Introducing the first leadership model for LTC administrators

As the long-term care (LTC) field is discovering, leaders are key to culture creation, culture change, and organizational success. As reinforced in the business literature for decades, leadership is critical in establishing a successful organization or business, and long-term care is no different.

Although scores of professionals have discussed the importance of leadership, they have not defined leadership or instructed leaders on how to create an effective culture. Experience and research has demonstrated that many leaders in long-term care desire an enhanced and more successful workplace, but are too overwhelmed and not educated sufficiently in the skills or mechanisms for doing so.

This article, therefore, serves as the starting point for an administrator or designated leader interested in this issue. A definition of leadership and the first leadership model developed for long-term care will be shared in an effort to assist leaders to learn through the experience of others who have been successful. Concepts, programs, and processes will be described, as well as a means of implementation so that others may replicate programs that are meaningful to their organization.

Defining leadership

Many authors have defined leadership in a variety of ways-there probably are as many definitions of leadership as there are authors. However, a new definition of leadership has emerged, developed specifically for LTC leaders. Leadership for this purpose and the model consistent for this leadership is defined as “the art of influencing and engaging colleagues to serve collaboratively toward a shared vision.”1 Leadership, many believe, is an “art.” Like effective art, leadership requires education, training, exploration, experience, and practice. Leadership is creative and innovative. It requires a person who, like an artist, is willing to see things from a different perspective and encourages others to see things that way too.

Leadership must engage staff-give them a reason to believe, something to work toward. Visioning is a means of accomplishing this. Visioning, both shared and collective, gives everyone a common ground, a solid understanding of what is to be created, and it enhances staff selection. For example, one needs to hire only those who can and will be supportive of the vision and want to work to see it to fruition.

Effective leadership uses a collective approach. It is not about one person having all the answers or power. While one person may initiate an idea or plan, many people are involved in its ultimate design and decisions. Tapping into the knowledge of others with direct experience enhances outcomes and helps make everyone part of the organization.

Passion and consistency

Central to this model is the overarching theme of passion and commitment. To be an effective and successful leader, one must have passion, be committed to the work, and encourage others to feel the same. Passion is the fuel; it is the burning desire to succeed, the belief about something that you want or care about. Passion breeds commitment. When people are passionate about something, they are committed. Tasks and skills can be learned, but passion comes from within. It is what makes an organization exceptional.

Commitment and consistency enhance the smooth running of a facility over time. Philosophies, values, actions, and programs, when committed to consistently and practiced continuously, give the staff the constant basis they need to work well.

The LTC leadership model

The specific leadership organizational model is S.E.R.V.I.C.E, an acronym for the seven domains: Service, Education, Respect, Vision, Inclusion, Communication and Enrichment. Each is defined and explained in the table on page 34. Implementation of the model has been addressed by coauthor Gilster in previous articles and two books: Changing Culture, Changing Care: SERVICE First (Cincinnati Book Publishing, 2005) and A Way of Life: Developing an Exemplary Alzheimer’s Disease and Dementia Program (Cincinnati Book Publishing, 2006).

The S.E.R.V.I.C.E. Leadership Model®




Using all gifts and talents to serve others and the vision.

  • Working for a purpose higher than self with hope and optimism

  • Serving others, rather than being served and seeing everyone as a customer

  • Being a servant, teacher, coach, mentor, role model for others

  • Living by the Golden Rule: Do unto others as you would have them do unto you

  • Valuing the empowerment and growth of others

  • Taking personal ownership of your work-“Running it like you own it”

  • Caring about others


Valuing and promoting education and learning as a lifelong process for self and others.

  • Being skilled and knowledgeable-the best for self and others, the expert

  • Providing educational mentoring and role modeling

  • Preparing staff for their roles

  • Facilitating on-going personal and professional education and support programs

  • Challenging and encouraging others to achieve goals and grow

  • Choosing education over discipline

  • Creating opportunities for collective learning


Valuing and promoting respect, dignity and personhood of others.

  • Establishing respect as a core value

  • Conducting all discussions in a private space

  • Maintaining fair, consistent practices

  • Treating all people equally and with respect

  • Recognizing and celebrating the accomplishments, contributions, and successes

  • Giving credit when and where due


Creating a total picture of what you dream of developing, including guiding principles and values.

  • Creating a vision, mission, and philosophy, being the best in the field

  • Establishing guiding principles and values (trust, integrity, honesty)

  • Looking at the whole versus a part-systems thinking

  • Long-term and short-term planning versus reacting to daily crises

  • Keeping the vision alive


Involving everyone as a partner in the evolution and progression of the project.

