Mrs. Lerner in the long term nursing unit has refused to allow staff to use a Hoyer lift to transfer her out of her bed, Mr. Doyle in the Alzheimer’s unit wants to be moved to a different room because his noisy roommate is keeping him up all night, the census is lower than the budget projections, the steamer in the kitchen unexpectedly needs to be replaced, and a financial report is due to the corporate office.

 

This is just a sampling of the myriad issues thrown at Donna Shaw, administrator of Woodbine Rehabilitation Health Care nursing facility in Alexandria, Va., on any given day.

 

For her, a typical day at the office is anything but typical. In addition to addressing each of these issues, she must contend with a dizzying array of phone calls, meetings, and unexpected crises. And despite this seemingly chaotic schedule, she still somehow manages to weave in several rounds of the building on each day.

 

Even more remarkable about Shaw’s job is the size of the facility: 307 beds, six nursing units, and more than 400 employees. Shaw, who has been with Woodbine for more than nine years, spends more than 50 hours a week ensuring the care and safety of the residents, families, and staff.

Nursing facility administration is not for the faint of heart. The job entails a hectic, unrelenting pace of work; frequent, unplanned interactions with others; many reactive activities that are brief and unconnected; and varied work content that covers everything from building maintenance to clinical performance, according to a recent paper on leadership in long term care, commissioned by the American College of Health Care Administrators (ACHCA).

“Administrators are overwhelmed with recruiting staff, solving regulatory problems, and dealing with surveyors. And when you’re finished with that, something else pops up,” according to the paper’s co-author, Bernie Dana, assistant professor of business at Evangel University in Springfield, Mo., and former executive vice president at Vetter Health Services, an Omaha, Neb.-based long term care provider.

In the paper, Dana and colleague Douglas Olson, associate professor in health care administration at the University of Wisconsin at Eau Claire, note that health care administration is often fraught with unexpected events that need immediate attention. “What the health care manager may have proactively planned to do is seldom accomplished in the normal course of a workday,” they explain. Crisis management often becomes the norm.

In addition to crisis management skills, an effective nursing facility administrator must employ an extensive battery of skills, knowledge, and education. A recent survey of nursing facility administrators found that the job can be categorized into five “domains of practice,” each of which requires an exhaustive list of related tasks that are supported by specific knowledge areas.

For example, the survey respondents reported spending 34 percent of their time working on resident-centered care and quality of life—a domain that is associated with at least one dozen tasks. These tasks, in turn, are supported by more than three dozen areas of knowledge that cover all aspects of nursing facility operations, from resident rights to admission, transfer, bed hold, and discharge requirements and regulations, as well as the basic principles of infection control.

Commissioned by the National Association of Boards of Examiners of Long Term Care Administrators (NAB), the survey also identifies a similarly comprehensive inventory of tasks and skills under each of the other four domains of practice.

Nursing facility administration has not always required this level of knowledge and skills, however. The last decade or two has brought a great deal of change to the nursing facility industry, and therefore to the role of the administrator, says NAB Executive Director Randy Lindner.

The job has become much more challenging “because nursing home resident populations have changed dramatically—the acuity level of residents is much higher than it was 20 years ago,” he says. “Nursing homes have become mini-hospitals. They are now more like subacute care centers, while assisted living is becoming what nursing homes were 20 years ago. That level of care requires more sophisticated leadership, more knowledge.”

The result, says Lindner, is that good administrators must be skilled in leadership, communication, and marketing, “whereas, in the past it was viewed as strictly a management position—not as much as a leadership role.”

The role of an administrator has indeed changed, as Betty Solomonson, a 25-year administrator, can attest. “Assisted living has changed the whole profession, as has home health care. The people we have now in long term care are much, much more frail than they were 20 plus years ago,” says Solomonson, whose facility, the Mt. Vernon Health and Rehabilitation Center, is located about 10 miles south of Woodbine.

She echoes Lindner’s assertion about the higher acuity of nursing facility populations today. “The patients we have in rehabilitation now are like hospital patients were then, and assisted living now serves the patients we had 20 years ago.”

