Chapter Contents


Emergency Preparedness
Proactive Risk Management in a Pandemic
Governance and Board Leadership
The Role of Your Board of Directors
Looking Ahead
Training/ Deployment of Existing Staff
Occupational Safety and Health Administration (OSHA)
Self-Care
End of Life Visitation
Management Visibility During All Shifts
Community Partnerships
Lessons Learned: Management and Crisis Intervention
Lessons Learned: Community Partnerships


The management of housing and services for older adults requires a level of personal commitment that is more of a “calling” than a “job”—and that is in the best of times. The onset of a completely unforeseen pandemic poses a leadership challenge beyond the scope of textbook knowledge. It calls for quick thinking, fast action, leading by example, and proactive planning for tomorrow. COVID-19 caught our health care system unprepared, stretched, and grossly unsupported over a long period of time. This section provides guidance to assist management and boards in leading with knowledge, empathy, and resilience.

Emergency Preparedness

Emergency preparedness for any crisis must begin with a full, systematic review of event details, anticipated or actual risks and liabilities, stakeholder assessments, resource evaluation and preparation, and strategic planning.

Leadership in a Pandemic

In a pandemic, leaders must set priorities clearly for both decision-making and for action, and must prevent the confusion that arises from differing priorities.  Criteria for managing the crisis must be shared immediately and conveyed with crystal clear messaging, to avoid misinterpretation and delay in action. It is also essential for leaders to express the reasoning behind key decisions to their staff in a way that instills confidence and trust. Realizing the potential for external scrutiny of major decisions made during a crisis, leaders must enact clear and consistent external communication that will enhance understanding and trust outside of the organization.

Difficult as it may be, stress must be kept in check so that it does not inhibit the focus of the leader or foster indecision and poor judgment.

As mission-driven organizations, our guiding principles can anchor us to the longstanding commitments we have made, particularly when times are tough.

LeadingAge resources:

Establishment of a Pandemic Committee

The establishment, leadership, and management of a pandemic committee is an essential component of successful crisis intervention and resolution. Drawing from an organization’s emergency preparedness process and policy, the pandemic committee should be created in the earliest stages of preparing for a pandemic mitigation and response effort. Selecting members for the committee should be done with the utmost care and consideration. Supporting and maintaining committee members—including planning for the rotation of duties and responsibilities—is a core aspect of the sustainability of the committee’s work, especially when a pandemic has an indefinite duration.

Contingency Planning

One of the greatest challenges of a pandemic—its unpredictability—can be mitigated by thorough and proactive contingency planning. Elements of such planning may include, but are not limited to: staffing shortages, supply inventory, the delivery of services to stakeholders, housing considerations for persons-served, and shelter-in-place agreements with nearby aging services providers.

Supply Management

Effective supply management in a pandemic—and in preparation for such an emergency—can help an organization successfully mitigate the spread of an infectious disease. Core areas of supply management may include personal protective equipment (PPE), cleaning and disinfecting chemicals and implements, food and nutritional supplements, supplies for entertainment and diversion (i.e., therapeutic recreation), housing, bedding/linens, and beyond. Each organization must evaluate the core items required to maintain operations and sustain resources for persons served.

Risk Management

Proactive risk management can greatly reduce an organization’s potential exposure to litigation by aggrieved stakeholders and/or citations or fines from regulatory and government agencies. Effective risk management begins at the leadership and governance levels. Examples are offered below, to inform outcome projections and ultimately, decision-making.

Proactive Risk Management in a Pandemic

 

This section comes courtesy of CLA, a LeadingAge Silver Partner

 

To be prepared for a crisis like a pandemic requires a risk management philosophy and process. To begin, review where you are presently and look at how risks have been (or could be) impacted by a pandemic. Understand the significance behind the changes you may experience, and what is needed to respond to any increased risks and potential opportunities that are created.

The Importance of Proactive Risk Management

The risk profiles of most organizations will shift significantly during a pandemic, especially for nonprofit senior living providers. There are new and heightened risks, faster risk velocities, and deeper risk impacts on strategy, operations, people, and infrastructure.

In the past, you could be “responsibly reactive” when it came to risk management. That meant you needed to know what was going on internally and externally, see the trends, understand risks, and respond in a reasonable timeframe to prevent, detect, mitigate, or transfer the risk so it did not threaten the safety of your organization.

Today, the nature, velocity, and unpredictability of the environment organizations operate in requires a new level of “proactivity.” Without this mindset, you could find yourself on the wrong side of a deadly risk event that could threaten the well-being or even the survival of your organization. Your risk identification, assessment, management, and monitoring processes must go to the next level—not because it was needed in the past, but because it is needed now and for the future.

Proactive risk management provides safety, protection, and a warning signal if a risk creates a gap, needs to be watched, or offers an opportunity to your organization. It is an important part of operational resiliency. Figure 1 illustrates how the 3 parts of a healthy organization should operate: with the board as a control tower, the management team as the pilots, and risk management (referred to in Figure 1 as “Monitoring Verification”) as an instrument panel.

Figure 1

Source: Integrated Governance Solutions LLC

So what makes up an effective and sustainable risk management process? To be a strategic asset to your organization, the process must continuously evolve and improve to align with goals and strategic initiatives established by the organization.

This need for an agile risk management process is highlighted during a pandemic. It is critical for organizations to develop and utilize a dynamic monitoring approach that evolves to respond to existing and new challenges that your organization might face.

The Risk VitalSigns™ graphic below (Figure 2) can serve as a guide for your organization’s process and outlines the 10 domains of risk management.

This process needs to be appropriate for the organization, its mission, its goals, and the type of clients you serve, and align with leadership goals. For example, if you are a small, rural organization, your approach may be very different from a large, multi-location organization with a varied and complex population.

Figure 2

Source: Integrated Governance Solutions LLC

It’s important to understand the strength and capability of your risk management process, especially during times of crisis. COVID-19 has certainly put a heavy strain on most, if not all, nonprofit senior living organizations—both now and for the future. The risk profiles of many senior living organizations have shifted and changed, and will continue to do so. Understand and proactively address these shifts to preserve the health and well-being of your organization.

