NAB NHA Exam- Leadership and Management

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Governing Body

REQUIRED by CMS, whether sole proprietorship, partnership, or corporation

corporations

are required by state to have Articles of Incorporation that specify officers, board, membership.

closely held corporation

less shareholders, most are 5 or less, less formal organization.

Public Corporation

many shareholders, very structured, bylaws

make up

may be one person or many - there is not typical board structure in NFs

Duties of Corp

Mission Statement - what facility is to do (major duty)|Board establishing measurable goas|Employ agent (NHA). Required by CMS|Establishing and implementing policies and procedures. CMS says legally responsible for operations|Approve budget|Evaluate administrator's mangement|Board does not get into day-to-day operations

Bylaws

mostly by corporations. Rules to govern corporation itself. Not too specific. Tells WHAT cop oration will do.Includes duties of Board, officers, committees. Prepared by corporate members. Used as basis for writing policies and procedures for each unit of corp. Tells HOW activities to be carried out. Usually prepared by administrator, and approved by board.

Governing body/administrator relationship

NHA only person reporting directly to GB, usually through the chain of command, e.g. regional director, VP of operations, etc. Represents his/her staff in best light-accurate, objective, factual. Reports to GB as requested - census, personnel, financial reports, regulation changes. (keep fully informed, otherwise grapevine gets to them.)

Directives/policies/procedures .|

of GB interpreted properly, whether agree or not. Let Employees gripe, but support GB

GB listen

to employee complaints but refer them to supervisor or NHA. Inform NHA

Role confusion -

GB members usually successful in another field. Not have same, clearly defined solutions

Duty of obedience partnership

partner owes his partners a duty to act in obedience to the partnership agreement on all business decisions. Personally liable if does not.

Corporation

Directors and officers must act within the authority granted them - usually in bylaws and articles of incorporation. Can be held liable for any unauthorized actions.

duty of diligence

Partners, board members, and administrators must discharge duties in good faith, with care and prudence, i manner she/he believes is inbest interest of organization. Adminstrtaor must exercise knowledge and skill he/she professes to have as a licensee.

Management

Creating and maintaing an environment within an organization that makes it possible for staff to work together toward common goals. Getting work done with and through others.

Functions of Managers (supervisors): Planning

setting goals, establishing PPR's, programs, budgets, etc. that determine what, how, when, where and by whom work is to be done. CENTRAL TASK is planning as it permeates all other functions.

Purpose

primary focus on obtaining goals |offsest uncertainty and change|develop economical operations, and|facilitate control|

Primary value

Administrator is charge whether she/he is present or not

Types of plans: mission

basic task assigned to an enterprise by society. In nursing homes the mission is LTC

goals or objectives

end results or product toward which all effort is directed||a. short range|b. long range|c. goal oriented needed||(These SHOULD STIMULATE action)

Strategies

general plan that focuses on long range goals. ||What will facility be like, look like, feel like, sound like, and react like, in the future

policies

broad general statements to guide decision making and to some extent action in achieving goals. allows flexibility in judgment.

procedures

step by step means by which tasks are performed. allows less flexibility in decision making

rules

specific, authoritative guides that require an action be taken or not taken. allows no flexibility in decision making. employees can use no judgment, so should have few as possible.

programs

summations of goals, PPR's, budgets, work and space assignments, and resources.

budgets

plan expressed in numerical terms that outline expected results

evaluating effectiveness of policies and procedures. Are they:

written|differentiated|taught/understood|monitored to be sure they are followed|help meet goals|flexible - if don't help, change|reviewed and updated regularly

organizing

grouping activities and people, assigning roles, delegating authority. Setting up department, shifts, work teams.

purpose of organizing

allows for growth and expansion; seeks to reduce friction and unsought consequences.

departmentalization

makes it possible for the organization to expand.**

chart of organization

shows lines of authority and communication, formal organization.||hierarchy. top to bottom

scalar chain

used almost entirely. || 0| I|__|I I|0 0

Span of management

How many employees a supervisor can effective supervise. Usually 8-12 at line level. |DEPENDS:|- difficulty of task|- clearness of policies/procedures|- training|- how well supervisor communicates|- experience|- closeness of control required

Unity of command

employee has only one supervisor insofar as possible. need clear authority lines - promotes job satisfaction, teamwork.

staffing (HR)

recruiting, interviewing, hiring, training, promoting, demoting, terminating, retiring employees. (terminate early in week)

Directing (leading)

influence of employees todo their work according to stander - who?when? how? invoves leading, motivating, communicating, giving instructions, goal setting, decision making, representing, coordinating, managing conflicts.

