Strategic Thoughts From an Experienced Administrator.

Most management gurus write about the manager as a strategic thinker. Nowhere does it seem more important than in a field such as healthcare, where money and market converge as a daily challenge. The long-term care owner/operator and/or administrator are the gladiators, struggling to balance cost reports, budgets, staff and resident care. In an effort to offer some support to those strategic managers, this month's Business Strategies column features an interview with Eli Pick, CNHA, CAS. Pick is an administrator and owner of Ballard Healthcare Residence and the PARC at Ballard located in Des Plaines, Illinois.

Ballard, which serves a long-term care geriatric population, is licensed as a 231-bed skilled nursing facility; the PARC is its transitional section and includes 110 of the 231 beds. Within the PARC is a 43-bed unit of separately licensed subacute hospital beds. It is part of a state demonstration project and primarily serves a population whose respiratory function is compromised--including those who require ventilator weaning. There is also a 39-bed rehabilitation unit that provides postoperative orthopedic, neurologic and general rehabilitation. The third 28-bed unit is for complex medical care and serves individuals with a mix of diagnoses, such as infections, wounds and general deterioration with multiple diagnoses. This unit also has a renal program that provides on- site hemodialysis under the direction of an RN program manager.

Hyatt: Can you share a bit of history about how you became a licensed nursing home administrator?

Pick: During my high school years I worked part time and over summer breaks full time at a retirement hotel in Chicago. This was my introduction to working with a geriatric population. I had many other work experiences, such as selling Amway products, construction jobs, hotel and motel office positions, and even telephone operator.

The culmination of these resulted in my working at a skilled nursing facility (SNF) as an assistant administrator right out of college. Soon after, I took the licensure exam and received my administrator's license in Illinois in 1977. As an owner/administrator, I have continuously maintained an active role in the administration of this facility since its inception.

Hyatt: What keeps you interested in this field?

Pick: I enjoy the relationships I have with the residents and patients. Even though the transitional patients are only with us for a short time, we strive to establish a connection. This makes it very rewarding for all the staff and builds tremendous loyalty with our patients. I get gratification from seeing satisfied families, patients and residents.

Although working in this environment has become increasingly challenging, I find that maintaining an optimistic attitude helps me keep my sanity, and as the demands grow, going back to spending time with clients keeps me grounded. I like what I do, and that is the fundamental reason I keep at it.

Hyatt: What is the community like where your facility is located?

Pick: Des Plaines is a northwest suburb of Chicago and has been predominately a middle-class community with active religious and community groups. This has changed somewhat in the recent past, with an increasing number of diverse blue-collar families taking residence. The facility's resident population has not changed much, but we are seeing more diversity in the transitional population.

Hyatt: Do you feel it is important for your organization to be involved in the community in which it operates?

Pick: Ballard has maintained an active role in the community by participating in civic and religious organizations. Ballard sponsors food and clothing drives for the shelters in our community, as well as blood drives. Also, staff volunteers aid in community-sponsored projects. I feel it is crucial for an organization to be a good community citizen.

Hyatt: What are some significant changes you have seen in the industry since you began working as an administrator?

Pick: The level of clinical complexity of patients being admitted has heightened dramatically, making the work much more complicated. As a result, the patient/resident profile has changed. These clients' ability to interact socially has diminished, and a greater emphasis on clinical services has emerged.

Another change is in the length of stay for the long-term resident. This has declined, primarily because residents are being admitted much later in the disease process. They are either staying home longer or going to assisted living facilities before coming to a SNF. This puts greater pressure on the operation to admit a higher volume to offset the reduced time of residency.

A dramatic increase in competition for new residents and patients is an additional challenge. This has forced administrators to be creative in developing new programs and services to identify new patient and resident populations.

Hyatt: What problems in the industry would you like to see addressed over the next few years?

Pick: The long-term care field must address the "old" perception of the nursing home of the past--a place intended for the care of lower-intensity residents. As the field has changed to adapt to the needs of higher-acuity populations, the public has not altered its views and perceptions. This is an issue that is being discussed by the provider associations. Administrators will have to be adept at strategy and better position their organizations in the local markets they serve.

The regulatory atmosphere has been challenging, to say the least, although that is expected to ease under the new administration in Washington. The need for administrators to be effective managers under the survey process is ongoing.

An additional area of concern is human resources. Staff has always played a critical role in the delivery of services, but today, staff members are harder to find and keep. This makes for an even greater challenge.

Hyatt: Can you explain the recent shortage of licensed administrators? Other than increasing salaries, what do you think can be done to reverse this trend?

Pick: I attended the National Association of Boards of Examiners of Long Term Care Administrators (NAB) annual meeting this past June in Chicago. A major topic of discussion was the decline in the number of candidates taking the licensure exam for nursing home administrators. This has been a pattern in the recent past and NAB, along with others, has been developing strategies to attract qualified candidates.

Of primary concern is the image of the field and how to effectively communicate the rewarding nature of the work. One of the difficulties is the way current administrators portray their job satisfaction--or lack of it. The current employment atmosphere offers many opportunities in long-term care, such as assisted living or retirement housing, that might not require licensed nursing home administrators and do not demand the same level of knowledge or skills. I believe that is siphoning off potential candidates from the pool.

Hyatt: If you were talking to someone interested in becoming a licensed administrator, what strategic course would you advise?

Pick: A tremendous amount of time is spent on studying regulations and requirements. Although this is important and necessary to pass the licensing exam, in my opinion, it is critical for administrators to also expand their knowledge base to include marketing and business development. This is essential in the current environment.

This does not diminish the other areas of management responsibility. Providing a quality product that meets the needs of clients in the community is always a core competency. However, the need to explore new opportunities and be open to developing new product lines is the future of skilled nursing care.

Hyatt: What has been a defining moment for you as an administrator?

Pick: It was the completion of the renovation and expansion of Ballard to open the PARC in 1995. This significantly expanded the type of patients that we treat and established outpatient services as a new product line for the organization.

The process of converting the organization is ongoing. The challenges came from market changes that were unforeseen (for example, PPS and the competition from other facilities that added similar services), and the struggle to respond rapidly to the existing strategic plan. There are continual efforts to refine the operational elements of the organization to fulfill quality standards.

These unexpected market transformations that have forced us to look for new and different customer groups have caught us off guard, and it's been a struggle. The continuing challenge is being competitive with increasing market capacity while the number of potential clients remains static or is shrinking.

On a positive note, the redesign of the physical plant to position the organization for capturing the targeted business was a very satisfying experience, reinforcing the concept that strategic thought and planning are an integral part of the process.

Pick offers important strategic thoughts about the industry and about being an administrator during these changing times. His experience is vast and he provides sage advice as he continues to lead by example. I would like to express my appreciation to him for participating in this interview.

As always, I would also like to thank the readers who write in support of this column. Please send ideas you feel would be helpful to the readers of Nursing Homes/Long Term Care Management to Laura Hyatt at [e-mail]. Be sure to include your name, the name of your organization, address and phone number with area code.

Laura Hyatt, MBA, is president of Hyatt Associates, and a member of the business faculty at Mount St. Mary's College.