Establish an Effective and Sustainable Risk Process

There are 5 key elements and 10 critical domains (as illustrated in the Risk VitalSigns™ tool) that need to be in place for a proactive risk process to become a best practice. These topics will be covered as follows:

  • Ownership: Risk accountabilities and capabilities
  • Understanding: Risk identification and assessment
  • Execution: Risk strategies and monitoring
  • Coordination: Risk reporting and decision-making
  • Integration: Risk interdependencies and organizational interdependencies

Ownership—risk accountabilities and capabilities: Operate in a holistic manner, with roles and responsibilities outlined and understood, to develop clear ownership of and commitment to risk management. Without clear ownership, the organization can flounder, make rash decisions, or simply fail to act in the most appropriate manner.

Individuals and teams across your organization must have the competencies (or know where they can find assistance from trusted third parties) to address changing risk management needs of the organization. Clearly defined processes and procedures provide structure and accountabilities so adequate measures can be taken.

Source: Integrated Governance Solutions LLC

Understanding—risk identification and assessment: Risks can change rapidly and create interrelated issues, particularly during a pandemic. A clear methodology and the use of internal and external sources allow your risk assessment to identify potential risks and opportunities. This analysis should be done before a pandemic occurs, and be reassessed as the impact of the pandemic evolves.

Assess risks in a portfolio or enterprise  manner to allow for the aggregation of risks, and to compare them to the risk appetite (what you can handle) and risk tolerance (the amount of risk you can accept) of your organization. This strategic view allows you to create an overarching risk strategy, define how it relates specifically to a pandemic, and determine when to change your strategic direction.

Source: Integrated Governance Solutions LLC

Execution—risk strategies and monitoring: Individuals and teams need clear direction for ownership and execution of the agreed-upon action plans for the identified risks. Actively manage and monitor action plans to provide clear reporting to management teams and the board. While risk strategies and responsibilities need to be established before a pandemic hits, it may be necessary to amend or update them as the needs and risks of the organization change.

The use of metrics and reporting helps align outcomes to desired levels of risk acceptance. Develop a watch list (i.e., a list of risks that need to be reviewed more often and monitored closely). Continuous and appropriate monitoring is particularly important during a pandemic.

Source: Integrated Governance Solutions LLC

Coordination—risk reporting and decision-making: Risk reporting comes in many forms and styles. During a pandemic, it is crucial for the reporting to become more relevant to the action plans, as well as more frequent, especially as it relates to newly developing risks. Understand the context surrounding risks so that your risk decisions are on target. Ask for guidance or assistance from internal and trusted external parties who can help you deal with these situations.

To make informed decisions, management needs to look at how risks impact strategy and short- and long-term goals. The board needs to be kept informed to provide oversight, while maintaining its fiduciary responsibilities.

Source: Integrated Governance Solutions LLC

Integration—risk interdependencies and organizational interdependencies: Remain diligent in the identification of interrelationships and dependencies (see the illustration of risk streams in Figure 3 below). When you know which risks relate to each other, then you can understand how one risk decision may impact another.

This is also true for risk appetite and risk tolerance considerations. If the cost to manage, mitigate, or transfer risks is out of reach, determine if it is within your risk appetite or if it has reached your risk tolerance. These concepts become more important in critical times when unexpected risks surface.

Source: Integrated Governance Solutions LLC

Tools to Help You Identify and Monitor Risks

A formal risk management process and a risk management function or committee can provide great value by reviewing the current risks and responding to the new—and sometimes overwhelming—changes brought about by a pandemic.

However, if you do not have a listing of your organization’s current risks—e.g., a risk register or risk matrix—utilize the risks outlined in the risk universe (Figure 3) as a “common language” for the senior living field. This listing can help you understand risks that may be present and how you should respond.

The 6 key areas of risk to review include:

  • Strategic
  • Operational
  • Financial
  • Human capital
  • Legal/regulatory
  • Technology

Industry-wide risks exist within these categories and there may be a few that you want to change or add. However, we have found that this list applies to most senior living organizations.

Across these categories of risk, you can more easily identify the inter-dependent risks or a “risk stream,” which occurs when a risk in one area is impacted by a risk in another area. You can identify and assess risks in a holistic manner to review how interrelated risks and opportunities may arise—and how your organization can respond to them effectively.

Example

The red risk stream in Figure 3 looks at the impact a change in care delivery strategies may have on care delivery quality and highlights how risks can be interrelated. The delivery of care certainly is impacted when a pandemic occurs, so you may need to implement procedures to keep clients in their rooms or otherwise apart from each other.

This can also impact the operational risk of the quality of care. These risks may then impact your revenue cycle management. From the standpoint of human capital, does your staff have the right skills and competency to meet the needs of your clients? Are there new or significant legal, regulatory, or compliance measures that you need to implement? What are the new related technology needs, costs, and training?

When one risk area needs attention, others may as well, due to the potential ripple effect.

Figure 3

Source: Integrated Governance Solutions LLC

Strategic Risk Profile

Another way to list out potential risks is through a strategic risk profile (Figure 4). This tool provides you a list of the risks that impact your organization’s strategy, goals, and objectives, and allows you to identify, assess, evaluate, act, and monitor the risks along this continuum.

Figure 4

Source: Integrated Governance Solutions LLC

In this example, the impact of a pandemic is identified for each affected risk type. Some of these risks may necessitate a short-term, mid-term, or longer-term adjustment, which can be captured in this tool.

While this example shows only a portion of the risk profile, here are the key steps to develop a risk profile tool for your organization:

Step 1: Identify Your Risks

Recognize the risks that will impact your organization’s ability to achieve your strategic objectives. Sort the risks by risk category, type, and description (with a pandemic overlay) to determine how the pandemic has changed or impacted the organization.

Step 2: Assess Your Risks

Assess the probability of the risk occurring (before consideration of controls) and the impact of the risk if it does occur. Determine the policies and controls that are currently in place to manage or mitigate the risk. From there, reassess the risk’s probability and impact to determine your residual risk. This can be done by utilizing a high, moderate, and low colored illustration (as shown in Figure 4).

