake and Mouton (1964) proposed a managerial grid in which each leader could be rated on both task orientation and person orientation and be classified into one of five leadership styles

 

1.  Impoverished management. Characterized by low task orientation and low person orientation, these leaders remain hands off and aloof. An NHA who spends little time at the facility and does only what is necessary to keep his or her job falls in this category. Long-term success of such administrators is highly questionable.

 

  2.  Task management. These leaders are highly task oriented. They are mainly concerned with getting work done and have minimal concern for people. A highly directive style becomes necessary for situations that require critical action or for turning around a failing operation.

 

  3.  Country-club management. These leaders rate very high on person orientation. They are concerned mainly with creating a pleasant and harmonious working environment and have little concern for accomplishing tasks. In rare situations, a facility may have highly skilled and self-directed department managers where such a style may work. A change in style would be necessary when the situation demands.

 

  4.  Team management. These leaders rate high on both person orientation and task orientation. They value their workers and solicit their participation in setting goals, making decisions, and accomplishing tasks. They try to achieve a healthy balance between directing the work of their subordinates and empowering them to make decisions.

 

  5.  Middle-of-the-road management. These leaders seek the middle ground and keep a moderate amount of balance between relationships and tasks. These leaders are generally able to maintain the status quo.

 

Situational Leadership

 

Contemporary management theories recognize that leadership styles must fit the situation. Different situations demand different styles, and to be effective, leaders must change their styles according to the situation. Conceptually, this situational approach is similar to Blake and Mouton’s managerial grid model. Instead of using task orientation and person orientation, the two dimensions in the situational model are directive and supportive behaviors. The situational model, however, goes beyond Blake and Mouton’s by suggesting that a leader should apply an appropriate measure of both directive and supportive behaviors as dictated by the competence and commitment of each worker or group (Figure 14–3):

 

•  Directing style, characterized by high directive–low supportive behavior, is appropriate when the development and commitment levels of a subordinate or group are low. The leader focuses on giving specific instructions and engages in close supervision.

 

•  Coaching style, characterized by high directive–high supportive behavior, is useful when the development and commitment levels of a subordinate or group are moderate to low. The style requires focusing on goals while soliciting input from the subordinate and giving encouragement.

 

•  Supporting style, characterized by low directive–high supportive behavior, is useful when the development level of a subordinate or group is moderate to high. In this approach, the leader uses supportive behaviors that bring out the employee’s skills. The subordinate is given flexibility in routine decisions, and the leader is available for consultation as needed. Listening, praising, asking for input, and giving feedback are commonly employed.

 

•  Delegating style, characterized by low directive–low supportive behavior. The delegating leader lessens his or her involvement in planning, control, and goal clarification. Once agreement is reached on what must be done, the subordinate or group takes responsibility for getting the job done (Northouse, 2001, pp. 57, 58).

 

Implications of Leadership Theories

 

Today, success in achieving high performance depends on building a deep sense of commitment among associates, not obedience extracted by threats. A basic premise of leadership is the belief that most people want to achieve success in their own careers: they want to accomplish something in their current positions and demonstrate their competence by doing their jobs well. People want to be respected for what they know and what they can do. They expect management’s support and training for things they do not know or cannot do so they can grow and develop into better workers. They want to be recognized for their demonstrated competence and accomplishments. An effective leader taps into people’s aspirations by aligning clearly defined facility objectives with the followers’ areas of responsibility. Leaders must direct but also engage their followers. Leaders must serve as role models and mentors, not martinets. “Leaders must try to make their fellow constituents aware that they are all stakeholders in a conjoint activity that cannot succeed without their involvement and commitment” (Gini, 1998). Bringing about nursing home culture change relies as much on sound leadership as it does on enriching the physical environment and delivering care according to the principles of person-centered care.

 

Building commitment requires a management philosophy in which associates are considered key stakeholders in the facility’s success. As stakeholders, associates also share in the rewards reaped from the organization’s success. In the commitment-based approach, each organizational unit in the facility functions as a team that is held accountable for performance. Continuous improvement is emphasized, in accordance with the expectations of clients and society. Compensation policies are based on group achievement. Some of the main obstacles to the commitment approach are the slow change in management philosophies and practices, uncertainty, and fear of exposure to possibilities for failure (Walton, 1992).

