Administrator, Medical Director and Director of Nursing: The Triad of Excellence

The relationship between the Administrator, Director of Nursing and Medical Director is similar to a tightly wound rope. Each represents a different function and is independent of one other; however, each must work together to ensure the operations and standards of the nursing facility are being upheld and maintained.

Together, these roles make examinations and decisions that ultimately affect the well-being of residents and the overall operation of the nursing facility (Singh, 2003, pg. 274-275). Each is an expert in their own realm and must work together to alleviate conflicts, increase resident satisfaction and reduce staff turnover.

According to Drucker (1974), the main components of the responsibility of an administrator include managing the nursing facility, managing the staff and managing the nursing facility in regards to the community. Additionally, Drucker states that this balance is required because “a decision or action that satisfies a need in one of these functions by weakening performance in another weakens the whole enterprise” (pg. 398).

The administrator maintains balance between mission and margin “through forecasting, planning, organizing, staffing, directing, evaluating, controlling quality, innovating, and marketing decisions” (Allen, pg. 43). The administrator is usually non-clinical; however, is required to understand the basic aspects of health care including clinical terminology, practices and professional requirements (Davis, et al, p.27). It is the role of the administrator to familiarize himself with these concepts to better: (1) Understand the delivery of care that is being given to residents, (2) Assist health care professionals solve problems associated with resident care, and (3) Evaluate the quality of care that is being delivered to residents.

According to Singh (2003, pg. 271), the medical director is considered to be the “chief medical officer” of the facility. He is responsible to ensure professional services are upheld and maintained; this can be accomplished through effective leadership, teamwork and routine observations of the staff and facility.

The medical director is responsible for implementing resident care policies and coordinating medical care in the nursing facility. The medical director is normally paid on a contractual basis and, according to Singh (2005, pg. 268), is expected to spend approximately 2-4 hours in the facility per week (estimation for 120-bed facility). The medical director assists the director of nursing with delivering good quality of care to its residents of the nursing facility (Allen, p. 126) and sets standards for clinical staff in appropriateness of caring for the elderly.

Additionally, the medical director should also participate in staff meetings, committees, educational opportunities, in-services, presentations and making rounds on a regular basis (Kane, et al., pg. 439). The medical director is clinical and has a reporting relationship to the administrator; however, acts as a clinical advisor and educator to staff and is a representative of the facility (Singh, 2005, pg. 268-272).

The director of nursing heads the nursing department, which is the largest department of a nursing facility. It is a position with great responsibility, and according to Singh (2003, pg. 273), the director of nursing is next in charge after the administrator; although they are not stereotypically skilled in management.

The director of nursing is expected to make daily resident rounds to ensure good quality of care (Allen, pg. 137). This increases morale, educational opportunities and promotes resident satisfaction. Overall, the director of nursing possesses clinical, administrative and supervisory responsibilities to the nursing facility. Additionally, the director of nursing is involved with staffing, training and patient care (Singh, 2003, pg. 274).

Areas where the administrator, medical director and director of nursing roles overlap include involvement in staff meetings, committees, in-services and representing the nursing facility to the general public. Additionally, each possesses responsibilities in the following areas: (1) Leadership, (2) Advocacy, (3) Education, (4) Policy, (5) Clinical and (6) Administration. Although levels of proficiency will vary based on the aforementioned role, each is responsible, in their own scope of work, to take ownership of such areas.

As an example, an administrator, medical director and director of nursing are all responsible to provide leadership to the staff of the nursing facility. The administrator may find himself doing this by continuously walking around throughout the facility recognizing staff for their hard work and dedication to their residents. This supportive style of leadership (Singh, 2003, pg. 430) enhances staff’s ability to perform well. Likewise, the medical director may provide leadership by being readily available and involving staff when conducting rounds and incorporating their knowledge of residents’ into individual care options. This coaching style of leadership (pg. 430) encourages staff’s involvement with resident care. Finally, the director of nursing may provide leadership by meeting regularly with staff to inform them of expectations and model effective methods of good quality of resident care. This directing style of leadership (pg. 430) enhances staff’s ability to feel well-educated and secure in their direct care roles.

Potential conflicts associated with successful direction from the medical director include staff retention and turnover, difficult expectations from residents, families and staff, and administrative issues (Bern-Klug et al., 2003). Likewise, conflicts can occur from the administrator and director of nursing when there is a lack of effective communication. Each role is vital to the operation of the nursing facility. Similar to the tightly wound rope, each must work together to ensure all aspects of operation are running smoothly.

Strategies to improve the effectiveness between the administrator, director of nursing and medical director include increased awareness and communication between departments, effective preadmission screening procedures and the continued use of quality improvement initiatives (Kane, et al., pg. 439). This can be accomplished by meeting on a regular basis (such as a weekly Triad Meeting) to discuss areas of concern, improvement and development, working together as one team that emulates the organizations’ mission and finally, understanding each others’ roles as it pertains to the overall success of the nursing facility.


Abrass, I., Kane, R., and Ouslander, J., (2004). Essentials of clinical geriatrics (5th ed.). Hightstown, NJ: McGraw-Hill Company.

Allen, J. (2003). Nursing home administration (4th ed.). New York, NY: Spring Publishing Company, Inc.

Bern-Klug, M., et al. (2003). I get to spend time with my patients’: Nursing home physicians discuss their role. Journal of the American Medical Directors Association 4, no. 3: 145-151.

Davis, W., Haacker, R., and Townsend, J. (2002). The principles of health care administration. Bossier City, LA: Professional Printing and Publishing, Inc.

Drucker, P. (1974). Management: Tasks, responsibilities, practices. New York, NY: Harper and Row Publishers.

Singh, D. (2005). Effective management of long-term care facilities. Sudbury, MA: Jones and Bartlett Publishers.