Long term/post-acute care centers are highly complex health care settings. This complexity comes in part from serving both patients with short-term rehabilitation needs and residents with long-term chronic illness and memory loss, while meeting the expectation that their quality-of-care and quality-of-life goals are met. Couple this with the onset of managed care, where the demands are increasing for positive results, shortened lengths of stay, and tightened budgets.
The changing regulatory environment includes new requirements for skilled nursing centers, intensified surveys for dementia care,  and new expectations for preventing avoidable declines. As the challenges mount for leaders to run a highly successful care center, resources remain limited for staffing, training, and physical plant.
These leaders must be able to maximize their effectiveness through excellent team-building and quality-improvement skills, but many of them have never been trained in these areas. That is the need that the Nursing Home Leader Academy of Excellence (NHLAE) was designed to meet.

NHLAE In California

The NHLAE program was the brainchild of the California Association of Health Facilities (CAHF) and Jocelyn Montgomery, its director of clinical affairs. First funded through a grant from the California Health Care Foundation, it is now self-funded through tuition and sponsorships. Three successful classes have graduated from the California program, with a fourth starting this spring.

“The goal of the NHLAE is to change the quality landscape, one leader at a time,” says Montgomery. “We know that education can only go so far in changing practice. We also know that professionals learn from each other and that good ideas are infective. That is why we provide peer networking as part of the active learning experience.”

NHLAE is designed to motivate and support participants to do what they need and want to be doing anyway—improving the quality of services in their centers and sustaining their gains through staff engagement, says Montgomery.

The Design

The academy is designed for practicing nursing center administrators and nurse leaders who want to expand their leadership skills and increase their quality improvement competencies. Participants learn to apply evidenced-based techniques and strategies for staff engagement, systems-based management, and quality assurance/performance improvement. An active learning experience is used with a combination of didactic instruction from nationally recognized experts, dynamic learning activities, peer support, and a web-based resource community.

Participants select individualized goals related to their specific targets. They can choose from clinical outcomes for residents, staff stability, hospital readmissions, and other relevant quality areas. They are taught to track data and develop and execute an action plan. Participants are then guided to explore professional standards of care and best practices related to those goals through a nine-month instructional period, with monthly peer support calls and in-person meetings mid-way through and at the end.

The academy teaches skills and a framework for improvement. With support from instructors and their peers, participants practice the concepts of high staff engagement in performance improvement in their own settings. By utilizing the engagement of their own staff in their Quality Assurance Performance Improvement (QAPI) process, they gain competencies they can then apply to any future quality targets.

The Iowa Experience

Mary Jane Carothers, vice president of quality and clinical affairs at the Iowa Health Care Association (IHCA) watched the California model launch with great anticipation and expectation. She had shared with the IHCA staff and board of directors a study, Analysis of Center Performance, from the American Health Care Association (AHCA) on the attributes of potential “at-risk providers,” which in part concluded that successful organizations clearly had management personnel who engaged staff in systematic improvement within the operation.

In staff meetings and board strategic planning sessions, the topic of the need to help facility administrators and directors of nursing (DONs) grow their leadership skills was revisited repeatedly. It became obvious that the key to not only future success, but the very ability to survive the rapid-fire changes in the reimbursement and regulatory environments, hinged on helping IHCA members develop critical leadership skills in their operations.

In addition, a statewide shortage in all areas of workforce made the retention of current staff more imperative, bolstering the idea that leadership training, not only for management staff but for charge or unit nurses, was much needed.

“We could see we were looking down the barrel of a loaded gun waiting to go off,” says Carothers. Her team decided to apply the skill of staff engagement in performance improvement from the California pilot to care areas reflective of Iowa’s provider needs.

Opening It Up

The Iowa facilitators changed their leadership series to include skilled nursing administrators and DONs and expanded it from three to four days, Carothers says.

“We added sessions on communication, staff retention, and leadership skills. We also beefed up the QAPI segment and tied it to whole organizational improvement. We then focused on an advanced leadership series, opening the door for administrators, DONs, and assisted living directors to attend.”

The Iowa Leadership Academy launched in June 2016 and concludes this June. Carothers feels it has been “an amazing ride.” The biggest revelation for her was that so many participants thought that they were practicing QAPI within their organizations, but without staff engagement in the process.

“We had to back up and help our leaders understand that the key to staff stability might well be found in engaging staff in the quality-improvement process. It was an ‘aha’ moment for many in the academy,” she says. Once they figured out that involving staff in root-cause analysis and problem solving created team bonding and relationships that led to improved care delivery, they could see leaders become “more inspired and confident.”

Administrator Involvement Is Key

In order to succeed in a value-based reimbursement system, administrators need to be consistently involved with implementing and sustaining interventions. A number of participants in the California academy chose reducing avoidable rehospitalizations as their goal.

One successful leader reduced his center’s rehospitalization rate by 76 percent with high staff involvement. The administrator focused on a few foundational interventions first—staff stability, staff satisfaction, consistent assignment, and huddles—that provided the foundation to implement more complex system changes later. The administrator pointed to a significant increase in communication regarding resident changes in condition as one of the keys to reducing avoidable transfers to the emergency room.

Involving Staff

The administrator regularly discussed the goal as he talked with his management team and with staff on the floor.

At multiple venues with physicians, caregivers, and family members, he consistently reported on how the center was performing in its overall rehospitalization goal and shared how improvements in staff communication and cohesiveness contributed to their success in preventing hospitalizations.

The administrator’s regular reporting to the staff of their score, and his regular discussion of the importance of their teamwork and communication, heightened everyone’s awareness regarding preventing avoidable rehospitalizations and made everyone feel as though they were in it together.

At these meetings, the administrator shared the systems he was putting in place to support this coordinated approach by staff. He increased staff’s clinical knowledge of identifying early warning signs and used tools designed to help the staff work together to reduce the center’s rehospitalization rate.

All of this significantly enhanced the pieces of critical information being exchanged at the huddles. In his end-of-academy reflections, the administrator realized it was his direct involvement that was the key to his success.

Creating Success

The NHLAE not only helps leaders maximize their effectiveness but also engages leaders in the art of building community and sharing one’s story. Though seemingly subtle, these two powerful actions greatly impact a leader’s success.

Academy leaders exercise these practices first by reviewing their data. They allow the data and their narrative to percolate without judgment or assumption. They share the data with others and listen, allowing for the story to rise.

By seeking numerous perspectives and the unique insights from those “closest to the action,” a greater understanding emerges. Through this process, leaders learn to trust the voice of staff and build staff into the center’s narrative, ensuring ownership and inclusion.

This is the first of a two-part series regarding the NHLAE. Stay tuned for next month’s issue where Provider will cover providers’ experiences with the program.
Jocelyn Montgomery, RN, is director of clinical affairs at CAHF; Mary Jane Carothers is vice president of quality and clinical affairs at the Iowa Health Care Association; Holly Harmon is senior director of clinical services at AHCA; Marguerite McLaughlin is senior director of quality improvement at AHCA; Amy Elliot is a research and evaluation consultant; David Farrell is vice president of subacute operations, Telecare Corp.; and Cathie Brady and Barbara Frank are founders of B&F Consulting.