MMHA 6501 Week 5 Dyad Leadership Memo Example

Memorandum

To: Medical Director; Director of Nursing, Maple Terrace Health and Rehabilitation

From: Administrator (MMHA student)

Date: Month Day, Year

Re: Proposed dyad for clinical acceptance rules, and a standing meeting for disputes over weekend admissions

The Conflict

Over the past two months, the medical director has declined several weekend admissions referred by the regional hospital, the admissions team has accepted others under similar circumstances, and the director of nursing has learned of each decision after the patient's arrival or after the referral was turned away. Two referred patients were declined on a Saturday and accepted by another facility; one patient accepted on a Sunday arrived needing intravenous medication the weekend nurse had not been told about. The referring hospital's case managers have asked who at Maple Terrace actually decides. That question deserves an answer, and this memo proposes one.

The Medical Director's Position

In the medical director's terms: a skilled nursing facility should accept only patients whose needs it can safely meet at the time they arrive. On weekends, Maple Terrace has no on-site physician or nurse practitioner, a thinner nursing staff and limited pharmacy delivery. Accepting a patient who needs frequent assessment, intravenous therapy or complex wound care on a Saturday afternoon exposes that patient to risk and the facility to liability. Federal nursing home rules put the medical director in charge of putting Maple Terrace's resident care policies into practice and of coordinating the physicians who see residents (42 C.F.R. § 483.70), and declining an unsafe admission is part of that responsibility.

The Admissions Team's Position

In the admissions team's terms: the hospital refers patients on weekends because that is when hospitals discharge, and a facility that declines weekend admissions loses referrals to competitors. Every declined referral is a patient who goes somewhere else, often farther from family, and a lost relationship with the case managers who decide where future patients go. The team has accepted patients whose needs it believed the facility could meet, using the clinical information in the referral. Its members are not clinicians, and they have had no written criteria telling them which cases to escalate.

What Both Positions Share

Both positions want the same outcome: patients admitted when Maple Terrace can care for them safely, and turned away only when it cannot. The dispute is not about values. It is about the absence of agreed rules and the absence of a forum where clinical and operational judgments meet before a decision, rather than after it. The director of nursing, whose staff must care for every admitted patient, has had no voice in either side's decisions. Adaptive challenges like this one require the parties to work out new ways of operating together rather than having a solution handed to them (Heifetz et al., 2009).

Proposal: A Clinical Leadership Dyad

I propose that the medical director and director of nursing form a dyad that jointly owns the facility's clinical acceptance rules. Together they would write criteria for which conditions and needs can be accepted at any time, which can be accepted only on weekdays or with advance arrangements, and which require their joint review before acceptance. The administrator would own capacity and payer questions: bed availability, insurance authorization and the relationship with referring hospitals. The admissions team would apply the written criteria and escalate any case outside them to whichever dyad member is on call that weekend.

Disputes would go to a standing weekly meeting of the dyad and the administrator, held Monday mornings, where every declined and every escalated referral from the previous week is reviewed. The purpose is learning, not blame: each review asks whether the criteria worked and whether they need to change. Dyad leadership pairs clinical and operational leaders so that decisions reflect both perspectives, and it works best when each partner's domain is clear and disagreements have a regular place to go (Northouse, 2021).

What This Memo Does Not Decide

This memo does not decide the clinical criteria themselves. Which conditions are safe to accept on a weekend is a clinical judgment for the medical director and director of nursing, informed by the facility's staffing and pharmacy arrangements. I will provide data on the last six months of referrals, including the diagnoses, times and outcomes of declined and accepted cases, to inform their work. I ask that the dyad bring draft criteria to the weekly meeting within four weeks. Until then, as an interim rule, I ask that the admissions team call the medical director or director of nursing before accepting or declining any weekend referral, and that the referring hospital's case managers be told that a clinical leader will respond within two hours.

Next Step

I would like to meet with both of you this week to discuss this proposal and agree on the first weekly meeting date. If either of you sees a better structure, I would welcome it; what matters is that the hospital's question, who decides, has a clear answer by the end of the month.

References

Administration, 42 C.F.R. § 483.70 (2024).

Heifetz, R. A., Grashow, A., & Linsky, M. (2009). The practice of adaptive leadership: Tools and tactics for changing your organization and the world. Harvard Business Press.

Northouse, P. G. (2021). Leadership: Theory and practice (9th ed.). Sage.