Do you have change agents on your staff? If not, you should seek out and encourage them (even if it's politically incorrect).

Entire industries can collapse under sustained external pressure. One industry that is currently under extreme pressure is long-term care. Constant congressional scrutiny of nursing home care, frequent legislative mandates for more punitive regulations, out-of-control lawsuits and liability costs, critical-skills labor shortages, and media that thrive on amplifying isolated incidents all add to the external pressures that threaten the preservation of long-term care. Without question, no industry can survive under this much pressure without acceding to change.

"Improve nursing home care" quickly is becoming the battle cry of opportunistic politicians and soon will be the announced target of district attorneys across the nation. As the LTC environment becomes more politicized, more negative attention toward the industry will become evident. The quandary for long-term care, within the context of a politicized environment, will be a heightened public perception that all nursing homes are substandard.

The old quick fix of writing eloquent mission statements or mounting warm-and-fuzzy public relations campaigns has become a futile strategic response to current conditions. Effective organizational management strategies to reverse negative public sentiment toward nursing homes can only be achieved by cultivating industry-wide change.

Enter, the Change Agent

What is a change agent? Change agents are the most genuine of healthcare executives--those who are progressive and innovative, intolerant of complacency, and constantly striving to invent better organizations. Change agents possess a commitment level that drives them to enhance core competencies and organizational capability to ensure that residents have the highest quality of life possible. Change agents make all employees, both below and above their authority, feel a sense of urgency to perform better. Most importantly, change agents are the "good consciences" of the industry; their management decisions protect frail elderly people.

What Change Agents Do

Change agents never cultivate superficial or artificial work environments; in fact, they challenge superiors who are mediocre or fail to provide the organization with progressive thinking and innovation. Change agents are the people sitting around the oval table who question ineffective ideas when everyone else is afraid to say a word. Unfortunately, many executives at all levels of management prefer subordinate employees who admire, praise, and agree with them unqualifiedly, regardless of how insignificant or bad their ideas may be.

Change agents fight for optimizing management environments by challenging everyone below and above them. True change agents will foster a communication system where uncomfortable questions are asked and explored, because they know candid exchanges of ideas are how management decisions are refined and shaped into efficient processes.

Change agents raise expectations by seeking to hire people more capable than they are in various capacities--the antecedent to enhancing organizational capability. Change agents never compromise their high standards or "hire down." Since time immemorial, great leaders have encouraged hiring the best in order to be the best. Unfortunately, many of the best executives in long-term care have left the industry, moving on to a career/life offering less professional grief. They've been replaced by a procession of lesser executives, who are welcomed by those with lower expectations and standards.

Unfortunately, hiring down is a common practice involving:

* Misfits. These are executives who are placed in key positions but just don't belong there. They are inept and clueless regarding residents' essential needs. Their hiring decisions are based on personal feelings, not what's best for residents.

* Burnouts. These are executives who smolder in long-term care year after year, collecting a paycheck and never contributing to industry capability. These executives have no desire to exert the effort needed to be progressive or innovative; they hire subordinates who lack progressive ideas or any desire to innovate so they won't be challenged by them (a growing crisis that has eroded successive layers of industry capability).

* Defenders of vested interests. These are executives whose only real interest is self-promotion--they consequently avoid hiring people with obvious talent and capability. Their main vested interest is hiding their own incapability. These individuals thwart change, rather than foster it.

* Posers. These are executives whose only real skills are schmoozing and convincing others that they care about residents, even though they don't. Posers lack capability and are generally hired by those whose egos need stroking.

The most alarming reason for hiring down is the acceptance of lower standards because the facility profit margin has fallen below the bottom line. Providers with this mind-set purposely seek candidates with low expectations and shun well-qualified candidates to ensure an environment where employees never question substandard practices. While this group is in the minority, they present a major threat to the frail elderly and to the industry as a whole.

Start With a Hiring Audit

The "change agent way" offers a different approach, starting with the hiring audit. CEOs and other corporate officials must routinely conduct random hiring audits to ensure subordinates are, in fact, hiring the most capable candidates. The audit consists of requesting copies of receipt logs for resumes submitted, as well as the actual resumes, for recent key hires. CEOs and other key operations executives must then review the resumes and compare candidates' relative capabilities. Chains should randomly select facilities for these audits.

