A way to empower a nursing home administrator

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Kevin R. McMahon
Kevin R. McMahon

Multifacility nursing home organizations have a fairly standard arrangement that centralizes the operating authority over individual nursing facilities in a regional office. The regional office, through operational directors, oversees the operation of individual facilities.  Facility administrators in this arrangement report directly to a regional director.

While the division of operational authority between the regional and the facility varies widely, the regional is universally viewed as the ultimate source of decision-making authority.

When this authority is widely accepted and acknowledged by other regional staff (consultants and the sort), as well as facility staff, residents and families, the power and authority of the facility administrator and management staff is undoubtedly diminished. 

This situation can easily become an incubator for passivity and detachment on the part of the facility administrator and management staff.  When this attitude is fully evolved, the administrator and management staff may come to adopt a worldview that says things like, “It's your business (I just work here);” “It's your problem (I have no incentive to think or solve it for you);” “It's your decision (I am resigned to interminable processing and being spoon fed the answer);” and “It's your world (the experts at ‘corporate' will explain our world to us).”

Obviously, these are extreme views. However, I would posit that variations on these views run as an undercurrent through the minds and worlds of facility managers who are micro managed to varying degrees by regional office staff. 

On a good day, the end result of these attitudes is the normal cynicism and disenchantment that runs rampant through the world of business. On a bad day, things can go horribly wrong and facility managers can, and do, lose their jobs. Ultimately, resident care and services are adversely affected and the forward progress of the facility is stymied.

At one point in my career, I worked for a company that experimented with an alternative arrangement to the centralized regional model for controlling the operation of far-flung nursing centers. I came to refer to myself and other administrators fortunate enough to work in this situation as independent operators. I have come to the realization that this arrangement makes a lot of sense on many different levels in many different organizational contexts.

The independent operator concept hinges on an administrator who has shown an inclination and ability to work without the close and direct supervision of a regional director. He or she is provided with broad operating parameters and expectations and allowed to move the facility toward these goals by exercising independent judgment. His or her decision-making authority would mirror that of the regional director in the traditional model.

The independent operator would report to an individual (not the regional director) who would act as the representative of the owner of the facility (owner's rep). The mindset of the owner's rep would be akin to that of a banker making ongoing assessments about whether to continue the funding for the facility being run by the independent operator. In this case, the decision by the owner's rep is whether or not the independent operator continues to be employed operating his or her building.  

The main advantage of the independent operator concept is the opportunity to energize and empower the administrator and the management team in his or her building to achieve success in meeting financial and operational goals. 

The central aim is to move the management team in the facility to a worldview that says things like, “This is my (our) business;” “This is my (our) problem;” “This is my (our) decision;” and “This is my (our) world.”  By making this subtle but ground shaking change in attitude, members of the management team in the facility can truly bring their creativity to bear on problems, react quickly to situations, and use their indigenous knowledge and insights into people and situations on the ground to guide their actions and decisions.

In addition to the above, the independent operator concept would provide a career path for capable administrators who enjoy being an administrator and the personal connectedness that comes with being in a facility. It would also serve as a recruitment tool as companies strive to hire the best and the brightest.

Finally, should an independent operator not meet the expectations of the owner's representative and a change is indicated, this decision becomes much more palatable for all concerned. When I worked as an independent operator, I was at peace with the possibility of being terminated because it was my decisions and actions that would have precipitated this action (not the decisions and actions of others from the regional office).

The concept of the independent operator need not be an all-or-nothing proposition. One possible strategy would involve the identification of current administrators who could operate as independent operators.  These individuals would be assigned a new person to report to (owner's rep) and start charting their own course within the operating parameters spelled out for them.

Going forward, regional directors could be offered financial incentives to hire and train administrators capable of becoming independent operators.   This would allow the culture of the organization to change over time to one that esteems independent thought and action.

In the traditional centralized regional model, the authority given to facility staff is limited and not commensurate with the ultimate accountability demanded. The independent operator model seeks to more closely align the accountability required of facility managers and the authority given to do their jobs.

The independent operator concept is by no means a panacea. It is, however, an attempt to take full advantage of the existing management talent in nursing facilities while at the same time attracting self-starting, creative and independent thinking/acting individuals into the field of long- term care administration.

Kevin R. McMahon is the administrator at The Merriman, a 136-bed skilled nursing and assisted living facility in Akron, OH.
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