Copyright 2011 by Health Professions Press, Inc. All rights reserved.

CONTENTS
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ix

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xi

The Touchstone of Nursing Home Quality: Managers

Concerns for Caregivers . . . . . . . . . . . . . . . . . . . . . . .
V. Tellis-Nayak and Mary Tellis-Nayak

xv

Foreword

A Note to Our Readers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii
Part I

Leadership

Journal

A Year in the Life of a Nursing Home Administrator .

David J. Farrell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 1

Leadership: What You Do Matters . . . . . . . . . . . . . . .

71

Part II

Practices for Stability

Chapter 2

Taking Time to Hire Right . . . . . . . . . . . . . . . . . . . . . .

Chapter 3

From Absenteeism to Attendance . . . . . . . . . . . . . . . . 117

Chapter 4

A Positive Chain of Leadership: Supervision . . . . . . . 139

Chapter 5

Achieving Staff Stability: A Case Study . . . . . . . . . . . 165

Part III

Moving the Flywheel

Chapter 6

The How of Change . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

Chapter 7

Moving the FlywheelGetting Traction . . . . . . . . . . 221

Chapter 8

Memo to Corporate . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Appendix A

What Are Your Financial Incentives? . . . . . . . . . . . . . 271

Appendix B

Tracking Absenteeism . . . . . . . . . . . . . . . . . . . . . . . . . 277

91

A Note About Our Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Copyright 2011 by Health Professions Press, Inc. All rights reserved.

INTRODUCTION
What you do does matter. This book serves both as a wake-up call to
leaders who doubt their impact and as an affirmation to leaders who
vigorously take up the challenge each day of making the most of their
impact. Based on the real-life experiences of the authors and other
leaders in the field with whom they have worked, Meeting the Leadership Challenge in Long-term Care offers practical, commonsense, easyto-implement practices that will yield immediate positive results. The
book is constructed to allow readers to pick it up at any point, based on
need and interest. Although the chapters are ultimately linked, they
are also stand-alone.
Part I, Leadership, begins with journal entries from a year in the
life of a nursing home administrator. David Farrell details his experiences turning around a home that was by all measures doing poorly. In
a years time, Farrell was able to stabilize staffing, improve quality, and
generate profit. His journal is not your usual sanitized description; it
is real, gritty, and inspiring. He depicts the difficulties, the triumphs,
the tragedies, and the mundane. From painting over daily graffiti to
reassuring distressed certified nursing assistants (CNAs) and residents,
he captures how hard as well as rewarding being a long-term care administrator can be. Farrells real-life experiences provide a blueprint for
practices that any administrator can put in play. He cares deeply about
his staff and his residents. By putting their interests first, he leads the
organization to perform at its best.
Part I concludes with Chapter 1 which, building on Farrells experiences, describes leadership practices that make a difference. Too
often long-term care leaders are overwhelmed by regulatory and corporate oversight and feel the limits of what they can do more than the
possibilities. For example, many leaders accept the common myth in
long-term care that staff turnover is an inevitable cost of doing business. This chapter debunks that myth and the common practices that
stem from it. The fact is that, time and again, administrators who take
daily work life in hand in their nursing homes achieve stability. Chapter 1 provides a step-by-step field guide for leaders who want to make a
positive difference.
In Part II, Practices for Stability, Chapters 2 and 3 detail concrete
strategies for hiring the right people and promoting their attendance.
xxxiii

xxxivIntroduction

Chapter 2, Taking Time to Hire Right, includes methods for getting

the right pool of candidates, screening well, and having a good welcoming process. Chapter 3, From Absenteeism to Attendance, describes ways to track and respond to absences, and support and reward
good attendance.
Part II continues with Chapter 4, A Positive Chain of Leadership,
which guides readers in how to provide the kind of daily supervision
and leadership that bring out the best in staff. Chapter 4 describes how
to make a difference in day-to-day supervision by developing the abilities of staff, modeling and promoting teamwork, and facilitating daily
problem solving. Investing in your staffs development is how you invest in your organization.
Chapter 5, Achieving Staff Stability, is a case study that brings
together all of the practices detailed in Part II. The chapter draws a
link between management attention to staff needs and staff stability.
It chronicles how leaders in one organization re-examined their fiscal
and management practices and realized they were fueling their own
instability by employing bonus practices common in the fieldsign-on
bonuses, bonuses for staff to take last-minute assignmentsinstead of
rewarding staff who are reliable. The chapter describes how administrator Scott West used classic quality-improvement processes to analyze data, do root-cause analysis, and put in place effective fiscal and
management practices to achieve sustained stability.
Part III, Moving the Flywheel, describes the how of change. It
builds on the concept of gaining momentum for positive change as
discussed in Jim Collins book, Good to Great (see A Note About Our
Sources at end of book). Chapter 6 provides the basics for an effective change process, and Chapter 7 focuses on how to get traction in
your change efforts. Both chapters address how to integrate quality improvement (QI), individualized care, and workplace stability practices
to support problem solving from the ground up. Staff stability and engagement are the prerequisites for high performance. While QI is often
associated only with clinical initiatives, it is equally useful in examining the extent and root causes of instability and implementing successful interventions to achieve stability. Chapters 6 and 7 describe how to
integrate the science and the psychology of QI, by using a high level of
staff engagement in the change process.
Chapter 6 provides a step-by-step guide to high involvement. It
cites leadership examples from a number of homes, including the extraordinary circumstances in New Orleans nursing homes during and

