For much of the nursing home’s modern times, administrator departures have been tied to fairly specific causes: retirement, regulatory stress, burnout after carrying so much burden during the pandemic. 

But with federal data showing that administrator turnover now hovers around 100% — meaning most are leaving before they finish a year in a new role — Mark Prifogle insists many more are leaving for “arbitrary” reasons that operators need to better understand, anticipate and combat.

The new board chair of the American College of Health Care Administrations and vice president of operations for Indiana at BHI Senior Living spoke with McKnight’s Long-Term Care News last week about how better training, mentorship and regional and corporate relief might help providers hang on to their building leaders.

What follows is a lightly edited version of that conversation.

Q: Is it particularly hard to find people to serve as administrators?

A:  I think it is, especially on the skilled nursing side. The majority of states still require [trainees to complete] an Administrator In Training program. I’m in several Facebook groups for people that are wanting to get into AITs or have started their AIT, and that barrier is still very real. Getting people into the profession is still as challenging as it’s always been. 

But I also think that because of the workload of the average administrator, the likelihood of them taking on a student or an AIT, it gets smaller as the workload increases. To do an AIT correctly, you’re teaching the majority of the time. Where we see disconnect is where people think, “Thank God I’ve got an AIT,” and they treat them like an intern and they’re getting coffee and making copies. Obviously, that person is not going to be as prepared to enter the profession.

Q:  Is it becoming harder to keep the administrators you do have?

A: From a retention standpoint, I think we’re in a pretty scary spot. … Our administrators aren’t making it on average more than a year in their specific position, at least based on what we’re seeing in [Payroll-Based Journaling]. That scares me because how can [your facility] be focused on priorities, whether it’s quality, whether it’s regulatory compliance, when you’re constantly learning your new boss? How are we supposed to be moving the profession forward when you have turnover at that significant rate? I really want to get in there and really look at some of the root causes. 

Q: What kinds of reasons are you hearing for quitting?

A:  They had a bad survey, a change of ownership, some of the common things. But operating on anecdotes, it can seem a lot more arbitrary. The feedback that I get from the average administrator is their decision-making is much more diminished than it has been in the past. There’s a concern when there are individuals either from a central office or from a regional perspective creating some challenges. 

Q: How do you handle that at BHI, with 10 Life Plan communities, including nine skilled nursing centers, across three states?

As somebody that manages a region, I’m not in the buildings every day. So I have to rely on the independent judgment of the licensed person who is there making the decisions daily, obviously within a structure. …  I think the closer you are, the better the decision is going to be. The executive director of each CCRC [working with an administrator of a skilled nursing unit] is responsible for their ultimate outcomes. We have budgets and we have targets for quality measures such as resident satisfaction and staff retention, but ultimately those EDs are responsible for the success or failure of their campus.

Q: And knowing you’re offering administrators some of the decision-making freedom they might crave working for others, how do you identify and attract candidates?

A: We have a really strong partnership with Indiana University of Indianapolis and their bachelor’s and master’s of health services management program. We have eight interns right now. We start working with them their junior year of college and hopefully they stick around, and then once they graduate then they start their administrator-in-training. We’re training three AITs this year.

We’ve continued getting some extremely talented, extremely bright, future- and now subsequently licensed administrators in at the ground level.

Humbleness is something that we hire for.

Mark Prifogle

Q: The administrator role has changed drastically, with young college graduates now often managing an entire staff, many of them likely older than they are. How do you address that in terms of workplace culture?

A: Humbleness is something that we hire for. Having a level of humility, recognizing that they’re there to learn and just fostering that culture of mentorship up and down the organization is important. At any given time, if you’re an executive in our organization, you should be being mentored, but also you should be mentoring in a deliberate way the individuals that either work for you or we have a high potential leadership development program internally called the BHI fellows.

We’re looking for that next generation of individuals that show management acumen, but maybe that just needs to be fostered. With that younger administrator, having somebody to go to whether it’s internally through our mentorship program or in ACHCA’s national mentoring program, they get perspective from someone that’s not [their boss]. Maybe that’s someone that is practicing in another part of the country, has deep experience and they’ve got that second sounding board and somebody outside the organization that has different ideas.

Q: How do you encourage mentoring without making it another burden on time-strapped administrators?

A: Our fellows come out of the campuses, but the whole program is run by central office employees. We’re not asking an executive director to do anything in addition. It’s individuals like myself or in our corporate structure that end up facilitating that program and also providing the mentorship. 

Locally, in Indiana they changed the regulation about two years ago so a regional can precept AITs. Kevin Ward, one of our operations directors, is responsible for our AIT program … which uses modified ACHCA/National Administrator Board’s AIT curriculum. We layer in that people management experience in a structured and well-supported environment.

We put people into a department head role at some campuses and allow them to manage people as we observe and teach so that their first conversation with a direct report isn’t when they’re already on the job. It’s when they’re still a student.

Q: Let’s shift and talk about your goals as the new chair of ACHCA.

A: One of the things that I talked about at convention is that as administrators, separate and unique from the trade groups, we have not been good advocates for ourselves and our positions. … I think it’s really hurt us as a profession. 

One of my priorities is making the administrator’s voice heard in a sea of a lot of different conversations within our industry. We approved as a board our public affairs committee, which we’ve never had before. We’ll be using that as a way to collect insight and feedback from the state chapters but also at the federal level so that we can take positions and give testimony. 

The other big thing is really going back to the development of new administrators and our national mentorship program — just really doubling down on that. We’ve got so many good people coming into the industry. We’ve got so many good people that still have a lot to give who are more seasoned. We’re really trying to lower the barrier for people to get into the industry.”