Leadership Excellence: The Exceptional Leader Self-Assessment System. Assessment Scales

Transcription

1 Leadership Excellence: The Exceptional Leader Self-Assessment System Assessment Scales Scale 1 Living Mission and Values...2 Scale 2 Modeling Effective Leadership...5 Scale 3 Modeling Supervisory Skills...8 Scale 4 Ensuring Optimum Care Standards...11 Scale 5 Attracting and Retaining Staff...14 Scale 6 Developing Staff...17 Scale 7 Championing Quality Improvement...20 Scale 8 Integrating Risk Management...23 Scale 9 Exhibiting Regulatory Expertise...26 Scale 10 Managing Resources...29 Scale 11 Communicating Effectively...32 Scale 12 Facilitating Change...36 Scale 13 Managing Conflict...40 Scale 14 Advocating Customer Satisfaction P age

2 Scale 1 LIVING MISSION AND VALUES Performance Descriptions The Leader in Long Term Care: A B C D E Is seen as the leader in collaboratively creating systems, setting and achieving goals; embracing the position with passion for service to others and demonstrates this commitment at all times; and assures alignment with the organization's vision/mission of all collaborative efforts. Consistently demonstrates knowledge of the organization's vision/mission; applies those values in his/her daily work; and seeks to collaborate with other disciplines in creating systems and implementing and achieving goals. Understands the organization's vision/mission; applies its values in daily work and relationship with others; and participates in the collaborative efforts of other disciplines to set and achieve facility goals. Shows some knowledge and interest in the organization's mission/vision; applies some of the organizational values; and participates in the interdisciplinary collaboration of goal setting and agrees to system changes. Demonstrates limited knowledge and application of the organization's mission/vision; participates in collaboration with other departments only when assigned; and accepts assigned responsibilities in the implementation of systems, processes, and programs. OPTIMAL PERFORMANCE CHARACTERISTICS The mission and values of a company are the basis upon which it is built and the motivation for its continued growth. A leader leads in setting and achieving goals, which apply to the company's mission and values. The leader is a model for others and exhibits those values through daily interactions involving personal excellence, integrity, enthusiasm, leadership, and collaboratively working relationships. leads in creating systems, processes, and programs that further attain the organization's vision, mission and goals. He/she advocates innovative and creative approaches to meeting the organization's needs and furthering mission/goals and reinvents his/her role as necessary to assist the organization in achieving its mission/vision. 2 P age

3 models excellence through daily interaction with others. With these interactions he/she is sensitive to staff needs (at all levels) to be involved and to feel part of the facility culture; demonstrates customer focus in all interactions by embracing the position with passion for service to all customers and caregivers and communicates the organization's vision/mission effectively to others. works collaboratively with other managers to implement and achieve facility goals; develops departmental long- and short-range goals, all of which are aligned with the organization's vision/mission to promotes and enable interdisciplinary collaboration and cooperation. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Demonstrating support for others and enthusiasm toward the work by coordinating meetings on a regular basis (department specific or team centered) that keep people informed and vested in the Mission and Vision of the organization. Sharing his/her vision with others and seeks and encourages fresh ideas via formal or informal communication systems, e.g. Mission Control Idea of the Month rewards incentive programs; o Examples: Maintenance creates an Ambiance Team to address how to change the environmental culture of the facility o Social Services conducts Mission Control meetings with staff to promote the facility mission and foster person centered care o Nursing launches a Simple Pleasures campaign to identify a daily simple pleasure that can be coordinated for all residents in the facility o Dietary works on the Mission Control team to identify positive changes in the food/dining experience o Activities works with nursing to help implement designated Daily Pleasures within their activities Translating customer wants and needs into action using formal and informal customer service feedback systems such as My Inner view Utilizes innovative strategies such as visual tools, (graphs, storyboards), newsletters, quality fairs, etc. to tell the story of process improvements Blending high expectations into daily routine and job descriptions 3 P age

4 Stating values and explaining how he/she exhibits and applies them in daily work Integrates values education into staff meetings, daily standup meetings, theme days, etc. Encouraging individuals to use their ideas, knowledge, and creativity Demonstrating special commitment to understand those we serve COMPETENCY CROSS REFERENCE 1.1, 1.2, 1.3, 1.4, 1.4.2, 1.5, 1.7, 1.9, , , , 7.7: 1.1 Models the organization s values and mission/vision in his/her daily work and interactions with others. 1.2 Works collaboratively with other managers to implement and achieve facility short and long term goals which are aligned with organizational vision/mission. 1.3 Collaboratively develops department's long and short range goals which are aligned with organization's vision/mission Develops implementation strategies to achieve those goals. 1.4 Leads in creating systems, processes, and programs that further attain organization's vision, mission and goals Reinvents his/her role as necessary to assist the organization in achieving its vision/mission. 1.5 Communicates the organization's vision /mission effectively to others. 1.7 Advocates for innovative and creative approaches to meeting organizational needs and furthering the mission/vision. 1.9 Embraces position with passion for service to all customers Is sensitive to staff needs (at all levels) to be involved and to feel part of the organizational/facility culture Models excellence and a commitment to quality Promotes and enables interdisciplinary collaboration and cooperation. 7.7 Models customer focus in all interactions. 4 P age