 

Research shows that, in nursing facilities, leadership styles can influence quality of patient care. For example, a leadership style that values consensus has a strong association with better quality (Castle & Decker, 2011) and reduced staff turnover (Donoghue & Castle, 2009). Consensus refers to seeking staff input on decision making and enabling caregivers to make meaningful decisions in their work—something that clearly requires leaders to incline significantly toward person orientation.

 

One may think that task orientation has no place in contemporary leadership. Although most research favors person orientation for achieving positive results, one study showed a significant positive relationship between workers’ (nurses and nursing assistants) job satisfaction and task-oriented leadership in an environment characterized by low staff stability (Havig et al., 2011).

 

Management

 

There is no universally accepted definition of management. In a very simplistic sense, management is what managers do to maintain an organization and to get things accomplished on a daily basis. Management is the “glue” that holds an organization together; it is the “oil” that keeps the organization functioning as smoothly as possible to fulfill the main purpose for which the organization exists. Management requires the efficient use of resources to accomplish organizational objectives. Hence, management is essential work without which an organization will slowly disintegrate into chaos. Effective management is mainly about managing stability; it is about finding what works and doing it well. Consistently pursuing this objective institutionalizes excellence and places the organization in an enviable position to respond to well-studied change whenever change is necessary to enhance value for the stakeholders.

 

Describing what managers do can be complex. However, management theorists have tried to simplify the understanding of management by describing management roles and functions.

 

Management Roles

 

During the course of a day, the NHA will function in a variety of roles. For example, the NHA’s day may begin by walking over to the dining area for a cup of coffee. On her way back to the office, the maintenance man stops and informs her that he would have to leave at noon to take his sick child to the doctor. The NHA may respond, “Certainly … and, oh, by the way, Sam, make sure Mr. Hollinger’s wheelchair gets fixed before you leave. I don’t want to hear from his daughter again.” Next, she stops to chat with the director of nursing (DON) about the salary she would be willing to offer to hire the night charge nurse they had both interviewed 2 days earlier. As soon as she sits down in her office and takes a sip of coffee, the social worker comes in and asks whether the facility will cover the cost of a lost hearing aid for a patient because Medicaid will not pay for it. Then, the receptionist comes in and hands her two messages about phone calls that came in earlier, one from the vice president of operations at the corporate office and the other from a family member. The NHA spends the next 20 minutes returning the two phone calls. The vice president of operations wanted to know why the accounts receivable had escalated during the previous month. A patient’s daughter wanted to report that the nurse was very rude to her the previous evening when she asked the nurse about why the leaky faucet in the patient’s room was still not fixed. The NHA spends the next 45 minutes in a department head meeting. She announces that the state had accepted the plan of correction submitted in response to the last inspection. To thank the department heads, she would like to plan a luncheon at a nice restaurant. Going forward, the facility should implement some changes to ensure future compliance. After the meeting, she receives a phone call from the local chapter of the American Red Cross inquiring whether the facility would participate again in the annual health fair. At 3:00 p.m., the NHA informs the receptionist to hold all phone calls and not to disturb her unless there is some urgent matter because she needs to set aside some undisturbed time to work on the budget for next year. Before going home at 6:00 p.m., the NHA tours the nursing areas and dining room and talks with a few residents. As she drives back home, she makes a mental note about setting up a luncheon meeting with the state representative for her area to discuss budget cuts proposed by the state’s governor that may affect Medicaid reimbursement.

 

On the basis of his observation of managers on the job, Henry Mintzberg identified 10 different but highly interrelated roles:

 

  1.  The figurehead role is symbolic and ceremonial. At the annual picnic, the NHA may grill hamburgers for the associates. Later, he or she may give out service awards.

 

  2.  Role of the leader is associated with staffing, motivation, training, performance evaluation, and disciplining.

 

  3.  The liaison role deals with relationship building, mainly outside the organization. For example, the NHA builds relationships with the local fire department and the local hospital and is an active participant in civic associations. The relationships pay off in terms of expertise and support that external agencies can provide.

 

  4.  In the monitor role, the NHA keeps him- or herself informed of changes occurring in the legal, political, economic, social, and technological areas. This information could be of strategic importance. For example, remaining current on legal and regulatory changes, learning about what the competition is doing, and understanding social and cultural changes taking place in the industry can have implications for the nursing facility’s long-term success.

 

  5.  As a disseminator, the NHA provides information to others. In this role, the NHA keeps the board informed on important matters, discusses issues with the department heads, and highlights the facility’s services to educate the local community.