  • Respecting, appreciating, and recognizing the input and contribution of others

  • Staying connected to staff

  • Seeking the right persons and trusting them

  • Communicating expectations and requiring accountability

  • Adopting a flat, organizational-chart philosophy

  • Listening, learning, supporting, and teaching

  • Creating dialogue, formal and informal, that is honest and open


Establishing an environment involving the active interchange of ideas and expectations.

  • Communicating information and expectations to staff

  • Remaining open and listening to comments, concerns, and suggestions

  • Creating opportunities to dialogue regarding new programs, innovations, and solutions

  • Implementing initiatives to improve work experience and quality of care

  • Establishing multiple mechanisms to inform/gather information

  • Valuing the feelings and thoughts of all

  • Getting to know individuals


Generating self-knowledge and conducting ongoing work with your self/spirit.

  • Knowing who you are and what makes you tick-self-awareness

  • Performing with integrity

  • Listening to your inner voice

  • Being open, having self-confidence, and trusting in your own ability

  • Taking risks, trying innovative approaches, being confident, decisive, yet human

  • Creating “balance” in your life

  • Maintaining self through time for contemplation, reflection

The acronym is explained as:

Service. In healthcare and long-term care, it is assumed that the primary job is to care for and serve others. Many focus their healthcare careers on a desire to do this. Yet, a service-oriented culture is not what many people experience in today’s healthcare environments.

Service involves providing for and caring for others. Service has several facets: the desire to serve, fulfillment of an obligation and, for some, a duty or “calling.” In leadership, the desire to serve is recognized as an important component for success. Service-oriented leadership involves putting the needs of others before one’s own, finding ways to meet those needs, and recognizing other individuals’ worth and value.

In this model, service is achieved when leaders and staff use their talents to serve and fulfill an obligation to others and to the organization’s vision and mission. The driving force is to have them work for something more important than themselves, something that will make a difference in the lives of others. The leader in this service model wears many hats, including colleague, guide, helper, teacher, coach, mentor, facilitator, role model, and cheerleader.

Education and new learning. From administrator to housekeeper, individuals are often asked to accept a position with little educational training and no specific expectation communicated. Still, they are expected to work “successfully.” When employees do not work up to these “standards,” although expectations are rarely communicated clearly, they shoulder the blame. They are considered lazy, negligent, or not very bright. The fault, however, lies with the system, facility, and leadership.

Supporting education begins with leadership valuing education and knowledge for themselves and others. Research has indicated that education is beneficial to staff performance. Education is more than training and skill development. It is a means of encouraging growth and development for staff in work and in life. It is a commitment to teaching and to continued learning as individuals and as an organization.

Ongoing training and educational support programs are essential to ensuring staff effectiveness. Educational needs do not end with the completion of orientation. Issues, questions, and problems surface continually, as does new information. Consistent and routine education and support meetings should serve to fulfill the educational needs of employees. Such programs also enhance communication, and demonstrate to staff that they are valued.

Respect. It is sad that the issue of respect must even be discussed-but it remains on the top of the list of what staff suggest is missing to ensure their workplace satisfaction. Employees in long-term care deserve more respect than they traditionally receive. Employees are to be treated with respect at all times, by all people. Staff is expected to respect one another; anything less is unacceptable and not to be tolerated. The message is: Respect others-or leave.

Vision. As already suggested, an exemplary organization begins with a clear vision and mission, guided by established principles and values, including respect, dignity, trust, honesty, and integrity. The vision is central to hiring, decision making, and problem solving, as it is the ultimate guide for the leader and all those who follow. The vision created or interpreted by all in the organization unites employees as they, in turn, share in the dream. A vision serves to move a group of individuals in an organization toward a common destination and provides meaning to their work.

Creating a vision that is shared by the staff takes time and effort; it does not happen on its own. The vision must be discussed and examined routinely as long as the organization is operational.

Inclusion. Involve staff in as much problem solving, decision making, and operational implementation as possible. This enhances staff interest and participation in the work and allows the organization to tap into their particular knowledge and experience. When staff is part of the plan and solution, it becomes a reality to them. Because they are a part of it, they own it, and will work hard to see that it is successful.

To facilitate an inclusive philosophy, routine meetings with all staff should be held to relay information, and to offer the opportunity to discuss issues, plan, and problem solve. Specific department meetings are an added vehicle in which employees can offer input and communicate with their coworkers.

