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- Brief Overview & General Background
Lippert Healthcare Incorporated is a privately owned multi-facility chain that currently operates ten skilled care facilities in the area. Having worked closely with the organization in the past, Lippert Healthcare appointed Tim to be the Nursing Home Administrator (NHA) of Cloverleaf Nursing Center. Overall, Cloverleaf is reported to have a stable management staff that oversees the daily operations of a 90-bed skilled nursing facility (SNF) located in a small town of approximately 33,000 population.
Previous administrators include Joe Atkins, who had managed the facility for approximately a year and a half. Although regarded as a people-oriented person, Joe would become confrontational if he disagreed with a subordinate. Overall, Joe had given free rein to most of his department managers, however, he was also found to favor some managers over others. One such member of Joe’s inner circle was Claudia Moore, the Director of Nursing (DON). Claudia had been employed at Cloverleaf for nine years and had functioned as the interim administrator during Tim’s transition to the facility.
Before Joe Atkins, Cloverleaf’s administrator was Margaret Bond. Overall, Margaret was described as having a passive personality and spent much time in her office. Additionally, those who worked with Margaret described her as “motherly” and “cliquish” as she would often give preferential treatment to the DON over other members of the staff.
Shortly after settling into his new position, however, Tim felt as if there was a tug-of-war between him and Claudia Moore, the current DON. In general, Tim thought that this situation was prompted by some recent disagreements and incidents that took place between him and Claudia. Such disagreements, which will be discussed in more detail below, centered around patient care, the handling of requests from personnel, unannounced nightly rounds, as well as meeting etiquette.
- Previous Leadership/Management & Its Effect on Cloverleaf Nursing Center
Leadership and management are closely intertwined, however, the two are not the same. Leadership is an essential tool for effective management and through leadership, managers influence, inspire and motivate associates to deliver services. Management, however, goes beyond being a leader and requires skills in planning, organizing, and controlling (Singh, 2016, Effective Governance, Leadership, and Management—Chapter 14). Based on the information at hand, Cloverleaf has experienced high turnover among administrative staff, with each new hire introducing their own leadership and management style to the organization.
As a whole, Joe Atkins leadership style is most similar to that of supporting style which is characterized by low directive-high supportive behavior. 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 (Singh, 2016, Situational Leadership—Chapter14). However, although Joe provided his managers with flexibility and free reign, he did not successfully use supportive behaviors that are typical with this type of leadership. Instead of listening, praising, and giving feedback, Joe became confrontational if he disagreed with a subordinate, often assigning personal blame when something did not go as planned.
Margaret Bond, on the other hand, demonstrated more of a delegating leadership style which is characterized by low directive-low supportive behavior. The delegating leader lessens his or her involvement in planning, control, and goal clarification (Singh, 2016, Situational Leadership—Chapter14) Additionally, Margaret displayed impoverished management due to her remaining hands-off, aloof, and her passive personality. 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 (Singh, 2016, Two Dimensional Model—Chapter14). As a result, the long-term success of such administrators in highly questionable. This was the case for Margaret when Lippert Healthcare Incorporated visited the facility during her absence after a negative annual inspection by the state’s Department of Health.
Overall, the hiring of both Joe Atkins and Margaret Bond suggest that the organization is struggling with turnover and retention. According to Singh, turnover among NHAs has been estimated to be at least 40%, with the median length of employment at a facility just over 2 years (Singh, 2016, Leadership Stability—Chapter 15). Moreover, a study of turnover suggested that there actually may be a bidding war among nursing facilities in an attempt to attract qualified NHAs, as indicated by the relatively large proportion of administrators voluntarily leaving their positions to pursue opportunities for promotions (Singh & Schwab, 2000). This phenomenon implies that administrators who possess the qualifications organizations seek are in short supply (PPD 601 Lecture 9, Internal Constituents in Long-Term Care). In turn, this type of instability at the top keeps the entire organization in a state of flux due to the fact that leadership and strategic direction are interrupted, causing many disruptions to occur (Singh, 2016, Selection, Orientation, and Mentoring—Chapter 15). Hence, I strongly believe that the stability of key leadership positions should be pursed as a major goal, as NHA turnover is a governance issue that the boards must address.
- Ruffie Jacob & Patient Care
Once such incident, as briefly mentioned above, centered around patient care and the treatment a patient named Ruffie Jacob was given during his time spent at Cloverleaf. In short, Ruffie was admitted to the facility from a local hospital Thursday evening without his medications due to the fact that the hospital’s policy did not allow them to send medications with a discharged patient. One such medication that Ruffie was prescribed was Intravenous Vancomycin, which needed to be administered twice daily. Unfortunately, the pharmacy that Cloverleaf was contracted with did not have IV Vancomycin in stock, thus causing the patient to miss a dose Thursday night. Although Claudia claimed to have the situation under control, the medication did not arrive until Friday evening resulting in the patient missing another dose of the medication. On Sunday the patient expired. Afraid of a potential legal issue, Tim informed the corporate officers which resulted in the Medical Director having a conversation with Claudia the next day.
Based on the facts at hand, I believe that Tim reacted appropriately by intervening and contacting corporate as it was clear that Claudia was not in control of the situation. By not ensuring that the patient’s medication was administered in a timely manner and refusing to transfer the patient back to the hospital, Claudia violated Ruffie’s rights as a patient. In general, patient rights are founded on both legal and ethical principles. In addition to autonomy, patients have the right to non-discrimination as well as freedom from abuse and neglect (Singh, 2016, Patient Rights—Chapter 4). From a legal standpoint, the organization could potentially be held liable for the death of Ruffie Jacobs due to the fact that the actions of Claudia resulted in injury to someone else. Overall, Claudia could be held personally responsible because she remained passive about a situation that resulted in a tort, due to negligence, and failed to take action (Singh, 2016, Personal Liability—Chapter 4).