Step 3: Evaluate Your Risks

Consider the following key elements related to a specific risk:

  • Direction: Is it increasing, decreasing, or steady?
  • Velocity: Is it moving fast, moderately, or slowly?
  • Effect on strategy: Does it have a direct or indirect impact?
  • Risk Interdependencies: What other risks might this one impact?
  • Risk appetite vs. current exposure: Is there an exposure gap where more mitigation is needed, or is there an opportunity gap where you may be able to take on more risk? Is this a situation that needs to be put on a watch list? Or is there no gap, where you are comfortable with the risk? With this information, rank the risks that you believe are in the top 10.

Step 4: Act on Your Risks

Determine the most appropriate type of response. Choose to either manage the risk through improved policies and procedures, or mitigate the risk through improved measures and controls. Provide an action plan of what will be done to improve your response to this risk, and include a due date and a status update (on-track, off-track, or completed).

Step 5: Monitor Your Risks

Assign a risk owner and consider a risk sponsor if the risk is significant. Include the date the risk was last reviewed and how often it should be reviewed (monthly, quarterly, and/or annually).

From this information, obtain charts and graphs to provide summaries for the risk categories or any of the five steps listed above. This provides an excellent tool to stay on top of your risk management efforts, particularly during a pandemic.

Leverage Proactive Risk Management for Sustained Success

To summarize and complete the picture, proactive risk management is a part of a bigger effort that includes your board, your management, and your risk management team. Clear duties and discipline will support your organization before, during, and after a pandemic.

The 3 active levels of risk management (Figure 5) are governance, strategy, and compliance. Most often it is the strategic level, using a risk portfolio, that is most challenging. With the risk management tools and outlines provided in this playbook, you can position your organization to pull the right pieces together.

Figure 5

Source: Integrated Governance Solutions LLC

The information contained herein is general in nature and is not intended, and should not be construed, as legal, accounting, investment, or tax advice or opinion provided by CliftonLarsonAllen LLP (CliftonLarsonAllen) to the reader. For more information, visit CLAconnect.com.

 

Other risk management resources:

Liability, Insurance, and Immunity

Insurance, liability, and immunity protections address the inherent risks and collateral damage that can result from an organizational response to a pandemic. In the event of a pandemic triggered by a highly contagious, infectious disease, organizations can expect these areas to include infection mitigation and control, medical malpractice or malfeasance, environmental or occupational hazards, mental or behavioral health effects, and similar.

Resources from insurance companies and law firms:

Other resources:

Governance and Board Leadership

In times of unusual circumstances—and a pandemic surely fits that description—the governance role of nonprofit boards will necessitate varying from the routine duties of care, loyalty, and obedience in order to protect organizations’ future from both expected and unanticipated occurrences. Boards must broaden their views and consider a potential perfect storm of increased expenses, decreased revenue, and declining occupancy.

Need for Resilience

The extended duration of a pandemic requires committed, resilient leadership and continuous, strong board support. Both must address the present and react to the future with balance, understanding, and collaboration; this cannot be a time of panic and rash decision-making.

In addition to immediate actions that leaders must implement, there are also long-term impacts that require early assessment. These potential, post-pandemic impacts will become more evident as the pandemic diminishes. Again, resilience is essential to navigating the present, considering alternative futures, and making thoughtful decisions.

The Role of Your Board of Directors

This section comes courtesy of CLA, a LeadingAge Silver Partner

 

Pandemics, like COVID-19, tend to create prolonged periods of disruption, change, and risk for most organizations, especially for health care and senior living organizations. The stakes are high and the task is formidable. As organizations face a pandemic, many boards of directors continue to adjust to this new reality by working with management to help navigate successfully and safely forward. This applies not only to the current pandemic, but also to the ever-changing landscape of our society and health care environment and any future challenges or crises.

Every senior living board of directors should ask 3 thought-provoking questions to continually assess and challenge their status quo:

  • Governance is about navigating well and wisely; what should we think about in this environment, and how should we think about strong navigation?
  • In today’s environment, board oversight, strategy execution, and risk management are critical navigation processes that must be strong and well-aligned/connected; how do we know if this is the case for our organization?
  • Risk management and board risk oversight have never been more important; how should we think about risk, and what is our role in risk management oversight?

The Importance of Governance as “Navigation”

Health care, and senior living specifically, have been dealing with a high level of disruption, change, and risk for quite some time. Crises like a pandemic take a pre-existing challenge and make it bigger.

Your organization’s governing system has a direct impact on how you navigate. In fact, the root of the word govern is “to navigate.” Attempt to look at governance this way if you haven’t done so already.

As illustrated in Figure 1, wise navigation is fundamentally focused on 3 things, which together provide organizational resiliency:

  • Direction: Where are you going, and how do you “position” yourselves to get there?
  • Performance: How do you execute well, and how do you get “traction” in what you are doing?
  • Safety: How do you avoid grave mistakes/harm, and how do you establish needed “protection” on your journey?

Figure 1

Source: Integrated Governance Solutions LLC

An attempt to predict what the future holds is a recipe for chronic fatigue at best, and disaster at worst. The better option is to have a nimble and finely tuned “navigation system” that guides the organization through whatever may come. This aligns to the idea that you can’t plan for everything, but you can be prepared for anything. The 3 primary “navigational” processes highlighted in Figure 1 can help you achieve this resiliency and nimbleness:

  • Board oversight
  • Strategy execution
  • Risk management

These are not new processes for nonprofit senior living organizations. But they do need to be more integrated and aligned to create the navigation system that is resilient and nimble enough to “be prepared for anything”—not because it was needed in the past, but because it is needed for the future.

Agile Board Oversight: Boards need to be more aware, more informed, and have the ability to make big decisions with long-term implications more quickly than ever before. For many organizations, this is going to require their boards to “go to the next level” in their board processes, deliberations, and outcomes.

Dynamic Strategy Execution: Implement more frequent planning, execution, monitoring, and refinement of your strategy, and understand that course corrections may be more dramatic than in the past. There will be continued societal shifts, behavior changes, and customer expectations that we can’t possibly predict right now, including their impact on our organizations and strategies.