 

  6.  In his or her spokesperson role, the NHA represents the organization to outsiders. For example, the NHA may discuss plans for future services with the chamber of commerce. The NHA may be invited to discuss the nursing home’s rehabilitation program with the physicians at the local hospital, or she may address the local media on the opening of a retirement center adjacent to the nursing facility.

 

  7.  In the entrepreneur role, the NHA initiates plans to bring about certain desirable changes. For example, the NHA may plan to convert some of the existing beds for specialized care.

 

  8.  As a disturbance handler, the NHA solves problems and addresses areas that require corrective action. Certain problems arise unexpectedly. For example, the DON resigns abruptly. Other problems may be chronic in nature and call for long-term solutions. For example, absenteeism and turnover are chronic problems in many nursing homes.

 

  9.  As a resource allocator, the NHA must decide how to distribute limited resources. Here are some examples: Should the facility hire a janitor or a certified nursing assistant (CNA)? Should it create the position of a medication aide? Should it spend money on an electronic medical records system, or should that money be spent on a new whirlpool bathing system?

 

10.  In the negotiator role, managers bargain to gain certain advantages. For example, the NHA may approve a new bathing system provided overtime in the nursing department is cut in half. The NHA may approve a dollar per hour extra pay when nurses and CNAs come in to work at short notice on their days off to alleviate short staffing.

 

Management Functions

 

In classical management theory, four basic management functions have been identified to better understand managerial tasks. The four functions are planning, organizing, leading, and controlling.

 

Planning

 

Planning includes defining or clarifying the organization’s mission, establishing objectives, and planning a course of action to achieve those objectives. Planning is forward looking. It requires deciding in advance what to do, how to do it, when to do it, and who is to do it. It makes it possible for things to occur which would not otherwise happen (Koontz & O’Donnell, 1972).

 

Plans can be routine, periodic, or strategic. While driving to work, NHAs routinely think about certain things they plan to address that day. They plan agendas for the regular department head meetings. The annual budget is an example of periodic planning. Strategic plans are long-range plans that are generally in response to changes occurring in the legal, political, economic, social, and technological areas. They often require a cost–benefit analysis. For example, given that many nursing facilities have incurred lawsuits and financial penalties for lapses in quality, would it make economic sense to invest in an electronic medical records system that incorporates assessment, care planning, and decision making in accordance with clinical practice guidelines? Various short-range plans are needed to accomplish the long-range plans. For example, major renovations of the facility would require short-range plans about hiring a decorator, engaging a contractor, making alternative arrangements for the continuity of services, etc.

 

Organizing

 

Organizing includes determination of what tasks are to be done, who is to do them, how the tasks are to be grouped, who reports to whom, and where decisions are to be made (Robbins, 2000). Even after an organization has been functioning for a while, the organizing function becomes necessary. For example, a decision to operate a laundry in house instead of relying on contracted services calls for organizing. It requires decisions such as how many associates need to be hired, what functions will each perform, who will manage them, and so forth. In other areas of nursing home operation, new technology may eliminate certain positions or may alter their job responsibilities.

 

There are certain well-established principles of organization that NHAs should pay attention to:

 

•  Departmentation and division of work is a long-established principle to organize related functions within departments and assigning responsibilities to various positions within those departments. Organizational changes are made as needs change because of technology, growth of the organization, or launching into new services. Cross-trained self-managed work teams may be organized to change traditional functions when necessary.

 

•  Line and staff relationships clarify who reports to whom and who in the organization have formal supervisor–subordination relationships. In an organizational chart, the solid lines indicate line relationships, showing the chain of command. Dotted lines indicate staff relationships, which are advisory in nature. The medical director, for example, formally reports to the administrator in a line relationship. There is staff relationship between the DON and the medical director. In other words, the medical director is not the DON’s boss, the administrator is. Conflicts often arise when line and staff relationships are confused. An organizational chart should include every position in the facility to show where employees can go when they need answers. Within the formal structure, members are granted authority over certain functions, held accountable for certain results, and given incentives for achieving those results (Griffith & White, 2002).