5 Scale 2 MODELING EFFECTIVE LEADERSHIP Performance Descriptions The Leader in Long Term Care: A B C D E Inspires confidence through visionary leadership that reflects credibility, integrity, and respect for others; enthusiastically reinforces positive outcomes and a positive facility image through community involvement; and actively seeks professional development opportunities, including professional credentialing. Models commitment to quality and a clear vision of the organization's goals; seeks new ideas and understands the importance of an effective public relations program; and participates in a variety of professional development opportunities. Demonstrates a desire for quality and is perceived as trustworthy; shows awareness of the importance of community perceptions and is open to new ideas; and develops leadership skills through readily available sources, collaborating at times with other organizations. Performs daily work with little awareness of the effect of personal behavior on others; makes changes only as needed, demonstrating limited understanding of public relations issues; and participates in professional development opportunities as directed. Demonstrates a disregard for integrity and respect for others; encourages the status quo, unreceptive to most new ideas and disregarding feedback from the community; and lacks awareness of need for continuing professional growth and development. OPTIMAL PERFORMANCE CHARACTERISTICS Visionary leadership is central to the effectiveness of long term care leader. This strong, effective leadership is demonstrated through personal behavior that reflects integrity and credibility in all relationships, openness to new ideas, and a commitment to lifelong learning and development. demonstrates integrity, credibility, and trustworthiness in the execution of his/her responsibilities. He/she inspires trust and confidence through modeling excellence, a commitment to quality, and a respect for the beliefs, values, and customs of individuals. He/she maintains a clear vision of the organization's mission and is able to communicate this vision in a way that inspires others. 5 P age

6 reinforces positive thinking and positive outcomes by actively generating new ideas and changes as appropriate, encouraging others to take calculated risks in decisionmaking, and demonstrating flexibility and openness to new ideas and paradigms. He/she functions as facility liaison with community professionals and leaders, improving the community perception of the facility's image through an effective public relations program while providing coordinated client care. champions lifelong personal and professional learning by systematically assessing his/her own need for personal and professional education, availing him/herself of a variety of growth and self-improvement opportunities. He/she uses various strategies to improve, such as continuing education, professional credentialing, collaboration with other community organizations, public speaking, research, marketing, networking, etc. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Department and facility examples of actions taken in response to positive and negative outcomes Departmental Examples o Maintenance participates in the facility safety program o Maintenance works with the Falls team to identify environmental deficits and opportunities to promote safety through lighting, grab bars, elevated toilet seats, innovative call systems, monitoring of call response times, and identification of new products for evaluation o Social Services works on the Falls Team and provides feedback/data on at risk residents, behavioral strategies and interventions, use of psycho actives and the current reduction plan, pain management goals, and resident and family education related to fall management o Therapy participates in the falls team and provides data and updates on therapy referrals/screenings related to those at risk; therapy coordinates a seating clinic with nursing and maintenance to look at seating options, restraint alternatives and least restrictive means, etc. o Dining is working with the Falls team on dining schedules and the coordination of a Walk to Dine program o Dining is working with nursing and therapy to coordinate more person centered dining times 6 P age

7 Departments work collaboratively and independently as an initiator/leader of process improvements and innovation in the workplace Examples of motivating and inspiring others (team building activities, employee recognition, performance appraisal process, etc.) Ways they have evaluated facility care services against current industry trends; Examples include ways in which the department has embraced the concepts of culture change Maintenance has assisted in writing an article on F323 and environmental safety Activities ands are involved in a professional association Participation in continuing education seminars or participation as a presenter at an educational event on topics such as Disaster preparedness, Safety, etc. Evidence of innovative projects that have been piloted by the LTC leaders Examples of how they encourage individuals to use their ideas, knowledge, and creativity COMPETENCY CROSS REFERENCE Primary 1.7.1, 1.8, 1.11, , , , , 1.14, 1.16, , , , 2.13 Secondary 1.5, 1.7.2, 1.7.3, 1.8.1, , , Primary: Models and reinforces positive thinking and positive outcomes. 1.8 Is flexible, adapting to new ideas and paradigms Consistently models effective leadership through personal behavior Executes tasks and responsibilities with utmost integrity, credibility, and trustworthiness Models excellence and a commitment to quality Respects the beliefs, values, and customs of individuals Inspires mutual trust and confidence Champions lifelong personal and professional learning Functions as facility liaison with community professionals and leaders for: Providing coordinated client care Maintaining public relations Improving community perception of the facility's image Seeks feedback on own performance from supervisors, peers, and staff. 7 P age

