PMIT HCA 410 Leadership in Long Term Care

Change Management in Long-Term Care “It should be borne in mind that there is nothing more difficult to arrange, more doubtful of success, and more dangerous to care through than change. The innovator makes enemies of all those who prospered under the old order, and only lukewarm support is forthcoming from those who would prosper under the new. Their support is lukewarm partly from fear of their adversaries, who have the existing laws on their side, and partly Changing Minds because men are generally incredulous, never really trusting new things unless they have tested them by experience.” –Machiavelli, The Prince As leaders in the long-term care industry, we must appreciate that change and transition is continual with our relationships and environments all being “works in progress.” For effective leaders, there are some basic beliefs about change that should be considered. 1. How successful you are at changing others has a lot to do with how much you are willing to be changed yourself. 2. People are everything in terms of success with change and its sustainability. 3. We learn most of our skills in change management from our own individual introspection. 4. Your beliefs as a leader are crucial and more important to managing change than all other strategies. Long-term care is in a flux of continual change due to the growing older demographics, the workforce conditions and shortages, the growing health care technology, and the changing health care regulation and quality initiatives. As leaders, the recognition that change, and more so, culture change is a daunting task is the first step. Second, the knowledge development around change management models and culture change will help support this inevitable process. Organizational culture is incredibly powerful and can lead to success or failure for most leaders. Organizational culture can be defined as what is valued, the leadership style, the language and symbols, the procedures and routines, and the definitions of success (Pratt, 2010). Initially, leaders need to assess the current culture and determine if it does support the evolving changes in long-term care. This comparison between “current” culture and what is desirable can be completed with all members of the organization—including employees, current leaders, patients/customers, and governing boards. Organizational culture can be assessed by focus groups, employee surveys, patient/family satisfaction surveys, and direct observation of the workplace. Queries such as why do you work here, what does the organization value, and how could this be a better place to work are all examples of assessing the culture. By direct observation, leaders can assess the employee attitudes, commitment to keeping the organization in great shape, participation in company activities, quality scores, and employee retention. A review of the mission, vision and values can also provide a leader with some guidance in determining the current organizational culture. Utilization of Change Theory for Leaders Leaders serve as the motivator, role model, change agent, and official leader and spokesperson for the desired new culture. Leaders must recognize that the current culture took a while to evolve, will require patience, consistency, and time to change. The use of change management models can help support culture change as well as smooth the path. Over 75% of change initiatives fail in organizations for many reasons. First, the complexity of an organization is sometimes overlooked with no systematic plan for change that will touch all parts of an organization. Change initiatives fail at times due to the lack of involvement by key stakeholders who must implement the change. For example, planning the transition to electronic health records in a skilled nursing facility would necessitate the certified nursing assistants as well as the nursing leadership to optimize the chance for a smooth transition. PMIT HCA 410 Leadership in Long Term Care

Change initiatives also fail at times due to the lack of ongoing attention and engagement by the leader. In summary, changes that are introduced and fail to alter the fundamental culture of the organization will not be successful. Although a crisis or a catalytic event may initiate change, it must have the people and leaders to sustain it. A planning model for change is a way to assure that you “go slow to go fast” in creating change. Change Models Kurt Lewin is sometimes considered the “father of change models” with the introduction of his basic change model consisting of Unfreezing, Implementation and Refreezing. Lewin’s main message was the need to thoroughly assess and prep the environment prior to planned change. Transformational change models include two different types of change. Incremental change is one step at a time, creating gradual separate changes which develop to become major shifts or trends. Sometimes these changes can be very subtle, occurring even while the old conditions remain. Transformational change occurs suddenly when something completely new emerges and all the previous rules and reality are different ( Schneider, B., Brief, A. & Guzzo, R. (1996). Peter Senge (2000) supports the development of dialogue skills for leaders engaged in change management. “Dialogue” refers to the ability to suspend one’s belief systems and truly listen to others engaged in the change. The use of dialogue is a good change management model in that it supports collective learning and inquiry. The process of change management or change transition follows a fluid process (shown by the transition curve) which is a useful tool for leaders in long-term care. Initially, many stakeholders or staff may have a negative response to the proposed change and refuse to engage. This “Denial” phase may be due to past history as it relates to change or simply hopeful that it will not progress to implementation. “Resistance” can occur in both overt and covert ways with everything from loss of staff to apathy about the change. “Exploration” of the change is an open process in which stakeholders are willing to pilot, take a risk, try the desired change which hopefully leads to “Commitment” and leadership for the new change. An example of this change process can be seen with the recent long-term transition from business as usual to active care management by Medicare Advantage health plans (Part C). Initially, long-term care organizations ignored the entry into the marketplace by newly formed Part C Medicare health plans which bundled together all Medicare services in a prospective payment model. There was