 

•  The principle called unity of command means that a subordinate should report to only one supervisor. Otherwise, the subordinate may be subjected to conflicting demands and priorities. On the other hand, unity of command is not absolute. A subordinate may have encountered problems with his or her superior. Efforts should first be made to resolve issues directly with the superior. However, associates need appropriate mechanisms to have their grievances addressed at a higher level. For example, associates should be able to bypass the chain of command to address problems related to harassment by a superior, favoritism, unethical conduct, corporate compliance issues, and other situations in which a superior may be misusing his or her authority.

 

•  Delegation of authority is another organizational principle. Authority refers to the right of making decisions without having to obtain approval from a higher-up (Ivancevich et al., 1980). Worker empowerment is characterized by a greater degree of delegation than traditional management, particularly for decisions regarding patient care.

 

Leading

 

Leadership and management are closely intertwined, but the two are not the same. Leadership is an essential tool for effective management. Through leadership, managers influence, inspire, and motivate associates to deliver the various services according to established organizational policies and standards. Management, however, goes beyond being a leader. Management requires skills in planning, organizing, and controlling.

 

Controlling

 

To ensure that things are going as they should, the NHA must monitor the organization’s performance against goals and standards. The process of monitoring, evaluating, and correcting constitutes the controlling function (Robbins, 2000). It is about controlling the structures and processes, not about controlling or manipulating people.

 

The functions of planning, organizing, and controlling are closely intertwined. Planning determines what results will be achieved, organizing specifies how those results will be achieved, and controlling determines whether the results are achieved (Ivancevich et al., 1980). In nursing home administration, the control function is perhaps best illustrated by compliance with the Requirements of Participation. The NHA must ensure that those standards are understood. Staffing, equipment, policies, and procedures must be in place to accomplish them. Training must be provided as needed. Associates must be motivated through leadership to “buy into” compliance with the standards. Internal review and monitoring systems must be established to evaluate compliance. Finally, reasons for noncompliance must be investigated, and corrective steps must be taken to ensure future compliance.

 

Tools for Effective Management

 

In this section, some of the main tools of effective management are discussed. These tools provide the necessary means for planning, for converting plans into actions, and for day-to-day management of the facility.

 

Vision and Mission

 

How does the administrator, and for that matter the other members of the organization, know that a certain course is indeed the right direction for a nursing facility? Operating an organization without a clearly defined vision and mission is like navigating in the open seas without a compass. The vision and mission comprise an organization’s guiding philosophy (Collins & Porras, 1998). Although much has been written about vision and mission, a lack of clarity still persists about what they are. In terms of focus, a vision is about the organization, whereas a mission is about key stakeholders—the customers, the community, and the associates.

 

The vision is a compelling picture of how an organization will look and function when its main objectives are achieved (Ciampa& Watkins, 1999). The purpose of a vision statement is to clarify what an organization should become, and to provide a long-range direction to the organization. For example, a nursing home’s vision may be to incorporate evidence-based practices into a changing cultural environment.

 

An organization’s mission defines its basic purpose and enunciates why the organization exists. A nursing home’s mission statement should incorporate its distinct competencies, its clients’ needs, and its relationship to the community. Exhibit 14–1 provides an example of a mission statement. The mission is derived from and is closely connected to the vision. However, the mission emphasizes the benefits that would accrue to patients and their families, the associates, and the community as the organization goes about the business of achieving its vision.

 

Accomplishing the vision and mission is not just a managerial activity. Organizational purposes and direction must be widely shared within the organization. A turning point occurs when the associates begin to share the vision of what can be accomplished and to put their energies behind it (Ross et al., 2002, p. 49).

 

Values

 

The way in which the members of a facility collectively think about what they do—and how they relate to patients, families, and coworkers—is based on certain beliefs and assumptions. Individuals have personal beliefs and values, which guide their thinking and behaviors in various social settings, including work. Such individual beliefs and values are likely to permeate the workplace in a sort of conflicting network unless the NHA clearly defines and communicates the core values on which the facility will base all its decisions, judgments, and actions.

 

Exhibit 14–1    Example of a Mission Statement

 

We pledge uncompromising dedication to excellence in helping older adults grow in spirit, live with a sense of fulfillment, experience dignity, and meet the challenges of their changing lives.

 

We aspire to be consistent in the quality of our care, distinctive in our approach, and outstanding in performance and to provide leadership in the field of service to older adults.

 

We welcome others who will join us in pursuit of our mission.