8 Scale 3 MODELING SUPERVISORY SKILLS Performance Descriptions The Leader in Long Term Care: A B C D E Constantly conveys performance expectations persuasively, utilizing well-established systems and processes to provide effective and timely feedback that help staff understand what is expected; empowers subordinates through effective delegation, providing excellent mentoring, coaching, and follow up to ensure clear understanding and successful completion; and masterfully promotes staff goal-setting, actively reinforcing successes through recognition and celebration. Communicates performance expectations, providing constructive and timely feedback, counseling, and disciplinary action and overseeing an effective performance appraisal system; delegates effectively to subordinates, providing strong mentoring, coaching, and follow up to ensure clear understanding and successful completion; and encourages individual and team goal-setting, reinforcing progress by celebrating their successes. Communicates performance expectations sufficiently, using performance appraisals, constructive feedback, counseling and disciplinary action, as appropriate; delegates responsibilities adequately, using feedback to ensure mutual understanding of the expectations; assists individuals and teams in goal-setting as needed. Utilizes performance appraisals and sporadically feedback to convey performance expectations; delegates responsibilities with some regard for the subordinate's ability to succeed; and assists individuals and teams in goal-setting when requested. Relies on disciplining actions to communicate performance expectations; delegates with apparent disregard for the employee's understanding or ability to succeed; and lacks awareness of how to support individuals and teams in goal-setting efforts. OPTIMAL PERFORMANCE CHARACTERISTICS Excellent supervision is a cornerstone of an organization's efforts to ensure quality care and exceptional delivery of services. As a leader and mentor, the leader s behavior is key to staff development of supervisory skills. By conveying and clarifying expectations, empowering staff through appropriate delegation, and encouraging staff in goal setting, he/she promotes the development of supervisory skills throughout the organization. 8 P age

9 conveys performance expectations clearly through well established systems and processes that are consistent with the organization's vision and mission. By providing constructive and timely feedback, including counseling and disciplinary action as appropriate, he/she helps staff understand what is expected. The leader oversees an effective performance appraisal system, supporting the timely completion and delivery of performance appraisals for all nursing employees. delegates responsibilities appropriately, including the establishment of a clear understanding of the expectations and the level of authority granted. He/she recognizes delegation as an opportunity to assist in the professional growth and development of subordinates, utilizing delegation to empower them to participate in decision-making, and encouraging them to develop new ideas and standards that exceed customer expectations. To ensure successful completion of the delegated task, the leader provides excellent mentoring and coaching and appropriate follow-up with the employee. encourages staff to set individual and team goals that are both measurable and attainable. By conveying expectations, promoting cooperative behaviors, and seeking feedback to promote mutual understanding, the leader supports appropriate communication for small groups and teams, enhancing their effectiveness. He/she helps the individuals/teams remain focused on the organization's vision and mission and reinforces their progress by acknowledging and celebrating successes. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Clarity of written and verbal communication outlining expectations, e.g., individual and departmental memos, newsletter articles, teaching/coaching notes, and methods to illicit staff feedback, etc. Frequency and quality of performance appraisals; participation in employee goal setting; Example: Safety Board with a listing of injury free days Quality and timeliness of performance counseling documentation Successful completion of delegated tasks Involvement of subordinates in decision-making and facility Mission and Vision Evidence of effective mentoring and coaching: Regularly scheduled meetings with staff, defined methods to solicit feedback and promote team work Evidence of appropriate staff goals having been supported and progress celebrated Staff satisfaction surveys and examples of how feedback was used to remedy or enhance satisfaction 9 P age

10 COMPETENCY CROSS REFERENCE Primary 1.5.1, , 2.2, 2.11, , 2.14, 3.8, 3.9.1, 4.7, 4.7.3, 4.7.4, 4.8, 4.14 Secondary , 3.8.1, 3.8.2, 3.8.3, 7.4 Primary: Helps teams and individuals maintain their focus on the organization's mission/vision Delegates as appropriate. 2.2 Communicates performance expectations clearly Empowers staff to participate in decision-making Encourages staff to set individual and team goals Acknowledges and celebrates successes to reinforce progress and achievement. 3.8 Supports appropriate communication for small groups and teams Presents feedback constructively. 4.7 Oversees an effective staff performance appraisal system Supports timely completion and delivery of performance appraisals by staff Ensures follow-up with coaching/counseling and mentoring/training. 4.8 Implements the organization's progressive disciplinary policy in a fair and consistent manner Models expert coaching and mentoring 10 P age