Introduction xxxv

after Hurricane Katrina. Leaders from these homes affirm the value of
involving and listening to their staff in the decision-making process.
Staff let their minds go and were able to innovate to address unprecedented challenges. The involvement continues post crisis and has
contributed to many homes ability to rebound from the devastation.
Chapter 7 describes structural processes to put in place to support
good working relationships, including change-of-shift and start-of-shift
meetings. It explains the importance of starting any change process by
addressing causes of staff stress, because their areas of stress are usually the canaries in the coal mineindicators of processes within
the facility that are not working and rife with errors. Practices such
as all hands on deck and managing by walking around help alleviate
stress while building teamwork. When stressors are relieved, staff are
free to work on making other improvements. Getting traction starts
with engaging staff in efforts that bring immediate tangible benefits to
them and to residents. The chapter suggests opportunities for changes
in care practices that individualize care for residents while reducing
staff stress.
The book concludes with Chapter 8, Memo to Corporate, in
which we once again hear directly from David Farrell about practices
that he, now as a corporate regional representative, has come to recognize he needs to put on his Stop Doing List. It explains the negative
impact of common practices, such as drive-by consulting and those
endless demands for instant turnaround of data that reflect an expectation that administrators should be in their offices answering e-mails
instead of making rounds out on the floor. The chapter offers specific
suggestions for practices corporate staff can employ to make a positive
difference in support of their on-site leadership.
Our book is not a comprehensive review of the literature. Nor is
it the result of specific research. It is based on our direct experiences as
well as those of people with whom we are in touch who work in nursing homes across the country.
This is a highly regulated field that quite often has only intrinsic
rewards. Meeting the Leadership Challenge in Long-term Care highlights
the deep caring and good practices that abound in this field. It is a vote
of confidence to those who toil daily to care for others. What you do
does matter! Your efforts make a difference. Make sure to make the
most of them. We hope this book will help you along the way.

FARRELL,
BRADY,
& FRANK

Make a difference in your organizationtoday!

This book should be required reading for all who work in care settings and the text
used for leadership and health care administration courses in colleges. . . .
Farrells personal journal is as compelling as a good novel, except it is nonfiction!
You want to laugh, cry, scream, and shout halleluiah.

MEETING THE

Joanne Rader, R.N., B.S.N., M.N., Nurse Consultant, Rader Consulting

The pages of this toolbox will be dog-eared from use. No more excuses! This works!
Rose Marie Fagan, Co-founder and Founding Executive Director, Pioneer Network

Nursing home leaders from the bedside to the boardroom need a field guide
to help them make critical decisions and this book fills the gap.

hether your care facility is flourishing or floundering, its success depends on what you do as
administrator, director of nursing, or other leader. Your decisions and actions can improve staff
performance and ensure high-quality care. The organization that prospers has staff who know you
care. Based on the authors abundant skill in guiding hundreds of nursing homes through organizational transformations, this book gives you the tools and strategies to achieve stable staffing, optimal
care, and high census, and to become a leader in a thriving nursing home. Read one administrators
compelling account of a year making a difference in his nursing home, followed by elucidating examples, advice, and wisdom that come from decades of first-hand experience working with long-term
care facilities. Learn about the practical and easy-to-implement approaches that will yield immediate
positive results, including how to
Get and keep the right staff
Promote everyday teamwork and reduce staff stress
Convert money spent on turnover into resources to support stability
Apply corporate strategies to encourage positive facility-level leadership
Engage staff in daily problem solving for individualizing care
Increase staff, family, and resident satisfaction.
This book is an essential resource for nursing home owners and corporate staff, administrators and directors of nursing, and all those committed to helping long-term care organizations to be better places
to live and work.
David Farrell, M.S.W, L.N.H.A., is a licensed nursing home administrator and a nationally recognized leader in quality
improvement, workforce retention, and culture change. He is currently Director of Organizational Development and
Regional Director of Operations for a private nursing home management firm in California. Cathie Brady, M.S., and
Barbara Frank, M.P.A., have long histories of advocating for and contributing to improvements in long-term care and
are co-founders of B&F Consulting, which works with nursing facilities, regional collaboratives, and statewide initiatives to stabilize staffing, individualize care, and improve organizational performance.
Continuing education units (CEUs) available to long-term care administrators
and nurses. Visit www.achca.org/ or call 202-536-5120 for more information.

IN

MEETING THE LEADERSHIP CHALLENGE

LONG-TERM CARE

Robyn Stone, Dr.PH., Senior Vice President for Research, LeadingAge, Washington, D.C.

LEADERSHIP
CHALLENGE
IN

LONG-TERM CARE
What You Do Matters
DAVID FARRELL
CATHIE BRADY
BARBARA FRANK
Foreword by V. Tellis-Nayak and Mary Tellis-Nayak

www.healthpropress.com