 

Values constitute principles and ideologies “held sacred” by an organization. Organizational values underscore the moral principles by which the organization will be governed as it goes about the business of realizing its vision and mission. Once the values have been defined and communicated, they are viewed by the stakeholders as standards that define the attitudes and philosophies according to which the members of the organization can be expected to behave. When values are clearly defined, communicated, and integrated into decision making and actions, over time they become the main driving force of an organization’s culture.

 

Administrators and corporate officers should develop a set of values that are relevant to the institutional delivery of long-term care. These values should be communicated to all members of the organization and, more important, should be espoused in routine conduct and decisions. As examples, some of the relevant core values are:

 

•  Respect: How administration and associates are expected to treat coworkers, clients, and other stakeholders

 

•  Honesty: How administration and associates will conduct their affairs so that their ethics are beyond reproach

 

•  Openness (or transparency): What information the stakeholders can expect facility administration to share with them

 

•  Fairness: How administration and associates will conduct their affairs to promote equality and justice

 

•  Quality: How quality is defined and how it will be incorporated into the services provided

 

•  Economic gain: Articulation of why profits are important and how profitability would accrue benefits for relevant stakeholders, such as better technology that would improve clinical care

 

Organizational values also play a vital role in hiring key associates. Besides considering a potential jobseeker’s qualifications and other desired characteristics, the jobseeker’s values should match those of the facility. Dissonance occurs when employees’ values are incompatible with those of the organization, and this mismatch creates cultural discord. A discord in values can eventually lead to dissatisfaction and turnover, which in turn create organizational instability (Singh & Schwab, 1998).

 

There can be substantial differences in core values among facilities operated under for-profit, nonprofit, and public ownerships. Business literature affirms that matching of values is a critical factor in achieving organizational success. For example, studies by Fernández and Hogan (2002) concluded that “the most effective CEOs were those whose values were most like those of the firm, rather than those who had the greatest knowledge of the firm’s industry” (p. 26). The lesson here is that governing boards must take into account a candidate’s core values, including leadership styles, when hiring NHAs. Similarly, candidates seeking NHA positions should try to discover the organization’s values by asking appropriate questions during the job interview and should evaluate the organization’s values against their own values to see whether a good match exists.

 

Decision Making and Problem Solving

 

Decisions are made by people at all levels in an organization, and decisions made at lower ranks are not necessarily less important than those made by the NHA. The main differences between decisions made by lower-level employees and those made by the NHA are in the quantity and complexity of decisions, in their strategic or tactical significance, and in the processes used for making them. Decisions at lower levels are routine and are often guided by established goals, rules, policies, and procedures that facilitate decision making. Routine problems are also better addressed by workers who are closest to their own areas of responsibility.

 

Decision making is commonly defined as choosing from among different alternatives. Problem solving also requires decision making, although not all decisions involve problem solving. The alternatives a decision maker considers must be relevant to actions needed to accomplish the desired objectives. The processes followed for setting objectives, for exploring different alternatives to achieve the objectives, and for selecting from among stated alternatives often involve a rather complex interplay of facts, opinions, judgments, and dissenting views, as well as consensus. These factors are carefully weighed to arrive at a decision. For leaders, it may be important to seek consensus in some situations. In other instances, the leader would encourage people’s input but make the final decision. Regardless of how the final decision is made, suggestions about possible alternatives as well as information and opinions provided by participants are valuable. An explanation of how and why a particular decision was made may help people understand that their thoughts and views were valued.

 

The NHA should always be aware that the decision-making process may be tainted with personal biases. Personal biases are not always easy to acknowledge. People’s opinions and judgments incorporate biases that may emanate from their own value systems, past experiences, likes and dislikes, and emotions.

 

Intuition generally plays a role in decision making, because few ideas are subject to factual analysis. Informed opinions and judgments must therefore be taken into account. On the other hand, data-driven decision making can help reevaluate old assumptions or challenge conventional wisdom. Certain decisions require analysis of facts, such as a careful recounting of events as they had occurred, official interpretation of a regulation, information on what competitors are doing, or data on the facility’s financial performance. Sometimes, organizations must stray from the norms and look for the “wild card” when making decisions on key issues. The wild card is the instinct for the right time to act—or not to act—in spite of data that may indicate the contrary. Taking some risk and acting according to unconventional approaches can stimulate organizational innovation (Ross et al., 2002, p. 235).