11 Scale 4 ENSURING OPTIMUM CARE STANDARDS Performance Descriptions The Leader in Long Term Care: A B C D E Establishes optimum care standards that exceed compliance requirements; develops dynamic systems and protocols; and uses a wide variety of methods to ensure that the optimum standards of health services are maintained. Establishes optimum care standards that meet or exceed compliance; improves current systems and protocols; and ensures that high level health care systems are maintained. Maintains care standards which meet compliance requirements; establishes systems and protocols that promote compliance; and ensures that minimum standards of health services are maintained. Maintains health care standard systems and protocols that meet minimum requirements; and displays limited ability to ensure that health services are maintained. Fails to maintain care standards that meet compliance requirements; makes minimal effort to establish systems and protocol that meet minimum requirements; and displays limited ability to ensure that health services are maintained. OPTIMAL PERFORMANCE CHARACTERISTICS The exceptional leader ensures that optimum standards of health services are established, operationalized, and maintained in the facility s daily operations. The leader does this successfully by achieving mastery of standards set by regulatory and accrediting bodies and professional organizations and by developing facility systems and protocols that promote meeting or exceeding these standards. He/she educates customers and staff on standards and ensures ongoing compliance through pro-active risk management and implementation of corrective action whenever areas of non-compliance are identified. establishes optimum care standards which meet or exceed compliance requirements. He/she maintains current knowledge and mastery of federal, state, and local regulations, and accreditation and industry standards. The exceptional leader is able to apply this knowledge and work collaboratively with other staff in the development of dynamic systems that promote survey preparedness at all times, placing the facility in the forefront of the profession. establishes systems and protocols that promote meeting or exceeding regulatory standards. He/she interprets these standards to residents, families, and professional 11 P age

12 representatives. The staff s knowledge of and adherence to the regulatory standards result in the high quality of care provided in the facility. ensures maintenance of high standards of health services in daily operations. He/she achieves this by educating his/her staff and other departments on regulations and standards, instituting pro-active risk management strategies, and implementing necessary corrective action based on accurate analysis of non-compliance areas. SUPPORTIVE DATA (current or past activities) may include but are not be limited to: Policy and procedures are current and reflect interdisciplinary oversight and collaboration; examples include the interdisciplinary Disaster Preparedness plan Current resources are available to include SOM, State regulations, Life Safety Codes, Building Codes, MSDS information, etc. Guidelines or protocols are current and are reviewed on a regular basis as part of the QA process Current clinical reference materials are available to clinical staff; Examples include SOM, Current PDR, periodicals, clinical guidelines, current P&P, etc. In-service programs covering a wide variety of current regulatory and standards information are offered and attended by staff Upon interview, staff can answer (or refer to the correct person) questions regarding resident's care and services in accordance with regulatory and clinical standards Upon observation, clinical staff performs their duties and job functions in accordance with regulatory and clinical standards. Survey preparation paperwork is complete, accurate, and available at the time of survey Compliance rounds and audits are conducted on a routine basis and the findings are addressed collaboratively Describing the survey process and proactive strategies necessary to achieve compliance. Attendance or participation, during the last year, in a program or seminar on regulatory and other professional standards COMPETENCY CROSS REFERENCE Primary 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.7.1, 6.9, 6.10 Secondary , 1.15, , , 4.5, 4.5.1, 4.5.2, 4.5.3, 4.5.4, 4.6.2, 5.8, 6.8, P age

13 Primary: 6.1 Maintains current knowledge of Federal, State, and local standards and regulations for long term care, such as those for certification, licensure, and accreditation, Medicare, state Medicaid and, if applicable, JCAHO. 6.2 Educates his/her staff and other departments on regulations and standards. 6.3 Interprets regulatory standards to residents and external customers such as families, discharge planners, referral sources, insurance companies, etc. 6.4 Establishes optimum care standards which meet or exceed compliance requirements. 6.5 Establishes systems and protocols that promote meeting and exceeding regulatory standards. 6.6 Ensures maintenance of high standards in all daily operations. 6.7 Promotes survey preparedness at all times Maintains survey readiness via current accurate reports and department records. 6.9 Implements necessary corrective action based on accurate analysis of non- compliance areas Institutes pro-active risk management strategies. 13 P age

14 Scale 5 ATTRACTING AND RETAINING STAFF Performance Descriptions The Leader in Long Term Care: A B C D E Applies innovative strategies to craft an optimal work environment; pro-actively assesses staffing roles to ensure congruence with hiring criteria and resulting decisions; and utilizes rigorous measurements of staff satisfaction and implement improvement meaningful to staff. Employs multiple methods to sustain a positive work environment; periodically assesses staff roles to update hiring criteria; and utilizes proven measures of staff satisfaction with consistent effort to make improvement. Demonstrates use of accepted strategies to assess staff satisfaction and attract and retain staff; and applies hiring criteria when selecting new staff. Displays some knowledge and effort in utilizing strategies for attracting and retaining staff; uses hiring criteria that are inconsistently linked with skill sets of new staff; and sporadically makes an effort to assess staff satisfaction. Makes hiring decisions that are poorly supported, and new staff come to positions lacking critical skills; lacks demonstrated understanding of staff needs; and makes little effort to assess or respond to staff requests. OPTIMAL PERFORMANCE CHARACTERISTICS The role of the Long Term Care Leader in attracting and retaining staff is paramount to sustaining the delivery of quality care and exceeding customer expectations. Vigilance in hiring the best staff and fostering a dynamic and vital work environment results in increased job satisfaction and stability. employs a wide variety of methods and strategies to foster an optimal work environment that promotes staff self-governance, independent thinking, empowerment, safety, and flexibility. pro-actively reassesses the roles of staff to guarantee that job descriptions reflect roles required and that hiring criteria clearly reflect the necessary knowledge, skills, and competencies. Hiring decisions are made based upon these criteria plus the individual s ability to contribute successfully to the organization. fosters high levels of job/staff satisfaction. This occurs through the clear articulation of the functions and values of each person s position and the interdependence of positions 14 P age

