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

1. A Case Study to Identify Executive Leadership Practices in Medicare Five Star Rated Nursing Homes Jason T. Munro Course 620

2. 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

3. 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

4. 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.

5. Literature Review • Characteristics of leadership theories • Leadership and Quality Outcomes • Description of The Medicare 5 Star Rating Scale

6. 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)

7. 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).

8. 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).

9. Methodology • Research Design: Qualitative • Strategy of Inquiry: Case Study • Participants: Anyone employed at the nursing home • Data Analysis: • Hand coding

10. Coding:

11. 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).

12. 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)

13. 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

14. 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?

15. 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

16. 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.