 

The principal criterion for weighing alternatives is the consequences a particular course of action is likely to produce. Another key factor that must be considered while evaluating alternatives is the feasibility of implementation. Sometimes the best alternative has to be rejected because resources needed for its implementation are not available, or it may be too costly to implement, or it may not fit the time schedule for action.

 

Once a decision has been made, it must be implemented. Finally, its progress and outcomes must be evaluated to determine whether the desired objective is being reached. Figure 14–4 presents a general model for decision making and problem solving. Rational decision making, as opposed to intuitive decision making, is a systematic process that begins with carefully evaluating the status of a given situation and articulating what is desired.

 

Implementation of the chosen alternative requires clarifying what steps will be taken and who will do what and deciding on how progress will be monitored. Managerial control is necessary to monitor progress, evaluate results against the objective, assess deviations, and take corrective action.

 

Effective Meetings

 

Meetings are an essential tool for management because they promote participation and personal interaction. Open-ended discussion of issues is often richer and more creative than isolated thought and action (Ware, 1992). Meetings can be a valuable tool when important information must be disseminated to people, particularly when personal interaction such as comments from people or gauging people’s reactions are important to managers. Announcement of some change that may have a significant effect on others is better handled in a meeting than through written communication. Sometimes, information is personally conveyed because of its symbolic value, such as achievement of a major goal by the facility. Similarly, a meeting can be an effective avenue for reinforcing the organization’s essential values, mission, and broad organizational objectives (Brody, 2000, p. 250).

 

Meetings are also essential when input from others is considered vital for decision making or problem solving. Such meetings may be either for the purpose of information exchange or for actually making a group decision. Problem-solving meetings provide an opportunity to combine the knowledge and skills of several people at once, and participants are selected on the basis of their potential for contributions (Brody, 2000). Generally, information exchange and problem solving should not be combined in the same meeting (Ware, 1992). Other meetings may be routine. In such meetings, “keeping in touch” on a regular basis is valued by the participants. Department head meetings generally fall in this latter category, although they are also used for keeping members abreast of any changes, discussion of operational issues, information exchange, and problem solving.

 

Whenever people get together as a group, some socializing and casual exchanges occur naturally. Open-ended meetings often have a tendency to drift along almost endlessly without accomplishing much of anything. However, even informal meetings can be given a sense of direction by having an agenda, which may or may not be formally written. An agenda helps the NHA focus on the meeting’s purpose, and it provides a plan that helps sort out relevant and irrelevant topics during the discussions. Another effective technique is to distribute ahead of time an annotated meeting agenda called a docket. A docket differs from an ordinary agenda in that the docket lists not only the items to be discussed but also provides pertinent explanations and details for each item. By saving time, a docket can be effectively used to cover a number of items in a short time (Brody, 2000). The participants can also place items for discussion on the agenda or the docket.

 

Every meeting with a clear purpose behind it needs some preparation. Once the agenda is established, preparation for a meeting requires collecting relevant information. The NHA should also think about how the information will be communicated, whether it will be communicated verbally, on a flip chart or chalkboard, in a handout, or using a PowerPoint presentation. If information from other participants is needed, they should be notified ahead of time and advised as to what exactly they should bring to the meeting. At other times, it may be necessary for all participants to review certain information before they come to the meeting. In that case, the materials should be delivered to participants well before the meeting so they have time to prepare.

 

Before a meeting ends, clarifying what should happen next is important. All items requiring follow-up should be reviewed. If certain individuals have responsibility for following up on something, that responsibility should be clarified along with any time schedules by which certain actions ought to be taken. If a follow-up meeting is necessary, it should be scheduled then and there (Ware, 1992).

 

The administrator is also likely to be involved in meetings with external stakeholders. In such meetings, the NHA should keep in mind a clear purpose but be willing and open to new ideas and face reality, ask questions, and, if it is relevant, explain how the facility can deliver value, or how a proposal can materialize into a win–win outcome for both the facility and the other party.

 

Conflict Management

 

Conflict is unpleasant, but it is an unavoidable aspect of an organization. Conflict is often dysfunctional to the organization, but it can also be functional if it stimulates innovation and adaptability. Conflict can be psychologically healthy for people when it enables them to vent frustrations in a constructive manner. According to modern organizational theory, too little conflict can lead to unhealthy conformance, poor decision making, and stagnation, whereas too much conflict can lead to uncooperative behavior, loss of productivity, turf battles, and sabotage.