Staff members will be open to change and innovation, and accept it willingly, if involved in the planning and implementation process. Many staff are creative-they can have wonderful ideas and be innovative in their solutions to problems. Employees are willing to try just about anything if it improves the care and outcome for residents. Therefore, their inclusion overall ensures a more effective organization.

Communication. When employees are asked to name what contributes to job satisfaction, the presence or absence of an effective communication system consistently ranks high. While no communication system is perfect, a variety of means for relaying and receiving information is essential to effectively leading the organization in a strategic direction. Such mechanisms must communicate not only the vision and direction of the organization, but how staff members are expected to work, interact, and care for residents and families. The purpose is to tap into all of the resources, knowledge, and talent at the disposal of the organization and thus design and implement the best possible mechanisms, programs, and solutions to realize the vision.

Regular, purposeful efforts to communicate with staff promote knowledge, accountability, awareness of problems and concerns, and dialogue about solutions. While the need for communication would seem self-evident, none of the other components of the leadership model are possible without the unimpeded exchange of information, thoughts, and ideas.

Active communication with staff, residents, and families must begin at the first encounter and continue throughout the relationship. There will be the need for consistent, regular reinforcement as the organization grows over time. Inevitably, unique events, situations, and problems will require the interchange of information and solutions. Without the existence of a plan for the free flow of information and decision making, confusion and dissatisfaction will be the likely consequence.

When communication flows readily in all directions, issues and concerns are handled quickly. This promotes better procedures and projects. Everyone is content when they feel free to communicate and know that they are heard to the benefit of all parties involved-residents, families, and staff.

Enrichment. Leadership abilities are enhanced by self-knowledge, and they become increasingly developed the more one knows about his or her values, beliefs, and what matters in life. The more certain leaders are about their own principles, values, and motivations, the easier it is for them to stay consistent and confident in the day-to-day work as a leader. If leaders are unaware of who they are, where they are headed, and what matters to them in life and work, there will be no consistency in the way they lead or the decisions they make. Their actions will be thoughtless reactions, taking into consideration only the events of the moment. They may even make different decisions given the same scenario. This constant change coupled with inconsistency makes it hard for coworkers to know what they want and how the leader wants them to behave. No one can follow because they do not know what direction the leader will take today or tomorrow.

Leaders with self-knowledge control what happens to them in their work. While outside forces may push or pull them, these leaders decide how they are going to handle these forces, and then do so. An administrator may encounter a regulation or corporate mandate that is perceived as silly and ineffective, and they have a choice whether to follow it, fight it, or try to work around it to minimize its ill effect on the facility. In any event, leaders control their actions and attitude.

To give to others, leaders need to “fill” themselves or they will have little left to give. While there are always things that need to be done and the “in-box” is always filled, leaders must stop and take time for self. Doing so is critical in order to maintain the self and stay in touch with what truly matters.

Model outcomes

The S.E.R.V.I.C.E model clearly includes many of the facets that most agree are important components in an organization and specifically long-term care. In the few facilities that have implemented the model across the country, the outcomes have been the same: increased staff, resident, and family satisfaction; decreased turnover and agency utilization; and increased census and profit. When an organization is this aligned, satisfaction for all is high, retention is high, outcomes are good, and profits follow.

It takes a passionate and committed leader who is willing to stay the course and not waver in times of trouble and confusion. The leader must hang on to the vision, be willing to use it to lead, and to inspire colleagues to hang on-and keep moving toward the organization’s dream.

Susan Gilster, PhD, NHA, FACHCA, developed the Alois Alzheimer Center, based in Cincinnati, Ohio, in 1987, as the first freestanding dementia facility in the United States. She has written Changing Culture, Changing Care: SERVICE First and A Way of Life: Developing an Exemplary Alzheimer’s Disease and Dementia Program. Jennifer L. Dalessandro, BS, NHA, is assistant administrator and research coordinator for the Alois Alzheimer Center and has been an innovative and award-winning manager for 18 years.

For further information, phone (513) 673-1239 or visit or To send your comments to the editor, e-mail


  1. Gilster SD, Dalessandro JL. A Story of Culture Creation: The Alois Alzheimer Center. Alzheimer’s Care Quarterly 2007; 8 (2): 116-32.


At a glance…

Leadership is an essential “art” for a long-term care administrator to master. The authors present their organizational model, focusing on the seven domains that teach leaders how to effect change collaboratively.

Long-Term Living 2009 August;58(8):32-35

Topics: Articles , Facility management , Leadership