NAB has expressed concern about the fate of administrators like Shaw and Solomonson, especially in light of the negative public perception of nursing facilities, a punitive regulatory environment, exposure to personal legal liability, and strained financial and human resources. These all result in a less than rewarding career experience, Lindner told the National Commission on Quality Long Term Care last year. “We fail these individuals by not adequately supporting and preparing them to be leaders in their profession.”

Supporting Lindner’s assertion is a startling statistic: Since 1998, the number of exams administered to candidates seeking initial licensure as nursing facility administrators has plummeted by more than 40 percent. What’s more, says Lindner, not all of the first-time candidates go on to become nursing facility administrators. Some choose to work in assisted living facilities or continuing care retirement communities, while others are consultants, academics, and other long term care positions.

“Considering the number of skilled nursing facilities that require a licensed administrator of record, the demographics of an aging profession, and high attrition rates, we will not be able to meet the demand for licensed administrators in the future,” he says.

Addressing these concerns will take a number of actions and will require the entire long term care profession to recognize the need for effective leaders to deliver quality long term care services.

To start, NAB recommends the development of such leaders through improved training programs as well as the establishment of uniform national licensure standards for both nursing facility and assisted living administrators.

NAB has already taken a step in this direction with the adoption of a Nursing Home Administrator Licensure Endorsement Agreement that establishes standards of education and experience that demonstrate equivalence to the most stringent entry level standards in the country.

Shaw began her career as a registered nurse nearly 13 years ago, never expecting to one day become an administrator. But the die was cast when she landed her first job with a long term care facility as a respiratory care nurse in 1995.

Following several promotions and a variety of positions, including admissions case manager, nurse manager, and director of admissions and marketing, one of her predecessors suggested she prepare for the licensing exam with an administrator in training (AIT)  program.

Shaw had reservations about taking on what she believed was a daunting position. “I never thought I would want to be an administrator. This position is not only about running a business successfully, it is about taking care of people. It’s such a large and serious responsibility, especially in a building this size,” she says. “My anxiety was mostly about how to do the things I was not familiar with, such as overseeing the maintenance and the electrical system of a building that is more than 40 years old. I thought, ‘What in my experience will qualify me to oversee that?’” At some point, however, she realized that her previous experiences were very helpful in preparing her for the job. “I am able to apply the same problem-solving steps to most of these issues,” she says. “I now realize that my experience with Woodbine has given me a broad base of knowledge about the facility and its operations. The other vital piece is to ensure that you hire top-notch department directors to work with you. You can’t do this job alone.”

The marked decline in administrator applicants has some basis in the establishment of the Medicare and Medicaid programs under the Social Security Act of 1968, according to Lindner. Under the mandate, states were given the responsibility of establishing their own licensing standards—thus creating a patchwork of 51 different sets of requirements for initial licensure.

“As a result of this wide range of standards, education and training vary significantly from state to state, and mobility is difficult,” Lindner says. For example, administrators crossing borders usually have to meet the requirements of the states in which they seek licensure, which may be significantly higher than their initial licensure requirements. Even though they have practiced successfully for a number of years, they may be required to seek additional education and enter an AIT program.

While most standards for nursing facility administrators include an AIT program, educational requirements range from a high school education to a baccalaureate degree, according to NAB.

What’s more, many AIT programs are either not funded by the state or the facility, or pay very little, making it difficult for both college graduates and mid-career professionals to make the transition. “With families to support and other financial obligations, the barriers are prohibitive,” Lindner says. “For college graduates who have many career choices and are already carrying the burden of costly college educations, working without pay is not an attractive career choice.”

In addition to the development of uniform standards, NAB has called for funding to support AIT candidates, preceptor training, and career path development for employees of long term care facilities. It proposes that the funding be used as federal reimbursement to long term care providers that serve as a preceptor site.

Federal grant funding for the establishment and start-up of a national registry of licensed long term care administrators could also prove valuable for facilitating licensure mobility and as a disaster preparedness resource to quickly move licensures where needed, says NAB.