overt resistance with long-term care providers indicating these plans would not survive financially and patients would not enroll in a plan which controlled their access to a closed panel of providers. However, as the early Part C plans documented lower hospitalizations and patient satisfaction, various providers of care became more interested and began the “exploration” process. Today, providers’ networks are strong in the Part C plans with “commitment” to improving health and quality for the frail elderly population. Leadership Skills for Change Management include being able to observe and do nothing initially. Leaders must have emotional literacy, be willing to change themselves, be able to listen, tell the truth, be flexible with the change, engage the appropriate stakeholders and honor past work that has been done in respecting the current organizational culture. The most critical part of change management is recognizing the importance of “refreezing” in Lewin’s terms. Frequently, leaders follow through until change is implemented and then move on to the next initiative or project. Norris, T. (2000). Facilitating community change. Avre: Clough & Norris. Pratt, J.R. (2010). Long-term care: Managing across the continuum. Sudbury, MA: Jones and Bartlett. Schneider, B., Brief, A., & Guzzo, R. (1996). Creating a climate and culture for sustainable organizational change. Organizational Dynamics, 7-19. CHAPTER 15 Leadership in Long-Term Care Learning Objectives After completing this chapter, readers will be able to: 1. Discuss the role of leadership in long-term care. 2. Identify the components of leadership. 3. Identify the characteristics of successful leaders. 4. Identify and understand the skills needed by successful leaders. 5. Understand how to gain or improve leadership skills. ■ Introduction It would be a huge understatement to say that leadership is one of the most important building blocks in the foundation of successful long-term care delivery. As the field of long-term care evolves, so must the profession transform itself to keep pace. Leadership is required now more than ever to continuously look for ways to maintain or bolster organizational creativity and innovation (Dana & Olson, 2007). As one group of authors stated: An organization’s leadership sets the tone for the entire system. Leaders’ visibility makes them uniquely positioned to define the organization’s quality goals, communicate these goals and gain acceptance from staff, make learning a priority, and marshal the resources necessary for the vision to become reality. (Smith, Saunders, Stuckhardt, & McGinnis, 2013, p. 257) ■ PMIT HCA 410 Leadership in Long Term Care

Leadership What is leadership, anyway? It is a term we use regularly, but not always accurately. It means different things to different people and different things in different situations. We each have our own concept of what it is and how it is demonstrated. There are many excellent and time-tested theories about leadership and an equal number of books, articles, and websites discussing those theories, including: • • • • • • • Transformational leadership Transactional leadership Strategic leadership Participative leadership Collaborative leadership Servant leadership Situational leadership It is not within the scope or intention of this text to discuss and elaborate on each of these theories, but rather to look at leadership as it applies to long-term care. There are also many scholarly definitions of leadership. Most are arbitrary and subjective. Some are more useful than others, but there is no single, correct definition of leadership (Yuki, 2006). The one thing the various definitions have in common is that they all involve purposeful influence in a group or organization (Dana & Olson, 2007). One definition that captures the essence of leadership particularly well came not from a scholarly journal, but from a popular novel of the 1960s. In The Pyramid Climbers, author Vance Packard noted that leadership “appears to be the art of getting others to want to do something that you are convinced should be done” (Packard, 1962, p. 13). The beauty of that definition is that it separates leadership into three distinct components: 1. Influencing others (getting others to do something) 2. Providing direction (something you are convinced should be done) 3. Getting voluntary acceptance (getting them to want to do it) Should any of these three components be missing, effective leadership will not be possible. Keep this definition in mind; it is the basis for our discussion of leadership skills. ■ Leaders: Who Are They? Who are the leaders in long-term care (or other) organizations? There are a number of questions, assumptions, and misunderstandings about who leaders are. Let us look at some of them with the goal of understanding leaders better. Are Leaders Born or Created? The question has long been asked whether leaders are born or made. Actually, what is really being asked is whether anyone can be a leader or only a few. James Kouzes and Barry Posner, authors of the highly successful text, The Leadership Challenge, answer the question emphatically and definitively, saying, “It’s just pure myth that only a few can ever understand the intricacies of leadership. Leadership is not a gene, and it’s not a secret code that can’t be deciphered by ordinary people” (Kouzes & Posner, 2007, p. 145). Leadership is not only for a few. Granted, leadership comes more easily to some than others, but it is a set of skills that can be learned. Anyone can have the fundamental requirements necessary for the leadership role. It has been said that there’s only one thing that a person needs to actually be born with in order to be a leader later in life: intelligence. A leader needs to be smart enough, but effective leaders aren’t necessarily the smartest people. They do have to know enough to do the job. We discuss those skills and how they are acquired and applied in considerable detail later in this chapter. Leaders Are Prescient Visionaries Are leaders more farsighted than others? Can they foretell the future? Do they know what tomorrow will bring? The answer to all of these questions is no. They are obviously intelligent enough to look at trends and try to proactively anticipate what may happen, but they have no special prophetic gifts. They study the past and learn from it. They apply skills such as strategic thinking and planning, which we explore later. Leaders Are Charismatic, Possess a Special Gift Leaders have the ability to convince others to follow them, but is that a special gift? Is it charisma—defined as “a personal magic