15 required to achieve quality care. This is supported by fair and competitive compensation and the inclusion and celebration of unique employee characteristics. SUPPORTIVE DATA (current or past activities) may include, but is not limited to: Examples of flexible staff assignments and creative, flexible staffing patterns and schedules to include weekends and off shifts Examples of hiring and employment incentives; Examples include Mentoring Programs Department specific employee recognition programs and strategies to promote job satisfaction; Example: Maintenance participates in facility Safety Programs, coordinates interdisciplinary Do You See What I See? Environmental Rounds, and provides a monthly prize for the Going Green tip of the month. Demonstrated opportunities for staff participation in decision-making, e.g. councils, task or project management teams Demonstrated review of job descriptions, and hiring criteria Periodic formal and informal satisfaction surveys with staff Stated satisfaction of staff with job descriptions, role responsibilities, and modification Stated satisfaction with level of compensation and related employee perks and incentive programs: give examples Absence of/ or minimal grievances regarding work environment issues Evidence of safety needs being heard and addressed Use of storyboards and/or visual data to demonstrate safety initiatives and progress towards safety goals Demonstrated use of bench marking Shows documentation of adherence to hiring criteria in selection of new staff Demonstrated performance evaluations of recently hired staff that show competencies Feedback forms from staff and residents that show satisfaction with coworkers, managers and staff. COMPETENCY CROSS REFERENCE 1.1, , , 2.11, , , 4.1, 4.2, 4.3, 4.3.1, 4.3.2, 4.3.3, 4.4, 4.7, 4.7.1, 4.7.2, 4.7.3, 4.7.4, P age

16 1.1 Models the organization's values and mission/vision in his/her daily work and interactions with others Is sensitive to staff needs (at all levels) to be involved and to feel part of the organizational/facility culture Values and incorporates staff opinions in decision making Empowers staff to participate in decision-making Promotes and enables interdisciplinary collaboration and cooperation Utilizes collective wisdom and decision making capabilities of staff. 4.1 Works collaboratively to recruit and select exceptional staff. 4.2 Exhibits skillful interview techniques. 4.3 Implements effective strategies to retain quality staff Participates in developing, reviewing, and revising job descriptions Reviews retention policies and procedures and modifies them as needed Makes jobs meaningful, challenging, and contributory to the department and the organization. 4.4 Ensures staffing patterns and processes which maximize resident care and deployment of staff. 4.7 Oversees an effective staff performance appraisal system Bases system on clear and meaningful, job-based criteria Collects objective data as basis for feedback Supports timely completion and delivery of performance appraisals by staff Ensures follow-up with coaching/counseling and mentoring/training. 5.4 Creatively manages flexible staffing patterns that meet changing client service level/needs. 16 P age

17 Scale 6 DEVELOPING STAFF Performance Descriptions The Leader in Long Term Care: A B C D E Ensures a complete, thorough orientation to health services and facility; uses new hire selfassessment for effective orientation and provides ongoing documented feedback throughout orientation, also actively provides and promotes that all staff receive/attend regular education/training programs; and seeks and empowers staff to participate in decision making along with encouraging staff to seek advancement opportunities. Provides a complete orientation to health services and the facility; gives feedback to new hire at mid-point and 90-day introductory period performance evaluations, and has consistent and regular ongoing education and training for all shifts; and involves staff in most decision-making, encouraging utilization of staff in leadership positions and advancement opportunities. Provides consistent basic orientation to health services and the facility; provides feedback to new hire at 90-day introductory period performance evaluation, and education/training programs are available to all shifts; and involves staff in some decision-making. Posts position advancement opportunities. Provides basic orientation to health services and inconsistently to the facility; inconsistently makes feedback or presents only if new hire requests; and makes occasional education/ training available on multiple shifts. Allows minimum staff participation. Provides minimal orientation to health services and the facility; offers feedback to new hire only in failure to perform; and offers sporadic training only on one shift. Disallows staff participation. OPTIMAL PERFORMANCE CHARACTERISTICS The Long Term Care Leader recognizes that orientation, education/training, and staff participation and advancement opportunities are key to successful operations and to enriching and developing highly exceptional staff. works collaboratively with administrative and interdisciplinary team members to provide orientation. He/she provides a complete and thorough orientation to health services and to the facility. The leader seeks staff self-assessment and provides feedback to staff throughout the orientation process. actively promotes and provides education and training for all health services staff. He/she utilizes staff as trainers and mentors; ensures staff attendance at trainings via 17 P age