If resumes that were entered in the receipt log are missing, find out why. If initial or second interviews weren't conducted with a qualified candidate, question it. And if one candidate is hired over others who appear to be more qualified, question the decision, If many such questions surface during the audit, evidence is building that those persons doing the hiring are protecting their vested interests and, consequently, hiring down.

This audit process is instrumental in holding those with hiring authority accountable and vividly reminding them that the objective is to hire the most capable, not the most likable, the most impressionable, or a perceived "best fit" for the facility management team. When it comes to hiring those entrusted with the care of the frail elderly, selecting someone because she is jolly and has a good sense of humor, because he can play the accordion at the staff Christmas party, or just because he is a friend/kin of another employee is absolutely not an option.

Using Your "Human Technology"

Companies often turn to outside consultants to learn why their performance is poor. These consultants are experts in organizational theory, horizontal differentiation, structural dynamics, functional grouping, and technologic innovation, all of which are impressive, in theory--but often these consultants have never worked in a company, and it's ludicrous to allow them to suggest changes in a company's environment.

The most overlooked resource in any LTC organization is its "human technology." Solutions to organizational problems are found inside the company, proposed by insiders. LTC organizations across the country are filled with employees who are intelligent, innovative, creative, and committed, and who can tell you exactly what's wrong with the organization. Just ask them.

To take advantage of such resources and improve and enhance the organization, though, top management must be willing to submerge their egos and accept the fact that many subordinates are smarter, more talented, more effective, and more capable in various areas of endeavor than they are.

The 360-Degree Evaluation

Start the change process by having all employees complete a 360-degree evaluation of the organization. Include top management in the evaluation, as well as individual departments, to obtain a better read on the total work environment. This process results in a candid and more accurate assessment of company performance from many constituents. Ideally, this type of inclusive look at the company culture gives top management a rare opportunity to see themselves as others see them, and it should subsequently prompt them to examine their own behavior.

Top management must clearly understand that they, too, are under scrutiny and subject to making changes to better the company. Executives must be willing to critically analyze all results in order to gain insight into how they are enhancing the work environment--or detracting from it. Moreover, executives must implement provisions for ongoing self-criticism with monthly minisurveys to keep communication flowing and to create an atmosphere where uncomfortable questions can be asked and explored.

The Change Renewal Process

Cultivate change with an ongoing renewal process that combats the formation of vested interests, and instead fosters the creation of an organizational climate wherein employees expect necessary change and embrace it. Recognize that this process can be shaped and accomplished by employees.

Establish a monthly program for employees to submit ideas to improve resident care, customer service, or quality of life for themselves. The program must focus on the message of change and "no-cost" or "low-cost" ideas that derive from ingenuity rather than expense. Select the best idea each month and reward staff with cash or other significant prizes.

Consider, for example, a facility that is receiving complaints about the poor phone manners of its employees. The administrator asks staff for ideas to improve phone customer service. One employee suggests placing a mirror in front of the phones to remind staff to smile while on the phone. This suggestion may seem insignificant, but it's not. It's widely believed that blind people know when someone is smiling by voice inflection and tone. The mirror serves as a low-cost, permanent reminder for staff to smile while on the phone and, by doing so, maintain an obviously pleasant demeanor.

If employees throughout the ranks are acknowledged and rewarded for championing changes that improve some facet of the company, its operations, and the overall bottom line, all employees might be more receptive to accepting necessary but less popular changes when management deems them necessary for the long-term stability and welfare of the company.

Being Truly Pro-Industry

Caring for America's frail elderly is one of the most honorable professions in the world, and residents in nursing homes should be treated with honor. The best way to honor residents is by weeding out and eliminating misfits, burnouts, defenders of vested interests, and posers. Replace them with change agents who raise standards and cultivate change.

Although "honoring residents" is what the forces driving the external pressures are demanding, don't mistake this article as a derogatory assessment of the industry. The basic message is that the future of long-term care is uncertain and that change is necessary. The philosopher Heraclitus said it best in 500 BC: "Nothing is permanent but change." If the LTC industry wants to survive permanently, it must seek continual improvement, welcoming and embracing frequent, forward-moving change--and the change agent. NH

Jaime Todd is a nursing home administrator and turnaround consultant based in Claremont, California. For further information, phone [phone]. To comment on this article, e-mail [e-mail].