Proactive Risk Management: In the past, most organizations could be “responsibly reactive” about risk management. Today the nature, velocity, and unpredictability of the current environment requires a new level of proactivity, or you could land on the wrong side of a risk event that could threaten the well-being or even survival of your organization. Optimize your risk identification, assessment, management, and monitoring processes.

The Board’s Role in the Overall “Navigation System” of the Organization

As with any navigation system, when your situation becomes more complex or sophisticated and the environment becomes more unpredictable or inherently involves higher risk, each component must perform its role to the most optimal level possible. As discussed above, the navigation system must also be more integrated, aligned, and real-time.

This idea of maintaining a robust navigation system fits well with the ever-changing environment in which nonprofit senior living organizations operate today.

Figure 2 helps depict these important relationships and dependencies in a governance context.

Figure 2

Source: Integrated Governance Solutions LLC

The 3 dimensions of a strong governing (navigation) system include execution, oversight, and verification. Consider the aviation analogy below to better understand. In most organizations:

  • The execution responsibility is carried out by a management team that serves as the pilot and co-pilot flying the plane.
  • The oversight responsibility is carried out by a board of directors, which serves as the control tower and provides needed guidance and big picture perspective to the pilot/co-pilot.
  • The verification responsibility is carried out by some form of monitoring system or disciplines, such as compliance, internal audit, ethics function, etc. The monitoring element is the instrument panel that provides alarms, early warning indicators, and controls to help both the pilot, co-pilot, and the control tower with the information and verifications they need to conduct a safe flight.

This analogy provides a useful way to look at your organization’s “navigation system” because:

  • The different sub-systems of the aviation navigation system are similar to an organization in a fast-paced, highly complex field like nonprofit senior living.
  • It makes the point that the navigation system (and the board’s role within that navigation system) must evolve within most organizations—not because things are being done poorly, but because the world has changed and will continue to do so quickly.
  • It challenges the members of a board of directors to ask themselves whether the board is the best possible “control tower” for the organization it serves.

The control tower (board of directors) plays a mission-critical role. Its oversight sets the stage and holds both the pilot/co-pilot and the monitoring system accountable to have the right execution and verification capabilities in place. The board also plays an important advisory role by providing needed perspective, advice, and guidance to the other components of the navigation system.

Adding Ethics to Navigation: Each of these dimensions of the navigation system also plays a vital role in the ethical health of an organization, especially during times of organizational stress, when integrity can be tested. Again, each role in our analogy provides an important role in maintaining ethical awareness.

  • Oversight (board of directors): “Wise Stewards”
  • Execution (management): “Humble Leaders”
  • Verification (monitoring): “Courageous Truth-Tellers”

If an organization is strong in all 3 areas, it will be successful despite periodic challenges. If an organization is missing just one of the elements, it will likely crumble during times of crisis. Think about our aviation analogy:

  • The control tower needs to guide the planes in the airspace for which the tower is responsible, just like the board provides overall guidance and leadership for the successful direction of the organization.
  • The pilot/co-pilot needs to trust in the guidance and direction of the control tower, similar to how management must work closely with and trust the board’s direction.
  • The instrument panel must provide accurate and sophisticated information to monitor the conditions and provide warnings, just as monitoring verification must deliver accurate checks on the activities of the organization and deliver prompt warning as appropriate.

The Board’s Critical Duties — the “Four Pillars”

Take a closer look at the board’s critical duties, which we refer to as the “Four Pillars.” Your board should fully understand these duties, discuss them often, and be able to assess how well it is carrying out these duties as a governing body.

There are 2 big points to keep in mind, regarding significant differences from what most directors are used to in their past/current leadership roles:

  • Most directors have spent most of their careers and gained most of their experience in management, not as part of a board.
  • The role of a board and a director on that board is to make decisions and act as a body, not as individuals.

Figure 3 helps depict these critical board/control tower duties.

Figure 3

Source: Integrated Governance Solutions LLC

Similar to a good control tower, the board’s primary focus and accountability is the organizational direction (position), unless there is a problem or emergency in one of the other two areas (performance and safety).

Given its perspective and proximity to your organization, this is the most valuable oversight and advisory element the board of directors can provide. Keep in mind that your board still has oversight and advisory responsibility around performance and safety, but it’s not the primary focus in the normal course of its responsibilities.

The board’s specific duties fall into 4 main areas (or Four Pillars).

Pillar 1: Mission

If a board does not fully understand its role as steward of the mission, vision, and virtues (values) of the organization, there is an issue. In organizational life, CEOs come and go. While the average CEO tenure in nonprofit senior living may tend to be longer than the average in corporate America, CEOs of nonprofit senior living organizations still turn over and retire.

Directors on the board also turn over, but the body itself is a constant for the life of the organization. It is mission-critical for every existing director and every new director on the board to have a deep understanding of the board’s stewardship responsibility for the organization’s mission, vision, and virtues.

Pandemic considerations: Especially in times of stress and crisis, keep focus on the primary mission and vision of the organization. This is a key duty of the board. The board can keep the organization “on-mission” even during a crisis.

Pillar 2: Strategy

The board’s duty is to help management set an appropriate and achievable strategic direction. If the board has a strong understanding of “Point A” (where we are now), and a keen, clear agreement of the desired “Point B” (where we are going, by when, and how we get there), then there can be full alignment on the mission.

Pandemic considerations: Understand that strategies might need to change or flex in times of crisis. Changes should be clear and agreed-to between management and the board, and not overly reactive to the situation (nor not responsive enough). A dynamic strategy process allows management and the board to succeed in their respective and appropriate roles.

Pillar 3: Risk

Another very important duty of the board of directors relates to “risk oversight.” However, this is one of the most misunderstood and poorly executed duties of many boards. This issue has many root causes, some of which will be addressed in subsequent subsections below. But a primary reason many boards do not perform this duty is a lack of understanding of what its duty truly is around risk, and that “risk oversight” (the board’s duty) and “risk management” (management’s duty) are 2 different, yet connected, things.