18 flexible scheduling; and maintains a current, readily available reference library to include a current employee handbook, policy and procedure manual, and regulatory guidelines. Also channels information about accessing outside educational opportunities. supports, encourages, and advocates participation and advancement opportunities for all health services staff. He/she strives to make jobs meaningful, challenging, and contributory by being sensitive to the staff s need to be involved and included, empowering and enabling them to participate in decision-making opportunities. The leader mentors and develops subordinates in their professional growth. He/she encourages all staff to set individual goals and to seek and attain position advancement and/or leadership opportunities. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Orientation checklist and calendar, completed, dated, and initialed within company orientation time line for facility and company operations for all new hires Education and Training binder is current with dates and synopsis of programs provided, and sign in logs of staff who attended Annual educational calendar reflects both facility provided and community available education/training programs Educational calendar reflects participation by all staff departments and is reflective of staff and federal regulations, community standards, and the facility strategic plan; Examples follow: o Social Services provides Advance Directives, End of Life Resident Rights, Grievance Policies, Coordination of Ancillary Services education, (etc) o Dietary provides education on therapeutic diets, substitutes, the ambiance of dining, food and sanitation, etc. o Maintenance provides education on Disaster Preparedness, Safety, Water temperatures, creating a culture of safety, and related regulations such as F323, etc. o The facility involves residents, volunteers, and families in the educational plan o Educational planning is done in conjunction with Risk and Quality Committee initiatives; the facility uses data to evaluate the effectiveness of the current plan and to make adaptations as needed Resource library is in a readily available location for all staff and houses updated policy/regulatory manuals and resource materials Staff Mentor list reflects current staff leaders with the tasks assigned and completed Staff bulletin board exhibits current position change/leadership opportunities and both internal and external education and training programs, via postings and current educational calendar 18 P age

19 Staff suggestion box is a user-friendly location, and a log of ideas/comments is maintained and complete with follow-up/response log Staff meeting s agenda/ minutes reflect staff participation in decision-making process COMPETENCY CROSS REFERENCE Primary 1.10, , 2.11, , 2.12, , 3.9.1, 4.5, 4.5.1, 4.5.2, 4.5.3, 4.5.4, 4.10, 4.11, , , 4.12, 4.13, , 7.4, 7.8 Secondary 1.7.1, , , 2.12, 3.6, 4.6, 4.9, 4.11, , 6.2, 6.8, 7.1, 7.8 Primary: 1.10 Actively seeks ongoing feedback to make necessary changes/adjustments from current to desired state Is sensitive to staff needs (at all levels) to be involved and to feel part of the organizational/facility culture Empowers staff to participate in decision-making Promotes and enables interdisciplinary collaboration and cooperation Promotes staff self-evaluation and learning targeted toward performance improvement Encourages staff to set individual and team goals Presents feedback constructively. 4.5 Enforces regulatory and employee law compliance. These may include: OSHA requirements Physical, TB, or drug testing Worker compensation Child/adult abuse reporting Provides staff with outside resources and other services as appropriate Provides effective clinical orientation and on-going training Uses adult learning principles Utilizes staff as trainers and mentors Collaboratively ensures that employee handbook, policy and procedure manuals, and other materials are current, readily available, and used in orientation and training Actively promotes training and education for staff, residents, and community Promotes flexible scheduling so staff on all shifts can attend. 7.4 Empowers staff to develop new ideas and standards to exceed customer expectations. 7.8 Supports staff orientation and ongoing training on positive customer service by all staff to all customers. 19 P age

20 Scale 7 CHAMPIONING QUALITY IMPROVEMENT Performance Descriptions The Leader in Long Term Care: A B C D E Pro-actively evaluates situations to identify performance improvement opportunities; performs ongoing systematic objective data collection and then uses the objective data to analyze problems and measure outcomes; and employs a wide range of planned interventions that promote performance improvement. Consistently evaluates situations to identify performance improvement opportunities and routinely reviews clinical practice standards; collects and effectively uses objective data; and is able to implement planned interventions that improve performance. Evaluates most situations to identify performance improvement opportunities and routinely examines clinical practice standards; uses objective data collection; and is able to implement planned interventions that contribute to performance improvement. Demonstrates limited ability to evaluate situations when they arise as means to identify performance improvement opportunities; minimally collects and analyzes objective data; and has difficulty identifying underlying root causes or implementing planned interventions that contribute to performance improvement. Performs daily work with minimal attention to evaluating situations to identify performance improvement opportunities or examine clinical practice; lacks ability to analyze problems; and rarely identifies underlying root causes or implements planned interventions for quality improvement. OPTIMAL PERFORMANCE CHARACTERISTICS The Long Term Care Leader embraces and pro-actively fosters the principles and processes of quality improvement, integrating them into the daily operations of the nursing department on an ongoing basis. He/she does this successfully by evaluating situations to identify performance improvement opportunities, ensuring implementation of planned interventions that promote performance improvement, and using objective data to analyze problems and measure outcomes to enhance continuous improvement. ensures implementation of planned interventions that promote performance. He/she empowers and encourages other staff members to fully participate in quality improvement efforts by promoting and enabling interdisciplinary 20 P age