 

An understanding of conflict can be used as a managerial tool to assess how strongly certain people may feel about an issue, to discern individual personalities and dispositions, to evaluate relationships among people, and to gauge territorialism and power struggles. Conflict may expose certain problems that may otherwise go unnoticed, such as a chronic shortage of supplies or equipment. An investigation may show that the current supplier frequently backlogs needed items or that the maintenance department is far behind in keeping up with repairs. Evaluating conflict may also help administrators understand their own leadership styles, which may prompt them to change the way they handle their interpersonal relationships.

 

Conflict resolution and administrative intervention become necessary when conflict may create disorder or pose a threat to the achievement of organizational goals. However, no one best way has been devised to manage interpersonal conflict. The NHA may be involved as an adversary, as would occur when a family member barges into the office very upset about some service-related issue. In other situations, the NHA may act as a third party to mediate differences between two or more individuals, such as when an angry associate comes in all upset about a supervisor “playing favorites.” In almost all situations, the NHA must keep strong personal feelings under control and remain objective.

 

Listening attentively is often the first step in resolving a conflict. The administrator must first understand the nature of the conflict and get perspectives from all sides. In many situations people are not expecting immediate action. Time taken for further investigation, fact gathering, and getting the “other side of the story” can result in better decisions when mediating conflicts between others. Also, when emotions are high, a “cooling off” period often gives time to reevaluate the situation from a fresh perspective. In other situations, accommodation or capitulation may make sense by giving one side what it wants, particularly when that side is right.

 

Other strategies for resolution of conflicts include negotiation, keeping the conflict controlled within certain boundaries, and constructive confrontation (Ware & Barnes, 1992):

 

•  Negotiation can be used if a compromise is desirable. Negotiation can produce a win–win outcome, especially when the pursuit of opposing goals by the two sides would be counterproductive.

 

•  Adversarial relationships may be controlled by separating two individuals, such as assigning the two adversaries to work on different units or on different shifts. If the two must work together because such a separation is not practical, control over their conflict ought to be exercised by adopting clear guidelines of behavior and following through with an impartial attitude.

 

•  Constructive confrontation is a strategy that begins not with a confrontation but with an attempt by each party to explore and understand the other party’s feelings and perceptions. As such, constructive confrontation may result in a new definition of what the problem was initially perceived to be, and it may forge new motives for seeking a common solution.

 

When the NHA is one of the parties involved in a conflict, he or she can retain control of a confrontational situation by focusing on the problem and issues and not engaging in personal attacks even when the other party may initiate such attacks. Depending on the nature of the conflict, the NHA may withdraw or remain neutral. Capitulation or “giving in” may also be a good idea if the NHA considers the issue of conflict to be relatively minor or when the other side has more power than the NHA does.

 

Relationship with Superiors

 

Management textbooks almost always ignore the important aspect of “managing the boss.” In this context, the term boss may mean the governing board, the owner(s), or a corporate official. Managing the relationship with corporate officers becomes even more critical in large multifacility corporations in which the administrator is often distanced from the corporate office.

 

The boss–subordinate relationship is based on mutual dependence. The boss needs the administrator’s help and cooperation, and the administrator needs the boss’s help and support. According to suggestions by Gabarro and Kotter (1992), the corporate boss can play a critical role in linking the NHA to the rest of the organization; in making sure the NHA’s priorities are consistent with organizational goals; in securing the resources the NHA needs to perform well; and in providing inside information about corporate thinking, culture, and values. Administrators should not adopt the attitude that they are self-sufficient, no matter how well they may be qualified in terms of education and experience.

 

The first step in managing the boss–subordinate relationship is to understand the boss’s leadership style, strengths, weaknesses, preferred means of communication, priorities, and need for information about facility operations. The NHA should seek out information about his or her boss’s goals, problems, and pressures and pay attention to clues in the boss’s behavior. Some bosses prefer to be more closely involved in the facility’s operations than others. Such bosses may want the NHA to frequently touch base with them. Others do not want to be closely involved but would like to be kept apprised of important issues or changes. The NHA should also understand his or her own needs, strengths, weaknesses, and personal styles (Gabarro&Kotter, 1992).