Leadership NH success depends on NHA's ability and willingness to lead. Basic characteristics of leaders:

visibility- out and about in facility out in front, not office-bound. (ghost can't lead)|decisive - must use authority and be accountable for what happens.|listening - hears what people say - good communicator with everyone.|pitches in - when needed, rolls up sleeves and helps.|understanding - gives staff right to be angry, non-judgmental.|goal oriented - quality resident care is foremost. plans so all know the NH goals|Competitive - wants his/her NH to be the best|knowledge base - broad knowledge base of all NH ape rations and of total health care.

Duties of leaders. duties are diverse. they include:

-goal setting - points teh way. good planner|-decision making - high priority, as it includes problem solving. makes decisions when needed - no - procrastination. uses his/her authority.|-giving instruction - types: specific or general, formal or informal, written or oral. Gives instructions of type staff best responds to.|-Listening - problems of staff, residents, families, and public. Good at crisis intervention. |-Representing - his staff in best light.|-Coordinating- People have different approach to work - slow and fast, interested or not, apply self fully or not, etc. He/She must coordinate those differences and still get job done.

Superior/subordinate relationship

gives rise to jealousy and anger; trouble begins. Some people DO NOT WANT TO WORK or be told what to do.

Authority

right to act or require action of others- instruct, approve/disapprove, veto action, change action, reward/withold.

Line

over all under one's direction - hire, instruct, monitor, discipline, fire

staff

advisory, recommend, teach. cannot enforce decisions- consultants.

functional

authority over a function (hiring, purchasing..) but not over person who carries it out. used in larger organizations.

delegation

effective when lowest person in echelon who is authorized and capable is making a given decision. key to effective management.

leadership style

-laissez-faire - give instructions and leave alone, easy going and supportive. May work for professional staff, and for highly motivated, capable staff.||democratic- allow employee input on how things are done. majority rules. a factor in TQM. administrator must retain veto power, cannot be 1005 democratic.||paternal, sympathetic, parenting - you do your job- i'll take care of leave, raises, benefits.||autocratic- dictatorial, threatening, intimidating. no confidence in staff; he knows all. "don't care if he likes me or not-just so work gets done"||situational- leaders adapt their style at times to meet circumstances in which they are working and/or the type of employee they are leading.

controlling

measuring of the work performance to determine if it follows guidelines, and correction of any errors in performance. requires good policies and procedures.

purpose of controlling

maintain harmony between plans and work performance. ||purpose of correcting erros is to improve work performance.

**three steps in correcting errors:

review how work was to be done - begin with mutual agreement.|point out error|indicate remedy

guidelines to correcting (4)

-correct first error, soon as possible, in private|-objective, specific, factual-no exaggeration|-make no excuse, be serious|-do not threaten that will watch to see|

management types

most effective now considered to be TQM and MBWA

TQM

builds employee interrelationships through work teams; utilizes employee knowledge. requires open communication, trust, mutual respect among employees and management.

focus on improving

skills and quality of output. concerned with productivity, safety, cost, resident satisfaction. how can improve quality of work, and their knowledge and skills.

result in continuous quality improvement (CQI)

greater job satisfaction, motivation, teamwork, growth of staff.

MBWA

NHA regularly visits all departments and observes performance and environment. sends out strong messages:||- interested, available|- expects quality|- monitoring|- provides opportunity to:| - reinforce good work| - prevent some problems| - enhance communication

employee centered management

is interested in needs and interests of employees. promotes positive work atmosphere, improves performance. (TQM and MBWA)

organization communication

- process of tansmitting information among two or more people. occurs when message received with understanding.

direction of organization communication-

upward, downward, horizontal (lateral) diaganonal

process of organization communication

ideation|encoding|transmitting|receiving|decoding|understanding|feedback

key to communication is listening

40% of the time. |active listening - hearing message and the feelings behind it.|

best form of organizational communication

face to face - as secure immediate feedback by expressions, questions..

barriers in organizational communication

poorly worded -use language of receiver|inattention - tune out and think of something else|transmission barriers- noise, poor hearing, stuttering, etc.|distrust of sender|fear of consequences|poor retention - 30% or less is retained|premature evaluation - give answer before problem is presented|upward communication barrier- filtering out some info before passing it along|over/under - more than need to make decision.

purpose of communication

usually CHANGE - schedule, procedure, new skill, further training. |

timing of communication

tell assistants first, department heads, supervisors, then workers. usually several days before implementation. never tell staff at once.