21 collaboration/cooperation; utilizing collective wisdom and decision-making capabilities of staff; and integrating the processes and programs across departments. He/she models continuous quality performance improvement philosophy and techniques in daily behavior. The leader uses each specific improvement opportunity to further develop and enhance the facility s overall quality improvement systems and processes and communicates performance expectations clearly. evaluates situations to identify performance improvement opportunities. He/she continuously examines clinical practice, identifying underlying dynamics or the root cause of the problem. demonstrates knowledge of quality improvement principles by collecting and using objective data to analyze problems and measure outcomes that enhance continuous improvement. He/She uses analysis strategies, including both quantitative and qualitative measures and implements, monitors, and updates plans to improve quality indicators. Based on this data, the leader determines the effect of the changes and identifies activities to sustain or enhance improvements. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Conducting data (current or past activities) collection, analysis, and presentation from possible data (current or past activities) sources: Notes/audits from clinical and environmental rounds, results of satisfaction surveys, etc. Environmental rounds are scheduled on a regular basis, at diverse times and include diverse staff representatives 24-hour nursing report is reviewed as part of a formal meeting with processes in place to address action steps and ensure follow up Departmental logs: Infection control, Incident/Accident, Grievance/complaint; durable medical equipment and safety checks, Advance Directives/DNRO, and logs and data tools that reflect department specific indicators for tracking and trending Medical record audits Satisfaction surveys: Resident, Staff, and Family Ongoing reviews of new interpretive guidelines and regulatory updates Resident Council minutes and related grievance reports such as Consultant reports (pharmacy, registered dietitian) and use of Quality Measure/Quality Indicator reports; CMS Nursing Home Compare, Advancing Excellence data, etc. Participation in Quality Assurance and Assessment (Quality Management) activities and Risk meetings. Demonstrating and applying Continuous Quality Improvement Tools: o idea generating tools (i.e. brainstorming) o consensus generating tools (i.e. multi-voting, rank ordering) o team meeting skills o Run charts, flow charts, control charts, etc. o action plans 21 P age

22 Examples of assistance provided to integrate Quality Management into daily work; daily standup meetings, rounds, etc. Providing opportunities for interdepartmental quality fairs and venues that emphasize facility initiatives such as safety, infection control, etc. Examples of motivating and inspiring others COMPETENCY CROSS REFERENCE Primary 2.1, 2.2, 2.3.1, 2.3.2, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 2.11, , , Secondary 1.10, 1.11, 1.12, , 1.13, 1.14, 6.5, 6.6, 6.9, 7.2, 7.3, 7.5 Primary: 2.1 Models continuous quality performance improvement philosophy and techniques in daily behavior. 2.2 Communicates performance expectations clearly Identifies underlying dynamics or root cause of problems Examines practice in all departments. 2.4 Maintains objective focus on needed changes in operational process rather than on people involved. 2.5 Collects objective data. 2.6 Uses objective data to analyze problems and measure outcomes to enhance continuous improvement. 2.7 Uses analysis strategies, including both quantitative and qualitative measures. 2.8 Ensures implementation of planned interventions that promote performance improvement. 2.9 Implements, monitors, and updates plans to improve facility/department quality indicators Develops and uses a variety of instruments to evaluate outcomes regarding customer satisfaction, employee turnover/retention, quality of care, etc Empowers staff to participate in decision-making Promotes and enables interdisciplinary collaboration and cooperation Utilizes collective wisdom and decision making capabilities of staff Integrates processes and programs across departments. 22 P age

23 Scale 8 INTEGRATING RISK MANAGEMENT Performance Descriptions The Leader in Long Term Care: A B C D E Pro-actively seeks opportunities for early identification of risk factors through analysis of supportive data; models surveillance techniques; and demonstrates an exceptional ability to lead in the integration of quality improvement strategies and collaboration with all disciplines. Consistently investigates accidents and incidents and ensures appropriate follow up to mitigate risk factors; assures ongoing surveillance; and promotes quality improvement initiatives. Adequately identifies risk factors; demonstrates acceptable surveillance techniques by tracking accidents and incidents; and supports quality improvement initiatives. Exhibits limited participation in quality improvement initiatives and the identification of risk factors; and demonstrates some understanding of necessary surveillance techniques. Demonstrates poor understanding of risk factors; lacks follow through on surveillance outcomes; and poorly participates in quality improvement initiatives. OPTIMAL PERFORMANCE CHARACTERISTICS Risk management is an integral component of the Long Term Care Leader s role. The most important aspects of risk management are identifying and preventing potential loss based on systems failures, as well as guarding against loss. assists others in recognizing major risk factors within the organization through careful analysis of objective data, such as incident/accident reports, Workers' Compensation claims, and Quality Indicator reports (where applicable). Such analysis includes tracking/trending of issues, in addition to carefully scrutinizing the identifiable risk factors associated with each specific event. He/she effectively manages the integration of risk identification, evaluation, and loss prevention, which are critical to the organization's risk management success. conveys the value of ongoing surveillance by all departments, with the goal of promptly identifying potential systems failures and recognizing areas needing improvement. Beginning with new employee orientation and continuing with ongoing staff collaboration to reinforce risk management concepts, the leader encourages others to identify risk factors in order to pro-actively prevent losses. 23 P age