of leadership arousing special popular loyalty or enthusiasm for a public figure (as a political leader) or a special magnetic charm or appeal” (Merriam-Webster, 2014)? Leaders certainly have charm and appeal that arouse loyalty, but again, it’s not something special that only a few have. Leadership Is Associated With a Superior Position Leadership does not automatically relate to a position as supervisor or boss. In an ideal situation, all managers will be leaders, but that is not always the case. Some managers are unable to make the transition to leader. Similarly, not all leaders are managers. In any organization or work group, there will likely be one or two individuals to whom others routinely turn for advice or counsel, regardless of their job or position. They are leaders. Leadership Is a Matter of Control There was a time (long ago) when managers were taught that they had to control those they supervised, meaning to dominate, manipulate, or rule them. It implied that those supervised could not be trusted to do what is right. That is not leadership. Leadership means getting those others to want to do what is needed. A leader “is one who converts followers to leaders” (Bennis & Nanus, 1985, p. 3). Leaders Are Remote and Distant Another outdated management belief is that managers must be detached from their subordinates; they must be remote and distant. The idea was that they had to be seen as superior and could not break down the barrier between them and their employees. Actually, all that demonstrated was the insecurity of the managers. Leadership requires just the opposite—that leaders be seen as approachable by their followers. ■ Common Characteristics of Leaders People look for certain things in their leaders, whether they are in long-term care or some other business. Research by Kouzes and Posner (2007) demonstrated that the top characteristics they look for are honesty, forward-looking, inspiring, and competency. Honesty Honesty goes beyond simply not committing crimes (although that is important). It also means being sincere. Followers want their leaders to be genuine. They want to know that what they see is what they get, and they reject phoniness, artificiality, and hypocrisy. Honesty means being fair and treating all equally. If some are treated differently from others—or are perceived to be treated differently—the leader will lose his or her followers’ respect. If the leader is seen as honest, followers will understand it even when things do not go as they might wish. Honesty also implies being trustworthy. It means saying what you mean and meaning what you say. Leaders should be willing to admit their mistakes and their faults. Followers must know that they can trust their leader. PMIT HCA 410 Leadership in Long Term Care

As leadership icon Warren Bennis puts it, “Leadership without mutual trust is a contradiction in terms” (Bennis, 2003, p. 131). Such trust takes a long time to develop but can be lost in an instant. A single failure of trust can invalidate many prior successes. Engendering trust is a competency that can be learned, applied, and understood. It is something that you can get good at, something you can measure and improve, something for which you can “move the needle.” You cannot be an effective leader without trust (Covey, 2009). Another aspect of honesty that is sometimes overlooked is being unselfish. Leaders must be secure enough in their roles to take blame for mistakes, even when those mistakes were the fault of others, and to give credit to others, even when the leader might properly deserve some of the credit. Being unselfish requires that a leader have patience with those who do not know as much as she or he does. There is a good feeling in knowing that you know—that should be enough. Forward-Looking People expect their leaders to be forward-looking. We have already said that they are not prescient, nor do they have special visionary powers. People expect leaders to have a sense of direction and a concern for the future of the organization. They must know where they are going if they expect others to willingly join them on the journey (Kouzes & Posner, 2007). A leader is not satisfied with the status quo. Inspiring Individuals want their leaders to be inspiring. The term inspiring is not used here in the religious sense, although most religious leaders are indeed inspiring. Rather, it means that a leader takes people where they did not think they could go. The leader makes them believe they can do things they had previously thought they could not. They “breathe life into people’s dreams and aspirations, making those people much more willing to enlist in the movement” (Kouzes & Posner, 2007, p. 34). To better understand inspiring in this context, readers are urged to look the term up in a thesaurus (it can be done very easily online). It matches terms such as invigorating, enlivening, encouraging, motivating, energizing, and stimulating. Competency Leaders are expected to know what they are doing—to be competent. Their followers must believe in them and their ability to lead. In a field such as long-term care, there are two kinds of competence. First, the leader must be competent in the profession being practiced, such as nursing, rehabilitation, or management. That does not mean that the leader has to know as much as all of the technical professionals supervised, but he or she must know enough about them to “speak their language” and know whether they are performing well or not. A leader must know what he or she can do and what she or he cannot. He or she should not show off (as opposed to demonstrating competence). Others will see through it quickly and lose respect. A second kind of competence is leadership competence. As we discuss later, there are specific leadership skills, and a person’s ability to practice those skills is all too observable to subordinates or followers. These characteristics are only a few of those common to successful leaders, but they are the ones most often cited. ■ Leadership Skills Do you remember the Vance Packard definition we discussed at the beginning of this chapter? It identified three components of leadership: (1) influencing others, (2) providing direction, and (3) getting voluntary acceptance. There are specific leadership skills involved in mastering each of these components. Readers should recognize some of them as representing the basic foundation of management. That is true, but the use of these skills by leaders goes well beyond routine management. Before moving on to the specific skills required for effective leadership, let us review several assump …