My future recommendations for a similar situation would be for Tim to address his boss-subordinate relationship with Claudia and work on building mutual dependence among one another. Tim should take the first step in managing this relationship by taking the time to understand Claudia’s leadership style, strengths, weaknesses, preferred means of communication, and priorities (Singh, 2016, Relationship with Superiors—Chapter 14). Hopefully, this will allow for coordination of care and open communication, encouraging Tim and Claudia to tackle problems together instead of separately.
Additionally, the situation above suggests that the organization is struggling with system fragmentation. One of the main difficulties with LTSS is that services exist in “silos” meaning that service sectors are often independent, and thus have very limited interaction with other services (PPD 601 Lecture 8, System Fragmentation and Integration). As a result, providers have a hard time coordinating care for their patients that require multiple services. One manner in which this can be done is through the formation of interdisciplinary teams, as well as partial or full integration of services (such as the PACE Program). Overall, a method for providing simultaneous access to care plans across the healthcare team needs to be established (Geriatrics Society Expert Panel on Person-Centered Care, 2015).
- The Supply Clerk & Handling Requests from Personnel
Another such incident centered around the supply clerk and the handling of requests from personnel. In short, an employee named Nancy filled out a request for time off and it was approved by Tim. Claudia, however, became upset stating that Nancy was her employee and that Tim had no authority to grant the time off. In the future, these types of situations can be handled more efficiently through the use of organization. Organizing includes determination of what tasks are to be done, who is to do them, how tasks are to be grouped, who reports to whom, and where decisions are to be made (Singh, 2016, Organizing—Chapter 14). More specifically, Tim should pay attention to line and staff relationships in order to clarify who reports to whom and who in the organization have formal supervisor-subordination relationships. By having such a formal structure in place, conflicts and confusion, similar to the situation with Nancy, can be avoided completely (Singh, 2016, Line and Staff Relationships—Chapter 14).
- Unannounced Nightly Rounds
An additional incident that caused tension to arise between Tim and Claudia were the unannounced nightly rounds that Tim would conduct of the facility on weekends. As a result, Claudia felt that the employees were being demoralized due to a lack of trust. Although I do believe it is appropriate for an NHA to conduct nightly rounds, I do not believe that the best approach was taken. In order to have a truly transformative influence in the facility, I believe it would be beneficial to have Claudia and Tim perform these rounds together and clarify to the staff the purpose for doing so.
Including Claudia in rounds will not only help to build trust but her expertise/knowledge as a DON can be used to monitor and improve the quality of care of all residents. As stated by Singh, regular rounds, observations, and attentiveness to any patient care concerns expressed by patients, associates, and family members are generally the means of monitoring the adequacy of clinical care (Singh, 2016, Oversight Role—Chapter 9). Overall, administrators strive to balance access to care, the cost of care, and the quality of care, thus making quality very subjective and a multifaceted concept (PPD 601 Lecture 7, Oversight, Regulations, and Quality of Care)
- Meeting Etiquette & The Prospective Payment System (PPS)
The last incident to arise was in regard to Tim taking over the PPS meeting due to the fact that he believed Claudia was overwhelmed with an increased workload, resulting in her neglecting certain clinical systems. In short, I do not believe it was appropriate for Tim to take over the PPS meeting. Although his intentions were pure, by not initially discussing the matter with Claudia he undermined her work and effort.
As stated by Singh, meetings are an essential tool for management because they promote participation and personal interaction (Singh, 2016, Effective Meetings—Chapter 14). In order to avoid a similar situation in the future, I would highly encourage Tim to sit down with Claudia before important meetings in order to establish an agenda and provide a sense of direction. Additionally, by working together, both the NHA and DON should determine how information will be communicated, and if information from other participants is needed (Singh, 2016, Decision Making and Problem Solving—Chapter 14).
- Conclusion & Final Recommendations
After taking into consideration all the facts and details of this case, I believe that the tug-of-war ultimately took place due to a lack of trust and dependence. Moving forward, I would encourage Tim to work on improving and managing his relationship with Claudia as 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 (Singh, 2016, Conflict Management—Chapter 14). Overall, inconsistent behavior and unreliability can erode credibility very quickly between both the NHA and DON. Hence, both parties should discuss needs for help, guidance, and support by encouraging open discussions about issues that could potentially turn into major concerns (Singh, 2016, Tools for Effective Management—Chapter 14)
- Geriatrics Society Expert Panel on Person-Centered Care, American. (2015). Person-Centered Care: A Definition and Essential Elements. Journal of the American Geriatrics Society. 10.1111/jgs.13866.
- PPD 601 Lecture 7. Oversight, Regulations, and Quality of Care
- PPD 601 Lecture 8. System Fragmentation and Integration
- PPD 601 Lecture 9. Internal Constituents in Long-Term Care
- Singh, D. A. (2016). Effective Management of Long-Term Care Facilities. (3rd edition). Sudbury, MA: Jones and Bartlett Publishers
- Singh, D.A., & Schwab, R.C. (2000). Predicting Turnover and Retention in Nursing Home Administrators: Management and Policy Implications. The Gerontologist, 40(3), 310-319.
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