24 promotes the total integration of quality improvement throughout the organization by modeling risk management strategies, including monitoring safety-related activities (such as ergonomics issues and needle-stick precautions). He/she enhances staff buy-in to the quality improvement process by effectively demonstrating the relationship between early identification and prevention of problems. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Ways the facility was assisted in the development of new systems; Examples include: a new wireless call light system, fall reduction strategies, Going Green strategies, introduction of technology into existing documentation systems, etc. Supporting interdisciplinary problem solving and creating a blame free environment when reviewing Safety Committee reports, maintenance logs, and OSHA logs Examples of assistance provided to integrate quality improvement into daily work Prompt analysis of objective data (current or past activities) such as insurance claims history, incident reports, and survey results Effective and efficient methods used to assure ongoing surveillance Careful tracking and trending of quality indicator reports, falls tracking system, and other areas with high risk potential Facility remains proactive in identification of new products and technology that can promote work efficiency, safety, and financial stewardship COMPETENCY CROSS REFERENCE Primary , , 2.1, 2.5, 2.6, 2.8, , 4.6.1, 6.10 Secondary 1.7.1, 1.8.1, 2.3, 7.5 Primary: Models excellence and a commitment to quality Mentors and develops staff in their professional growth. 2.1 Models continuous quality performance improvement philosophy and techniques in daily behavior. 2.5 Collects objective data. 2.6 Uses objective data to analyze problems and measure outcomes to enhance continuous improvement. 24 P age

25 2.8 Ensures implementation of planned interventions that promote performance improvement Promotes and enables interdisciplinary collaboration and cooperation Initiates, maintains, and follows up on each work related injury/illness with complete and accurate worker compensation reports and records, adhering to company policy Institutes pro-active risk management strategies. 25 P age

26 Scale 9 EXHIBITING REGULATORY EXPERTISE Performance Descriptions The Leader in Long Term Care: A B C D E Possesses mastery of regulatory standards; establishes systems and resources, which enable performance that exceeds regulations; and takes an assertive, pro-active position, serving as a strong client advocate and seeking an opportunity to influence the profession s direction. Models thorough knowledge of regulatory standards; applies knowledge in developing systems to meet standards; and exhibits a pro-active position and client advocacy skills involving input to influence the profession s direction. Demonstrates sufficient knowledge of regulatory standards; collaboratively develops systems to meet regulations; and exhibits some pro-active and client advocacy skills. Exhibits some knowledge of regulatory standards; assists in developing systems to meet regulations; and sometimes serves as a client advocate. Shows some knowledge of regulatory standards; and lacks expertise to promote facility regulatory compliance. OPTIMAL PERFORMANCE CHARACTERISTICS The Long Term Care Leader has a current mastery of all Federal, State and local regulatory standards. It is critical that he/she ensures that the operational system and staff training and resources meet or exceed compliance. He/she actively participates in professional/educational organizations. He/she seeks political opportunities that influence the regulatory process and the profession s direction. masters and maintains updated knowledge of federal, state, and local regulatory standards. He/she continuously expands his/her knowledge base and maintenance of his/her expertise. ensures continuous compliance with regulatory standards. He/she develops, implements and maintains systems, which exceed these regulatory standards. He/she effectively empowers and ensures staffs exceed compliance standards through education and use of available resources. 26 P age

27 actively participates in continued development of regulatory guidelines. He/she takes pro-active positions and seeks opportunities to influence the regulatory process and profession s direction. SUPPORTIVE DATA (current or past activities) may include, but are not limited to: Past survey reports and implementation of any necessary plan of corrections with demonstrated processes in place to sustain the gains Examples of survey readiness; Examples: Generator run time logs, Durable Medical Equipment checks, disaster drills, daily, weekly, and monthly safety checks; participation in education, etc. Examples of recently attended/completed professional regulations updates, and resources Participation in facility education and regulatory updates and readiness Reviewing staff training and available resources Examples of pro-active or client advocacy positions COMPETENCY CROSS REFERENCE 1.4, 1.6, 1.12, 1.13, 1.15, , , 2.2, 2.3, 2.8, 2.9, 2.11, 3.5, 3.6, 4.5, 4.5.1, 4.5.2, 4.5.3, 4.5.4, 4.10, 4.12, 4.13, 6.1, 6.9, 7.1, Leads in creating systems, processes, and programs that further attain organization's vision, mission and goals. 1.6 Serves as an expert resource, involving other disciplines to achieve quality care and service Carries out supervisory responsibilities in accordance with organizational policies and applicable laws Efficiently uses time management principles to ensure timely accomplishment of all duties Actively participates in the profession's efforts to implement and improve standards of: Professional practice and Long term care. 2.2 Communicates performance expectations clearly. 2.3 Evaluates situations to identify performance improvement opportunities Empowers staff to participate in decision-making. 27 P age