June 13, 2019
In his book, Doing Justice: A Prosecutor’s Thoughts on Crime, Punishment and the Rule of Law, Preet Bharara, former US Attorney for the Southern District of New Year (SDNY) wrote of his experiences pursuing criminal indictments of politicians, hedge-fund managers, the mafia, and terrorists.
Mr Bharara emphasizes the importance of understanding the impact of being fair-minded, demonstrating the value of treating people equally, and demonstrating the ability to make decisions that are equitable rather that determined by the status or position of the individual.
His mantra noted in his book, “Do the right thing, in the right way, for the right reasons,” can be applied to how nursing home (NH) personnel manage the clinical care of residents. I believe his mantra can also be applied to admission and discharge policies, a NH’s approach to staffing and staff education, and finally the leadership role for administrative personnel. For example, in a long-term care (LTC) setting, administrators need to implement and follow policies applicable to all employees rather than implementing different sets of rules for licensed vs non-licensed staff.
In his discussion about ambition, Mr Bharara wrote, “Ambitious people tend to think of every endeavor as a ball game in which they’re going to pitch a perfect game. It doesn’t work that way.” Instead, he says, that approach is both unrealistic and arrogant. As administrators, we need to direct our staff to learn how to be good rather than perfect—how to do the right procedures, to communicate with residents, family and other staff members, and the right way to strive for greatness. We are meant to support our staffs’ commitment to care, to help them acquire the knowledge and skills they need to address the complexities of the residents we serve, and to encourage them to have patience with others who may not possess the same level of knowledge and skill.
We also want to support and cultivate our employees’ curiosity about the “whys” of care delivery. Simply telling staff to follow a policy or procedure without providing a rationale as to why this is the accepted way to provide care is not enough. We want our staff to ask questions, even if those inquiries seem basic, controversial, or challenging, as we all come from different perspectives with different experiences. This is most important when working with certified nursing assistants who may not have a basis of understanding about why we render specific care or follow a particular regulation for a given individual.
One technique that Mr Bharara championed is to understand how much the employee knows about a specific task. He said it is important to ask the question, “’Tell me how you do this procedure as if I’m your nine-year old nephew.’” According to Mr Bharara, this allows us to get to the heart of what the staff understands about the procedure as well as the rationale for doing it in a particular way. Further, it allows us to clarify any missteps or inconsistencies in their base of knowledge.
He also suggested that “soft words do more than hard blows” when attempting to determine the truth from someone being accused of a crime. This may be helpful advice when an administrator is trying to determine how a report of abuse or neglect or a possible work rule violation occurred.
In his prosecution of a variety of powerful criminals and institutions, Mr Bharara noted, “Every institution is vulnerable, no matter how great. No matter how much you’ve achieved, no matter how far you’ve gone, no matter how much power you’ve garnered, you are vulnerable to decline.” This statement makes me think about the concept that the administrator is expected to be the smartest person in the room—the pressure of which leads to choices that result in facility decline. However, when a person is trying to play this role, two things tend to happen. The first is that a person who has a need to be the smartest person tends not to be able to hear what is being said by others, as their primary focus is on staying one step ahead of everyone else rather than listening. The second issue is that this individual also tends to select those around him or her who clearly are not the best and brightest—presumably so as not to threaten or compete with that person’s intelligence—which leads to a downfall of the facility, poor morale of the individuals, and a clear lack of leadership.
Through his years of prosecuting criminal behavior, Mr Bharara noted that individuals and their businesses tended to focus on profit and market share while providing almost no discussion about integrity. Compliance programs and regulatory authorities can provide little intervention if employees fail to see behavior as problematic or to know how and why to report issues they observe. With his experience in massive frauds and cover-ups, it took people without integrity to enable those crimes to occur and for those crimes to go unreported, whether it was a Ponzi scheme or the sexual abuse of children.
Integrity does not require a formula, but it does require that individuals use their common sense when dealing with issues that do not pass the smell test. It also requires a culture that is not willing to cross the line into unacceptable behavior, whether that includes an inappropriate length of stay, known yet unreported errors, or the insufficient number of staff to meet the needs of the residents.
How administrators shape the culture of the facility and promote the values of the organization has a profound affect upon whether staff stay or leave; whether residents feel they receive appropriate care; and whether families have confidence in the staff to provide for the care of individuals. In the end, this is what we all want for our employees, our residents, and ourselves.
Bharara P. Doing Justice: A Prosecutor’s Thoughts on Crime, Punishment, and the Rule of Law. New York City, New York: Alfred A Knopf; 2019.