If a board tries to understand the details of risk at the same level as management must, it will likely either fail altogether or create a difficult dynamic/relationship with management. The board’s risk oversight job is to understand the overall risk profile (the “big picture” of risk), so that it can work closely with management to set appropriate risk appetites that will allow the organization to achieve its strategy.

Pandemic considerations: It’s common for a board to be either completely unaware of the overall risk profile and risks of the business, or to be so far down into the weeds that it lacks the needed big-picture perspective. Either way, it doesn’t have the necessary understanding of the overall risk profile of the organization.

The end result, especially during times of crisis or organizational stress, is often one of these:

  • There is a misalignment between strategic objectives and the required intelligent risk-taking (especially when the strategic profile, risk profile, or both are changing in times of crisis or challenge) which prevents achievement of the strategy.
  • The board does not understand and is not overseeing risk-taking effectively. This often leads to surprises and broken trust, which can be very hard to repair.

To avoid these negative consequences, make sure your board stays fully aware of their risk oversight duty and is fully equipped to carry it out on behalf of your organization.

Pillar 4: Controls

The board must also oversee the control environment and cultural health of the organization. The tone needs to be set by the board and followed by the CEO and management, not the other way around.

Specifically, the board should oversee the development of a “navigation system” for the organization that is well-governed, well-controlled, highly ethical, and includes:

  • Leaders of virtue—people of character who do the right thing.
  • Cultures of trust—relationships and cultural norms built on integrity, accountability, and transparency.
  • Structures of integrity—structures that create strength and balance with strong oversight by the board, outstanding execution by the management team, and appropriate verification mechanisms carried out by the monitoring system.

Pandemic considerations: It can be a strain to maintain appropriate “guardrails” within and around the organization during crisis. Vulnerabilities can lead to unethical behavior, fraud, or external attacks that can make a difficult time even more challenging. The board should set an appropriate tone, but also pitch in and provide more active engagement like a good control tower provides during a bad storm.

Integrative duties: These duties, taken together with everything else we have covered thus far, can be summarized as the 4 integrative duties of today’s governing systems. Review a summary of the duties below, and the board’s part in those integrative duties in bold to understand their interdependence (including the foundational role of the board):

  • Integrative duty #1—clear mission: fulfilling (management) and stewarding (board) the mission, vision, and virtues ethically (monitoring).
  • Integrative duty #2—aligned strategy: achieving the strategy (management) and overseeing strategic direction (board) consistent with strong corporate responsibility (monitoring).
  • Integrative duty #3—managed risk: driving the operations (management) and overseeing the desired risk appetite and profile (board), consistent with established risk tolerances (monitoring).
  • Integrative duty #4—strong controls: creating the effective controls (management) and overseeing the control environment (board), while ensuring consistent compliance (monitoring).

Establish a Strong and Capable Board Process, Even Under Stress

We have clearly established the critical and foundational role of the board as part of the “navigation system” of the organization. Your board also needs to focus on how it can foster a strong and capable board process on a consistent basis—even during times of crisis, challenge, and organizational stress.

A strong board process means you understand:

  • The critical outcomes of a good and healthy board.
  • The process to assess itself against these critical outcomes.
  • How to be a “continuous improvement” board.

In order to be a strategic asset to the organization and an effective “control tower,” the board must constantly evolve, refresh, and remain responsive to the needs of the organization and the challenges at hand. The pandemic has highlighted the need for an optimally functioning board that is agile and strategic.

As a tool for your board to use as a guide, Figure 4 highlights Board VitalSigns™, which depicts the 10 domains of the board process that must be considered and highly functioning to meet the objectives of a top-quality board, especially in times of crisis.

Figure 4

Source: Integrated Governance Solutions LLC

The key goals of a strong board are to be sufficiently objective, aligned, equipped, informed, and engaged. The framework above defines 2 domains within each of those 5 objectives. Utilizing a diagnostic tool and process like Board VitalSigns™ can help boards quickly and effectively measure and assess how well they are performing within the 10 domains to achieve the five objectives.

Within those 10 domains, there are a total of 20 critical outcomes that must be achieved at a level that is appropriate to the organization and to the satisfaction of the board itself. Figure 5 summarizes the 20 outcomes to measure in terms of effective achievement.

Figure 5

Source: Integrated Governance Solutions LLC

Once these outcomes are measured through a board self-assessment, there is also an entire set of defined board capabilities for each of the outcomes, supported by proven practice tools and content. These can be put in place or strengthened in order to improve the board’s achievement of a given outcome to the desired level.

How the Board’s Role Shifts in Times of Crisis

Does a board’s role vary or change in times of crisis or challenge? The answer is both yes and no.

No, in the sense that the board’s roles, duties, and process really do not and should not change. Yes, in the sense that the level of intensity and engagement needed by the board to operate may vary or change. For example, the board may need to:

  • Meet more frequently.
  • Meet with less pre-planning or prior notice.
  • Spend more time to help oversee and advise management through difficult choices, issues, or trade-offs.

Again, think of the aviation analogy: Do the roles, duties, or overall process of the control tower change in times of challenge (e.g., a severe thunderstorm) or crisis (e.g., a serious mechanical issue or on-board health event)? No, but the level of attention, intensity, and engagement in performing its role likely does. The frequency of communication and touchpoints by the control tower likely increases. The level of real-time or unplanned communication between the control tower and the flight crew often increases. The level of guidance and hands-on problem-solving or issue resolution provided directly by the control tower typically increases from normal or more routine levels.

Specific “Navigation Topics” That Can Arise in Times of Crisis

Take a brief look at some of the navigation topics that often arise to dive a bit deeper into your board’s role during a crisis.

Establish a Dynamic Strategy Process

As previously mentioned, the 3 critical navigational components for any organization are agile board oversight, dynamic strategy execution, and proactive risk management.

As a starting point, Figure 6 depicts the Strategy VitalSigns™ framework as a way to think about and assess your organization’s strategy planning, development, execution, and monitoring process.