written communication preferred when:

info must pass thru several mgt. levels|employees not well trained|involves significant change |provides guidelines of long duration|supervisor tends to forget what has told employees

computerized information

learn basic terminology. value- provides quicker, more accurate, greater amount of information for decision making. especially useful in financial management, inventory control, etc.MIS needed in nursing homes| a. online survey certification and reporting (OSCAR) system. All NH's must input assessment and care plan information. surveyors use in planning focus of survey.| b. extensively used in accounting, assessment, care plans.| c. internet - much information for NH survey results| d. FAX| e. voice response| f. e-mail

informal organization and communication

grapevine - tends to be used and depended on more than officia communication; tends to be believed and acted on. CANNOT destroy. learn to use.||offset by open, frequent, official communication. supervisors trace rumors.||coffee cliques and other informal groups talk about work, procedures, changes, how they will react. undue influence on performance

privileged communication

between physician/patient, attorney/client, nurse/patient, husband/wife. NONE in child abuse cases|

change

causes work slow-down or stoppage until employees learn how it affects them

timing of change

announce before start, allow time to adjust, get off chest. ask for reactions, promote discussion - how affects you?||avoid 2 words: effective immediately

no change

no change in any unit until all others evaluate impact

principals of reciprocal action

no change can occur in any unit of an organization without affecting all other departments directly or indirectly||(don't ask why: employees get defensive. "i understand you were late, what are the reasons"

motivation - process by which administrators initiate and direct employee behavior

1. Maslow's needs hierarchy - needs in acending order of importance from biological (food, clothing, shelter) to self-actualization. ||2. motivation primarily internal - employees wants to be seen as capable, competent||3. well motivated employees identify with facility goals, see as their own. ||4. money seldom motivates over period of time. employees must know raises depend on performance. may motivate if sizable in terms of what accustomed to.||5. rewards - important to job satisfaction

types of rewards

organizational approval - pay increases, benefits, longevity pins, letters of recommendations, parking space, good supervisor relationship.||social environment - important. work with pleasant, cooperative employees - co-worker recognition.||work itself - interesting, stimulating, satisfying.

risk management

program to reduce occurrences (incidents) that may lead to action damaging to facility and its reputation. economic loss through tort action -civil suit. primarily to protect facility, but also to protect residents, staff, and visitors.

risk factors

-administration - PPRs, staff qualification, follow-up of complaints, accidents, insurance...|-nursing - restraints, PRN orders, medications, lack of proper assessment and care plan. #1 are of concern|-environment - LSC, ANSI, ADA, OSHA - poor security and preventive maintenance, inadequate safety and infection control. Housekeeping safety.|-Dietary-infection control, spoilage, food taste and appearance, garbage disposal.|-tools for developing good program:| proper plans for each dept| adequate insurance| training| documentation| quality assurance and assessment| monitored by NHA (MBWA)

Marketing

act of offering services or product in the marketplace. managing flow of goods between producer and consumer. developing sales potential

open market

ordered by court. Cannot restrict advertising health services and prices

research - do market opportunity analysis first. gives info on:

a. needs of elderly|b. nature and effect of competition|c. structure and relations of current services.|start no new service, or expand, until research shows it's economically feasible.|

market opportunity

depends on demand for service, size, nature.. success depends on this|

marketing attitude.

all marketing oriented to meeting consumer needs. number one goal; starting point

advertising

emphasize unique aspects of your service. false advertising - such as "we meet and exceed all state an federal standards" is prime ammunitions for lawyers

strategy

plan of action used to meet goals. marketing program lists strategies in sequence to be carried out, who , when, etc.

punlic relations

managing communications between organization and its many publics. difference: marketing focused on potential user, PR focus on all people.

overall goal

interpret facility to public and public to facility.|bonds and involve th two in an interrelationship. | a. earn respect and pproval of community.

image building

major means of meeting goals is to sponsor fund raising event, donate proceeds to a charity - show interest in community. Tour of facility usually best method. Others:| wellness fair| be geriatric resource center| educate public officials on needs| respite care| serve on boards, committees of community organizations| speaking engagements| handling nursing home telephone

use of news media

featured articles. negative rumors - work with reports

newsletters*

inform public of facility services, inform residents/family of comment resources. send to agencies, civic organizations, local government, health care organizations.

educational institutions

participate in HS career days, involve student groups (social studies classes, clubs). inform of what nursing home industry involves

professional training

train AITs, interns from colleges. encourage professors to have students visit, do term paper on aging, LTC, facility operations.

written program

public relations program should be written. show the role of employees, residents, ramify, volunteers, and administrator in improving relationships within facility (staff/residents, staff/family, staff/staff, staff/community)

legislative issue

1. work with state health care associations and state and other health care groups|2. keep local legislators informed of LTC needs and issues.|3. know applicable bills and let legislators know possible opposition.|4. contact all members of legislative committees that will handle LTC bill. do not wait until committee meets and try to educate them

Omnibus Budget Reconcilation Act of 1987 (CMS)

provides Gederal Care Guidelines (42CFR) for all nursing facilities that are certified

OBRA - licensed administrators

of all nursing facilities, except state may waive NHA for distinct part and swing beds.

