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A Case Study to Identify Executive Leadership Practices in Medicare Five Star Rated Nursing Homes

Jason T. MunroCourse 620

+Introduction

In 2008 half a billion people were over the age of 65 years old (Tolson et al., 2011) In 2040, 1.3 billion 65+ (Tolson et al., 2011) Fastest growing population is “oldest old” 80 years or older (Tolson et al., 2011)

The stigma based on public opinion

A 92 year old woman toppled down a nursing home stairwell to her death in 2004. A jury awarded her son $200 million last month (Tampa Bay Times, March 1, 2013)

Medicare annual surveys Poor care

Lower census = low revenue Expensive Consultants

Overall, better care for residents

Lack of leadership training program for Nursing Home Administrators

+Trend in the Literature

Previous research: In a study by Cummings et al.(2009) concluded that transformational

leadership behaviors can be learned.

Hospital Leadership Nursing Leadership ER, ICU, Acute Care Setting, Home Care, Nursing Homes

Addressing the Gap: According to Tolson et al. (2011) states that there are a small number

of health professionals with expertise in nursing homes. Lack of information pertaining to Medicare Five Star Rating Scale and

Nursing Home Leadership requirements Line staff perspective. What leadership practices are required to create successful five star

rated Nursing Homes

+Purpose of the study:

Develop a Leadership Training System to address the short falls in Nursing Home Executives leadership.

Theories: Characteristics of theories will be examine to discover a trend in the interviews to obtain best fit pertaining to Medicare 4+ star rated Nursing Homes.

The purpose of this case study is to examine the leadership styles in Medicare 4+ star rated Nursing Homes.

+Literature Review

Characteristics of leadership theories

Leadership and Quality Outcomes

Description of The Medicare 5 Star Rating Scale

+Topic 1: General Leadership Theories Definition of leadership: “Leadership is a process whereby an individual

influences a group of individuals to achieve a common goal” (Northouse, 2010).

Different descriptions of leadership

Trait vs. Process leadership Intelligence, self-confidence, determination, integrity, sociability, emotional

intelligence

Assigned vs. Emergent leadership Skills approach, three skill approach, skills model

Style approach 4 categories: (S1) high directive – low supportive style (directing style) (S2)

Coaching – high directive – high supportive (S3) Supportive approach – high supportive – low directive and (S4) low supportive – low directive or delegating approach (Northouse, 2010)

+Topic 2: Leadership in Healthcare Transformational Leadership (Burns, 1978)

The creation of a connection that raises the level of motivation and morality in both leader and followers

Servant Leadership Chief motivation is to serve other first, not to lead. “I am the leader, therefore I

serve first, not to lead first” (Greenleaf, 1977)

Leadership in healthcare

Healthcare market use a transactional leadership style and remain stagnant (Schwartz and Tumblin, 2002).

Non-healthcare service industries are using transformational, situational and servant leadership and are successful (Schwartz and Tumblin, 2002).

Flattening traditional institutional hierarchies, build team driven and mission oriented change (Schwartz and Tumblin, 2002).

+Topic 3: Medicare Five Star Rating Scale

Nursing Home Compare, Five-Star Quality Rating System. Stars ranging from 1 -5 stars

In December of 2008, The Center for Medicare and Medicaid Services (CMS) enhanced the nursing home reporting site (CMS, 2012).

Website is available to the general public

The system reports on three quality areas for Nursing Homes care (CMS, 2012).

A nursing home can receive stars in the following areas:

health inspections, staffing and quality measured (CMS, 2012).

+Methodology

Research Design: QualitativeStrategy of Inquiry: Case StudyParticipants: Anyone employed at the nursing home

Data Analysis:Hand coding

+Coding:

+Participants/Procedure: Employees working at the Nursing Home, all departments.

Interviews will be conducted with the identified participants at a location off site or at the facility based on their personal preference in an office.

Some interviews will be conducted during the participants scheduled worked hours.

Participants will be given the opportunity to pick a site that best meet their needs and is conducive to conducting an interview after completing scheduled worked hours.

Audio recording procedures will be utilized for all interviews to ensure information is not missed.

Live scribe pen will be utilized as a recording instrument along with audio recording using an I pad.

All procedures will remain the same for the duration of the study.

A pre-designed formed will be used for the researcher to take hand written notes during the interview (Creswell, 2009, p.135).

+Methodology 1.1

Validity: Researcher, triangulation, peer review, clarify research

bias, feedback with participants, rick thick descriptions, external audits (Creswell, 2007 p.209)

Reliability: Obtain detail field notes, transcribing the tape, coding

(significant statement and grouping), staff assistance without knowledge, use multiple coders, (Creswell, 2007 p.210)

Ethical Issues: Research problem, Purpose and Question, Data

Collection (IRB), Data Analysis and Interpretation, Writing (Creswell, 2007 p.88)

+Methodology 1.2

Limitations unable to generalize – seeking transferability

(look for citation) Skills as an interviewer Bracketing is difficult (bias)

Delimitations Backyard research, building trust with

participants

+Questions

1. Are you aware of the number of stars this facility has?

2. Who do you think is responsible for making this facility a 4 star facility?

3. Why did you pick _____ as the person responsible?

4. What actions did this person take to make this happen? Examples?

5. What characteristics does this person display?

6. Can you give me an example of the behaviors this person engages in that motivates you to work at this nursing home?

7. Can you tell me how this person makes you feel about completing your assigned tasks?

8. If this person went to another nursing home do you think he/she would have the same level of success and why?

+Results

The following categories appeared most frequently during the coding process.

Service (20) “he treats people how he want to be treated” (R 3, 2013)

Task Oriented (14) “anything job related I think he is very organized”, “the pusher” (R 4, 2013)

Team work (9) “ all of us working as a team”, “I think it is a team thing” (R 1, 2013)

Supportive (6) “goes and visits the staff”, ““he supports when I am going to do something

different” (R3, 2013)

Transformational & Servant Leadership

+Discussion, Conclusion,Recommendations

Discussion: The research shows that quality outcomes in a nursing

home is more likely to occur when a leader displays characteristics commonly associated with Transformation and Servant Leadership.

Recommendations: A quantitative study could follow up this study to obtain

information that is generalizable to the population.