Figure 6

Source: Integrated Governance Solutions LLC

Similar to BoardVitalSigns™, within each of the 10 domains, there are 20 critical outcomes to achieve. The organization must assess its outcomes, capabilities, and performance to leverage a responsive and dynamic process for developing, executing, and monitoring strategy, especially during a pandemic. Strategy and strategic planning topics like scenario planning, succession planning, assessing your business model, and considering affiliation or merger tend to be especially important in times of crisis.

Scenario Planning

Scenario planning is a critical part of a dynamic strategy process for an organization. It defines possible alternate strategic scenarios (often placed into scenario categories like pessimistic, most likely, and stretch, etc.) so that the organization can be more prepared for future organizational developments.

There tend to be three “upstream” considerations and three “downstream” considerations for good scenario planning.

  • Assumptions (upstream) — Define and document the key strategic assumptions to apply assumed levels of growth, market conditions, customer expectations, demographics, and other factors to each defined scenario. Well-defined assumptions allow your board to challenge the strategy.
  • Interdependencies (upstream) — Define and document the key strategic interdependencies (i.e., strategies or sub-strategies that might be dependent or interdependent with other strategies, sub-strategies, or events/circumstances). Not understanding interdependencies can lead to failure.
  • Concentrations (upstream) — Define and document the key strategic concentrations in terms of strategies or sub-strategies. In higher concentrations these could severely impact the organization’s performance or results if they fail or fall short of expectations.
  • Sensitivities (downstream) — Define and document the key strategic sensitivities. This includes the operational and financial projections that consider and forecast (quantitatively and qualitatively) the variables associated with the selected alternate scenarios (i.e., assumptions, interdependencies, and concentrations, etc.). Understand the possible operational and financial sensitivities under the selected strategic scenarios (often referred to as “sensitivity analysis”).
  • Contingencies (downstream) — Define and document the key strategic contingencies (i.e., the fallback plans and mechanisms if strategic results vary significantly from target levels) based on the strategic scenarios and sensitivities defined as part of the process.
  • Appetites (downstream) — Define and document the strategic appetites. This culminates the process of scenario planning. It relates to the appetite the organization has for growth and profitability, and the tolerance the organization has at any point in time to be operating outside of that established strategic appetite.

Succession Planning

During a prolonged crisis like a pandemic, turnover at board and management positions can be more likely and can present a larger challenge as well.

Nonprofit senior living often has above-average tenure for leaders at both the management and board levels. There may also be a higher-than-average ratio of current senior living leaders who may retire in a fairly short window of time.

A pandemic and its extra stress may not be how some leaders envisioned their sunset years in their leadership roles. This may lead to the industry seeing a trend of leaders retiring earlier than planned.

Turnover at key management and board leadership levels can create extra challenges during a prolonged pandemic, as the loss of institutional knowledge comes at a time when that deep knowledge and experience could help your organization navigate tough issues. Boards should assess their risks and contingency plans for planned or unplanned turnover at the leadership level for both the management team and the board of directors.

Business Model Assessment

Make a periodic reassessment of your business model during times of crisis. The industry may see significant changes to customer expectations, demographics, and industry trends, and may face new or higher regulatory scrutiny in both the near-term and the long-term. The trend towards home health is one example of an established trend that will likely accelerate during the pandemic and impact senior care.

A periodic business model assessment is part of a dynamic strategy process (see the Strategy VitalSigns™ in Figure 6) and a strong scenario planning process. Possible affiliation or merger considerations and a robust risk assessment and management process are also part of a successful approach to the periodic assessment of the organization’s business model.

Consideration of Affiliation, Merger, etc.

Often in a high-change, fast-paced environment, organizations find that they cannot do it all themselves. A pandemic is one of those times that the level of change, disruption, and risk may lead many nonprofit senior living organizations to consider an affiliation or merger in order to stay relevant and to grow and thrive in the future.

Such consideration requires an agile board, a dynamic strategy process and plan, and a proactive risk management process — both to understand the risks of making such a strategic move, as well as the risks of not making such a move.

Establish a Proactive Risk Management Process

It’s critical for organizations to think about and assess their risk identification, assessment, management, and monitoring process, which is outlined in the Risk VitalSignsTM framework (Figure 7).

Figure 7

Source: Integrated Governance Solutions LLC

Similar to Board VitalSigns™ and Strategy VitalSigns™ discussed in the sections above, within the 10 Risk VitalSigns™ domains, there are a total of 20 critical outcomes that must be achieved for appropriate risk management. It is an important responsibility for leaders of the organization to understand and assess its risk outcomes, capabilities, and performance in order to leverage a dynamic process like Risk VitalSigns™ to identify, assess, manage, and monitor the risk of an organization.

This is especially important during times of crisis or challenge. The risk profiles of many senior living organizations have shifted and changed, and will continue to do so. Understand and proactively address these shifts and changes to preserve the health and well-being of the organization.

For nonprofit senior living organizations, there are a few critical aspects of risk and risk management that tend to be especially important in times of crisis, such as the current pandemic (Figure 8).

Figure 8

Source: Integrated Governance Solutions LLC

Clarity of Risk Management Duties

A critical element of strong risk management and board risk oversight is clarity of risk management duties (which connects to the Four Pillars). But in Figure 8, we can also see how critical the connection is between the board’s risk oversight duties and management’s risk execution duties, as well as the monitoring system’s risk verification duties. The connection is also made between those duties and the three key levels at which a sound risk management discipline itself operates.

Strength of Risk Management Discipline

Understand that effective risk management occurs at 3 fundamental levels as illustrated by the center portion of Figure 8.

  • Compliance level — To fully understand the shape, dimensions, and interconnections of given risks, detailed risk analyses are often performed to dive into the dimensions of that risk. A good compliance level analysis of the risks that require this level of analysis and assessment allows you to form an overall picture of risk — i.e., the strategic level of risk management.
  • Strategic level — Consider where certain risks are connected to form the entire, broad look at the organization’s total risk. A clear, accurate, and timely strategic level view of risk (often referred to as a risk profile or risk portfolio view) is critical to the effective setting of risk appetites and tolerances, and the resulting risk decision-making that takes place at both the management and board levels — i.e., the governance level of risk management.
  • Governance level — Assurance that robust risk management activities and detailed assessments occur as appropriate (compliance level), and the availability of a clear, accurate, and timely overall picture of risk at a board-appropriate view (strategic level), allows for the board to perform its risk oversight duties at the governance level. Well-informed decisions can be made about setting the risk appetites that allow the organization to achieve its desired strategy and fulfill its stated mission.