For Shaw, describing a typical day at Woodbine is difficult because every day brings something different. However, two consistencies are evident: Expect the unexpected, and start your day early. “You must have the ability to constantly re-prioritize your day as issues arise and present themselves,” she says. “A day may start out following a schedule, but as problems come up, you manage them into your schedule without losing your focus. You must stay incredibly organized. Your attention needs to be balanced between resident, family, and staff issues.”

Shaw’s workday begins between 7:00 and 7:30 a.m., which allows her time to prepare for the day ahead in the solitude of the early morning—before the frenetic pace of her day sets in. She uses the time to write a to-do list and review the “24-hour report,” a compilation of mini-reports that detail any significant change of status, discharges, and admissions in the previous 24 hours.

“The report lets me catch up on what’s going on with the residents—who was discharged, who was admitted, have there been any incidences, does someone have a fever,” says Shaw. Her meeting schedule includes some variation of the following on any given week: daily stand-up meeting at 9:00 a.m., daily nursing meeting, weekly meeting with the nursing department to discuss open positions and recruitment, and a weekly meeting with each department director.

As she strolls through the facility’s four floors and six units each day, Shaw takes time to stop and speak to residents, nurses, and family members. Her calm demeanor does not reveal the flurry of activity around her. Clearly, she is in her element.

Although she acknowledges that she is in this line of work because she enjoys being around people and taking care of them, it does have its challenges. “One of the toughest parts of my job is keeping employees motivated and ensuring that they are caring for the residents in the proper way,” says Shaw. “You have to trust that staff are doing a good job, but you also have to hold them accountable.”

Another challenging aspect of Shaw’s job is marketing. “The facility’s relationships with hospitals in the area are very important,” she says. “Relation-ships with social workers and discharge planners at the hospitals are key. In an effort to move patients out quickly, hospitals are now expediting their placing process, which, in many cases, means a patient is referred to the facility that has the first available bed.”

This urgency makes it more challenging for Shaw’s admissions staff because they must complete a strict review and admission process before accepting a new patient. “But we have to be on top of it,” she says.

“No two days are ever the same,” says Solomonson, “ever, ever.” She gets in to work at about 8:00 a.m. each day and takes a round of the facility. “I check in with each nursing unit. I also review my e-mail, discuss any issues with the director of nursing and the director of admissions, the director of social services. I find out if anyone will be discharged that day. I also always try to stop at the physical therapy unit to check on the residents. In the afternoon, I take a second round of the facility.”

Solomonson also makes an effort to attend each of her facility’s interdisciplinary team, care plan, and discharge meetings. “I try because it’s very important to me that we’re doing the best thing we can for the resident,” she says. “I always expect things to crop up during the day, such as meetings with family members or staff. You have to be so flexible; you have to remember to do the most important things each day, because it gets filled up with so many things.”

Solomonson concedes that being an administrator is very challenging. “But it’s so rewarding,” she adds.
“As I drive home from work each day, I’m always reminded that I made someone’s life a little better today. That always makes up for it.”

Changes in consumer preferences, growing quality expectations, human resource limitations, stressed finances, and competitive marketplaces have raised the bar for health and aging services administration, the ACHCA paper says, creating the need for proficiency in both management and leadership. “The need for the entire long term care profession to meet high levels of performance excellence is unchallenged,” the authors say. “Providers should allocate resources to develop a systematic and objective leadership development process.”

Training for long term care managers and supervisors should include work design, conflict resolution, performance evaluation, communication styles, problem-solving methodologies, and coaching, the authors say.

“Leaders and managers should also learn to use idea-generating and consensus-building tools, effective meeting techniques, and quality improvement tools.” According to Dana and Olson, many individuals are able to develop the traits of effective leadership by developing new habits to guide their behavior; learning the principles, skills, and techniques related to leadership; and translating new knowledge into meaningful activities and actions.

In addition to the need for leadership skills, an effective administrator must possess some practical abilities. According to Solomonson, the administrator of the future will need to be a more astute business person. Given today’s complex payment and reimbursement systems, people interested in becoming administrators will have to know their way around these systems, she says.