OBRA: ownership

all participating facilities file Disclosure of Ownsership. FOR CMS (1513). If party has 5% or more ownership, show|1. name and address|2. relationships between any two owners|3. any named person's 5% or more interest in any other participating facility||annual update by administrator

OBRA: lab, radiology, other diagnostic

must have agreement with qualified sources

transfer agreement

(written) with one or more hospitals. include transfer procedures, records. EXCEPTION document if no hospital will sign.

ombudsman

programs required. Includes state advocacy agencies for MI and MR. established by Older Americans Act of 1965, as amended.

Duties

primary: to investigate and resolve complains made by or on behalf of LTC residents. An ombudsman is an individual who protects and promotes the rights of individuals before, during, and after a placement into a NF, adduct care home, or other assisted living. the service is offered at no cost to the client and is confidients|

ombudsman involved in

1. services that could adversely affect health, welfare, safety, or rights|2. facility notify of survey noncompliance findings|3. state notify of any action against facility.|4. must have access to residents; records only with written consent.|give resident the name, address, phone number of ombudsmen.|fed and state notify when give facility waiver.|state notify of urvey and allow to sit in on an exit interview, suggest residents and families to interview

survey process: tasks surveyors perform

1. offsite prep

Tasks surveyors perform

A. OFF-SITE PREPARATION - review CMS's Online Survey Certification and Reporting (OSCAR III and IV) system and QUALITY INDICATORS to determine areas survey is to focus on.||b. ENTRY CONFERENCE - request any records||C. Initial TOUR - may uncover new areas of concern which they list.||D. SAMPLE SELECTION AND INTERVIEWING- no longer look for light care and heavy care. Select residents according QI report. Administrator and DONs who study these reports have an insight on which residents the surveyors will be reviewing.||E. Information gathering||F. Information analysis||Exit interview||

Scope

how many residents involved:|- isolated: one or a limited number of residents affected; occurs occasionally in limited number of locations||- pattern: more than very limited number of residents are affected||- widespread: pervasive inf acility; systematic, affected large portion or all of the facility

level of deficiency

level 1 - NO actualy harm with potential for minimal harm; minor negative impact on residents.||level 2 - no actual harm with potential for more than minmal harm; EXAMPLE: medication error rate, harm of short duration as falls, a laceration, etc. - easy to remedy.||level 3 - actual harm that is not IJ. A negative outcome that has compromised resident's ability to maintain or reach highest level of functioning. EXAMPLE: pressure sore of urinary tract infection occurring after admission.||Level 4 - IJ. Immediate or corrective action necessary because noncompliance in one or more requirements has caused or is likely to cause serious injury or harm, impairment, or death. EXAMPLE: nurse call system not functioning, severe staffing shortages.

Exit Interview

includes resident and ombudsman. define areas not in compliance (not by Tag Number). ||PURPOSE: to inform facility of observation and findings. findings written and discussed (284) surveyors must revisit for deficiencies with a scope and severity rating of "G" or higher. They have the option on all citings below the "G" level. ||DOUBLE G's: CMS imposes denial of payment when provider is cited for actual harm deficiency, corrects, but is cited again within 9-15 months.

POC (plan of correction)

Facility submits plan of correction showing:||a. HOW corrective action will be taken for residents affected by deficient practice.|b. HOW facility will identify other residents having potential tobe affected by the deficient practice.|c. WHAT measures or changes will be made to ensure non-recurrence.|d. HOW corrective actions to be monitored to ensure non-recurrence. No consolation can be given by surveyors or CMS.|

2567

Statement of Deficiencies|referred to by its catalogue number.|Once the state sends this form to the facility it must be completed per instructions and returned to teh state agency within 10 days. the POC must be posted within the facility so anyone can review it. the facility must keep the past 3 consecutive years of POC's in-house.**

Informal Dispute Resolution (IDR)

Facility may request informal resolution process. Must include in writing what findings (by Tag #s) you contest-time period specified by state

remedies

imposed by CMS and the state

remedies: category 1 remedies for "d" and "e" deficiencies

directed POC|state monitoring|directed in-service

Category 2 - for deficiencies widespread with no actual harm but potential for minimum harm (f)

Denial of payment for new admits|denial of payment for all Medicare and Medicaid residents as imposed by CMS regional office|Civil money penalties of $50 to $3000 per day of noncompliance

Category 3

for cases of immediate jeopardy (level 4 deficiencies)|-temporary manager appointed|-terminated of provider agreement and/or|-CIVIL MONEY PENALTY OF $3,050 TO $10,000 PER DAY OF NONCOMPLIANCE|||||(QIS Survey being implemented in all states incrementally)

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