In many nonprofit senior living organizations, the strategic level of risk management is the weakest, which hampers the ability of the board to fulfill its duties of risk oversight at the governance level. Address this strategic level gap through improved processes and available tools to achieve organizational resiliency.

For further information on risk management, please see the playbook section titled ‘Proactive Risk Management in a Pandemic,’ which goes deeper into risk management duties at all levels, especially in times of crisis.

Establish Sufficient Board Communication

Boards must become more agile in the performance of their important fiduciary duties and roles. This agility comes from the enhancement of the board process, a continuous refresh of the board composition, and an improvement of the board’s communication. Such communication is required at a number of levels (Figure 9).

Figure 9

Source: Integrated Governance Solutions LLC

First, consider the health and alignment of the board culture periodically. The factors listed in the “Board Culture Assessment” section of Figure 9 facilitate a healthy board culture that promotes strong board communication.

Next, communication occurs at the following key levels as it relates to a board of directors (health factors for each can be seen in Figure 9):

  • Individual director-to-board dynamics.
  • Intra-board dynamics.
  • Board-to-management dynamics.
  • Board-to-stakeholder dynamic.

All of these factors contribute to healthy board dynamics and strong board communication—even during a crisis or when the organization is undergoing stressful challenges.

Charting the Course of Your Board

Remember, it’s all about organizational resiliency. And today, that resiliency comes from strong governance and wise navigation.

The 3 most critical “navigation” processes in today’s turbulent world are:

  • Board oversight that is agile.
  • Strategy execution that is dynamic.
  • Risk management that is proactive.

We hope this framework of objectives, domains, and outcomes for board oversight, strategy execution, and risk management is useful to your board and leadership team.

The information contained herein is general in nature and is not intended, and should not be construed, as legal, accounting, investment, or tax advice or opinion provided by CliftonLarsonAllen LLP (CliftonLarsonAllen) to the reader. For more information, visit CLAconnect.com.

Looking Ahead

To focus forward with confidence, leadership and boards will have issues to resolve and contemplate. For example:

  • Is there a leadership succession plan?
  • Is there confidence that the current business model is sustainable?
  • Has the board considered organizational variances from the status quo, depending upon post-pandemic outcomes?
  • Is affiliation or merger a future consideration?

Scenario planning is an approach to strategic planning that considers vastly different, future-oriented variables simultaneously, in order to gain insight into forces that may result in change that is negligible, extreme, and everything in between. LeadingAge used this process in 2002, 2006, and 2018, and has shared a wide range of tools with members to enable them to conduct the process at an individual organizational level.

Resilience:

Succession Planning:

Governance:

Scenario Planning:

Affiliations, Mergers, etc.:

Business planning:

Rethinking Design

Developers and architects that specialize in senior living construction and renovation routinely prioritize resident safety; however, “safety” took on an entirely new meaning in 2020. Safety measures may have included non-slip flooring, stable seating in common areas, strategically-placed handrails, etc., but none of these measures can make a difference in terms of the spread of a pervasive viral infection. This is what future prospective residents will ask about.

Looking ahead, to mitigate risk and attract potential residents, change in our thinking about design is essential. Design that incorporates features that deter the spread of infection—or even subtly encourages social distancing—will help our field respond to consumer concerns proactively.

Training/Deployment of Existing Staff

Internal development, training and deployment of current staff within an organization is an important component of pandemic preparedness. Staff members who are on the front lines of service delivery may be supported, supplemented or substituted by other colleagues who may be cross-trained for a variety of roles. This can be especially helpful if frontline staff are unable to work due to personal illness or family caregiving responsibilities, particularly if the pandemic involves a highly contagious infectious disease.

Occupational Safety and Health Administration (OSHA)

Among many federal agencies, OSHA standards and guidelines provide essential safeguard measures that protect workers and promote a safe and healthy work environment. It is important to remember that the work environment can be any place where an organization’s employees deliver services or care, including within a client’s home. Ahead of a pandemic, organizations should cross-reference their workplace safety protocols with any specific guidelines or requirements that OSHA may put forth.

Self-Care

Life’s stressors can be challenging to manage during “normal times”; in the event of a pandemic, self-care and effective coping skills prove to be critical for every individual that an organization may employ, serve, and support. It’s important to recognize that the mental health effects of a pandemic are just as essential to address as the physical health effects. Organizations that promote the healthy self-care of all persons served—employees, families, visitors and partners—not only equip them with tools to help navigate the many challenging aspects of a pandemic, but also build trusting relationships that ultimately serve to protect both the individual and the organization itself.

Keep your employees safe and well! Without them, you have no chance of emerging from the crisis. Your managers and supervisors are the people who deal directly with your employees. Educate them about the possible effects of a crisis or disaster on employees and how to spot indicators of emotional or behavioral conditions that need attention.

End of Life Visitation

The advent of a pandemic—especially one that involves a highly-contagious infectious disease—can bring the importance of end-of-life preparation and support into intense focus. Health care providers in all settings must consider how their employees, persons served, and other stakeholders will be supported, particularly if a disproportionately high number of pandemic-related deaths are expected and experienced. Planning for end of life visitation is a core component of ensuring persons served, families, and staff have the support and closure needed for healthy grieving. Hospice, palliative care, and other end-of-life supports and services should be considered essential. In the resources below, a spectrum of approaches is reviewed, including advanced care planning, decision-making for end of life visits, and helping families cope with grief and loss.

Management Visibility During All Shifts

The concept of a “working manager” implies a unique level of commitment and visibility during a pandemic. Leadership practices in moments of crisis concretely define how the effects of the pandemic will unfold and be dealt with among all levels of staff. The staff who provide direct care will be on the front lines of the pandemic, and their morale, diligence, and commitment will hinge on the modeled behavior and support of their supervisors and organizational leaders.