“You will also have to be a people person—you have to be out there with staff and residents every day. You have to create an atmosphere of being a pleasant place because people are scared to death to come to a nursing home. [They] are afraid that it’s going to be a terrible place.”

The job requires as much hospitality as it does clinical skills, she adds. “You have to be very customer-service-minded. Essentially, being an administrator means you’re on call 24-seven.”

Although many administrators do not have clinical training, Shaw cannot imagine being an administrator without a nursing background. “You really have to learn what it’s like to be a certified nurse assistant or a nurse in the facility,” she advises. “I am constantly drawing upon my experience as a nurse, and I believe that it helps.”

Changes in the industry have affected nursing facility administration in many ways, says Marianna Kern Gracheck, ACHCA president and chief executive officer. The expansion of multifacility corporations is one example. “In many cases, being part of a multifacility company means that decision making has been shifted to the corporate office, resulting in less autonomy,” says Gracheck. “Budgets are frequently handed to them, while discretionary decision making has been diminished.”

The result of this shift has forced some administrators to learn how to balance responsibilities to the facility while answering to the corporate  office when it comes to budgets and expenditures.

For Shaw, that kind of corporate pressure is not apparent. The facility is owned by a small multifacility company, Cambridge Healthcare Management, in Richmond, Va. However, she did experience similar demands in a previous position with a “large long term care company.”

Shaw says that while she can see how the expansion of corporate ownership could impact individual administrators in that manner—she reports to the company’s vice president—she also finds solace in having the freedom to contact one of the other two Cambridge administrators. “It’s wonderful to have the other two administrators to network with, to know that you can call one of them without feeling they are a competitor,” she says.

Whatever the situation, Shaw says that her responsibilities to ensuring the quality of care for her residents and the safety and satisfaction of her employees are paramount. “The buck stops with me,” she says. “I hold responsibility but I also have someone to answer to. As this company grows, the buildings will likely become more similar in style and operations, but for now, it’s wonderful to have the other two administrators to compare best practices.”

Despite Shaw’s relatively short duration as administrator, she has made her mark at Woodbine. One of her first initiatives was to “deep clean” every room in the facility. This meant stripping the floors, washing and re-waxing them, and cleaning the curtains and walls.

In a cost-cutting move, Shaw recently visited three off-site storage facilities that Woodbine had been maintaining. The items within were archived and evaluated for the possibility of future use. “We were able to reduce the inventory by a significant amount and bring the remaining items in for on-site storage,” she says. “This has saved us money by eliminating the need for off-site storage while increasing access to those materials.”

Shaw’s impact on the facility can also be seen in day-to-day details. During her daily rounds of the building, she scans the area for any stray items, such as housekeeping carts or lobby chairs, all in the name of facility safety and resident comfort. After speaking to residents in the dining room, Shaw even takes the time to bus a food tray or two from a table.

“As I walk around the building, I look at the environment and think about what I would want my home to look like. It’s important for our residents to have a clean and attractive environment,” she says.

Another priority on Shaw’s to-do list is to finish installment of a wireless Internet access network throughout the facility. “Patients come in and expect to be able to use their laptops while they’re here. The desired set of amenities in long term care is changing, and it’s important that we listen to, and act on, customer demands.”

Shaw has also taken steps to enhance the dining rooms with flat-screen televisions, tablecloths, and china dishes. In addition, Woodbine now offers residents a broader selection of meals.

“There is nothing like reading a letter from a family member that describes the positive experience they had while at Woodbine,” she says. “Excellent customer service isn’t just a tag line or the first line of a mission statement when you are talking about long term care. It’s about people’s lives and the lives of their loved ones. The commitment to doing it right is a huge undertaking that requires full cooperation from many, many people on our staff.”

But there’s nothing like the reward of learning that someone has taken the time to “let us know that we did a good job,” she adds. “That’s why I got into this business and why I’m still doing this every day—those letters and that feedback. That’s why we’re all here.”