 

The potential for friction often exists. The NHA may make a decision or proceed with some action only to be thwarted by his or her boss. Often, the reality is that bosses have their own pressures and concerns that are sometimes at odds with the wishes of the NHA. Depending on their own personalities and predispositions, some NHAs may become resentful (a counterdependent behavior) and at some point may even become openly rebellious; others may submissively comply (an overdependent behavior). In both instances, the NHA should try to provide more information than the parties in conflict have at the beginning. In some instances, the boss’s mind may change. In other situations, a compromise may be reached. At the very least, the NHA may gain insights into the boss’s thinking regardless of the outcome.

 

The second critical step for the NHA in managing the boss–subordinate relationship is to understand mutual expectations. The boss may not always be straightforward in expressing what his or her expectations are. Questions asked during face-to-face meetings may lend important clues about the boss’s expectations. The NHA can pose questions such as: “Am I providing you all key information you need?” “Do you have any particular comments on this?” “How often should I do this?” “Do I need to check back with you on this?” “How important is this to you?”

 

Gabarro and Kotter (1992) suggested that managers often underestimate what their bosses need to know. Keeping the boss informed is an important rule to follow. Few things are more disabling to bosses than NHAs on whom they cannot depend or NHAs they cannot trust. Inconsistent behavior and unreliability can erode an NHA’s credibility very quickly. Shading the truth a little, or playing down problems and concerns, is a bad idea. Such behavior can at some point create surprise problems, when the boss is likely to ask, “Why did you not tell me about this earlier?”

 

Finally, the NHA should discuss needs for help, guidance, and support with the boss. There should be open discussions about issues that could potentially turn into major concerns. It is alright for the NHA to acknowledge, “I really don’t know how to address this. I need some help.”

 

Risk Management

 

The health care environment, particularly the long-term care sector, has been characterized by an upsurge in litigation (Folk &Haciski, 2013). Regardless of the outcome, legal action against a facility is costly when the direct costs of defense, distraction from daily operations and care of residents, and the indirect costs from loss of reputation are factored in. Hence, risk management has become a critical domain of nursing home administration. Risk management means identifying, analyzing, and reducing or preventing risks (Becker, 2001). For an administrator, the primary focus of risk management is on risks affecting patients and patient care, but a risk management program should also include consideration of the risks to associates, contracted staff, visitors, and facility assets.

 

Written policies, procedures, and practices are the first line of defense against potential risks. Such policies should address informed consent, handling of disruptive patients, patient transfers, restraint use, confidentiality, and other concerns discussed in previous chapters. Evidence-based practices should be formally adopted in the delivery of patient care. Policies must also cover routine practices to be followed in the delivery of services by each department of the facility. Plan of care for each resident must be followed exactly. Ongoing training of the staff and monitoring the staff’s work are necessary for compliance with established policies.

 

Risk identification involves collecting information about all incidents. An incident is any unexpected negative occurrence involving a resident, associate, or visitor. Patient care occurrences, no matter how small, and all other events that present potential loss to the facility must be investigated. Meticulously documenting patient care assessments, care plans, and progress notes is also essential. Similarly, adverse clinical outcomes, accidents and incidents, errors in treatment, and complaints from patients or family members must be carefully documented. Documentation should include what was done in each situation. Risk identification also requires looking for early warning signs that may appear in security reports, quality improvement studies, licensure and certification inspections, and client complaints (Kavaler& Spiegel, 1997).

 

Associates must be trained to report all incidents, no matter how small, to the appropriate supervisors. Supervisory personnel should receive training on how to document incidents, which may involve patients, coworkers, or visitors. The language used in documentation should be accurate, objective, and factual; it should avoid opinions, confessions, or accusations. Inconsistent explanations or remarks to patients or families by different members of staff should be avoided. One properly trained person should be designated to handle questions from patients, family members, associates, and external parties (Becker, 2001). Honest, above-board conversations with the family can often result in greater understanding of a situation and have a calming effect once facts are properly communicated (Folk &Haciski, 2013). Potential as well as actual lawsuits should be reported to the facility’s insurance carrier.

 

Folk and Haciski (2013) recommend other insurance-related safeguards. Some of the risk can be transferred by leveraging another party’s insurance. Certificates of insurance must be obtained for all contracted professional services, such as rehabilitation, beautician, and any other contracted services. The contract should include specific indemnification language, minimum limits of insurance the other party must carry, and maximum amount of deductible, if any. The facility’s existing liability insurance policy must also be reviewed to ensure proper coverage. It must include sexual abuse (including resident/resident situations), punitive damages, and selection of legal counsel. Other legal areas should be reviewed with a trusted insurance advisor.