Keep the leadership visible and stay firmly in charge. Let employees know who is in charge of each aspect of your emergency response or recovery efforts—and what those efforts are. You might lose loyal and valuable employees if they sense the organization is disorganized or lacks leadership and a plan for the future. Don’t react rashly or without thinking through all your options.

Community Partnerships

At the heart of planning and managing a response to a pandemic is a vital external connection: establishing community partnerships. Proactively seeking and negotiating partnerships with a variety of community groups—hospitals, faith communities, food and supply networks, local and state health agencies, staffing agencies, mortuaries and funeral homes, investors, and insurers—can make the difference in an organization’s ability to navigate the challenges of a pandemic.

Establishing key community partnerships can also enable an organization to manage risk and liability concerns, supply chain shortages, staffing shortages, end-of-life support for stakeholders, care coordination for those affected by the pandemic, and community relations. Cultivating the relationships in non-emergent times, and maintaining these relationships with regular and proactive communication techniques, will enable an organization to make the most of community partnerships if/when a pandemic should arise.

Cultivate Referral Relationships

For aging services providers that operate post-acute care settings such as nursing homes, the maintenance of referral relationships with local hospitals is essential to sustain occupancy, especially during a pandemic that involves a highly contagious, infectious disease. However, to ensure that both the post-acute care setting and the hospital or referring health care provider are protected from the risk of disease transmission, it is essential that all organizations negotiate, in advance, on how enhanced infection control and prevention will be accomplished. Communicating with one another regarding (and even establishing shared) clinical protocols and emergency management measures are vital.

Partnerships With Hospitals and Home Care Agencies

The pandemic has changed the way most Americans look at our health care system. In order to best coordinate the care of persons served who may be affected by the pandemic, aging services providers should build solid partnerships with local hospitals and with one another. Working together during a pandemic is necessary for survival, but developing lasting partnerships is an essential mitigation strategy.

It is prudent for all such health care providers to coordinate, communicate, and consider transitions of care as people move between acute, post-acute, and long-term care providers. Seamless transitions between levels of care and between different providers are essential components that are difficult to master, especially during a pandemic. Partnering with quality providers at each level and developing a highly communicative exchange between each provider at each level puts elder care as the top priority, builds trust, and provides for future collaborative opportunities and referrals.

Hospital-Based Systems of Long-Term Services and Supports (LTSS)

Several LeadingAge member organizations have an acute care component within their multi-tiered system of care and services. We asked a few of these organizations to provide insight on if and how a pandemic is addressed when a hospital inter-relationship is inherent rather than sought via external partnership.

Hospital-based systems may have better access to infection control experts and specialists who are able to work closely with the CDC and local public health authorities to explore and identify avenues to detect, protect, and respond to a pandemic in accordance with evolving recommendations and guidelines.

In addition, such systems are better positioned to take proactive steps with distributors and suppliers to ensure access to supplies, including personal protective equipment (PPE). They may be able to arrange expedited shipments directly from manufacturers, assessing alternative products and taking advantage of the ability to make inter-facility inventory transfers when appropriate.

At all times, systems should maintain open communication among all hospital and LTSS partners. The transition of persons from one level of care to the next must be conducted as smoothly as possible. During the COVID-19 pandemic, LeadingAge was aware of hospital-LTSS activities to design and open designated admission units to safely admit new residents and those who may show a positive infection sign or symptom.

Partnerships With Home Care Agencies

Many aging services providers have home health care and other home- and community-based components within their systems, and these organizations played a prominent role during the pandemic. At the same time, there were many older adults who refused any care at all, because they did not want people coming in and out of their homes. Since much of the apprehension has subsided, and more education on prevention and safe practices has come out, care at home has been on the rise for many different care settings.

Members as well as many other organizations across the country are sharing stories about expanding service models, changing the way care has traditionally been delivered, and bringing it into the home.

Partnerships With Funeral Directors

Aging services providers who are preparing for the effects of a pandemic, especially one that involves a highly contagious, infectious disease, must anticipate a higher-than-usual morality rate among their persons served. To ensure the dignity of their deceased residents, aging services providers should proactively establish partnerships with morticians, funeral homes, and other related service providers. The remains of the deceased will need to be housed, handled, and transported to the appropriate caretakers. Given the nature of a pandemic, providers should prepare the loved ones of persons-served for the possibility that they may be unable to be physically present with their loved ones post-mortem, and that funerals, celebrations of life and other customary memorial gatherings may necessarily be postponed indefinitely. Similarly, morticians and funeral homes will need to have adequate space and provisions to preserve the remains of persons-served for an indeterminate time frame.

Partnerships With State and Local Health Departments

Even during “normal times,” it is advantageous for aging services providers to have respectful and collaborative partnerships with their state and local health departments. Providers can expect, during a pandemic, that guidelines and requirements will be issued at heightened frequency from health departments. To respond to changing information on the disease and directives from federal agencies, health departments may rapidly alter guidance with little advance notice to aging services providers. Trying to comply with so many changing rules can be quite challenging; finding ways to collaborate with state and local health departments can help everyone accomplish goals and learn best practices together.

Lessons Learned: Management and Crisis Intervention

In the midst of an emergency as impactful as a pandemic, we must often act first and reflect later. It’s common for leaders to ask themselves retrospective questions, such as:

  • Did I act too quickly or too slowly?
  • What could I have done differently?
  • Did my approach of choice work as well as I anticipated it would?
  • How can I improve my responses if a pandemic recurs?

Of course, there is a lengthy series of “What ifs?” that we ponder.

LeadingAge has received numerous “lessons learned” tips from members during the COVID-19 pandemic, which we are sharing at the conclusion of each related Playbook Section. In addition, a compilation of shared Lessons Learned may be referenced in the Playbook Appendix.

LeadingAge resources:

LeadingAge LTSS Center @UMass Boston research reports:

Lessons Learned: Community Partnerships

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