A phased roadmap for competencies, succession and retention you can adopt now
Long-term care leadership is being rewritten as a quality standard rather than a management preference. On Oct. 31, 2026, the National Association of Long Term Care Administrator Boards asked the WHO to add a "Leadership for Quality Long-Term Care" standard to its global framework, with competencies, culture and leadership continuity built in.
Directors of nursing would carry most of it out: hiring against competencies, evaluating leaders, naming successors. ACHCA's letter to the WHO ties administrator turnover to lower nursing home quality ratings.
That makes the phased roadmap, accountable role first, succession planning last, worth testing whether or not the standard is adopted.
Leadership is the missing piece in the WHO's long-term care draft, and two US organizations asked the agency to fix that. On Oct. 31, the National Association of Long Term Care Administrator Boards (NAB) proposed a new standard titled "Leadership for Quality Long-Term Care," as reported by McKnight's Long-Term Care News.1 The American College of Health Care Administrators (ACHCA) backed the proposal in its own letter to the WHO.1
The WHO's Global Standards for Long-Term Care Framework is billed as the first global framework for planning, delivering, monitoring and improving care for older people. The consultation draft, released May 18, 2026, runs to 34 standards and 106 quality statements across eight chapters. It is not a certification scheme and carries no operational criteria. Publication is planned for 2027, though no final date is confirmed.
ACHCA's argument is simple. The draft addresses workforce training, staffing, governance and quality improvement, yet sets no expectations for the organizational leaders who hold those pieces together. That is the difference between a list of ingredients and someone accountable for the recipe.
NAB's proposal, placed in the workforce chapter as a new Standard 17, rests on three statements:
NAB also urged organizations to build these competencies into hiring, performance evaluations, professional development and succession planning. It stressed that the standard is not a universal credential, a standardized licensing model or a prescriptive staffing rule.
If approved, the standard would apply across residential care communities, home-based services and community-based care, adaptable to differing resources and regulatory systems. ACHCA added its own recommendation for a statement on organizational leadership accountability and favored a phased rollout over a single standardized model.
Treating leadership turnover as an HR cost rather than a quality risk leads to very different budget decisions. The evidence leans toward the second view, though it is thinner than the advocacy around it suggests.
The Ohio researchers suggested leadership training, workload support and culture change as responses, and proposed that CMS publicly track DON turnover.1 You do not need to wait for that. Your own tenure, your charge nurses' workloads and your successor pipeline are inputs to quality, not paperwork. Retention and succession planning belong on the same agenda as survey readiness and staffing.
This is an expert framework, not text from the proposal, though four rows mirror language the proposed standard names directly: person-centered care, workforce support, accountability and continuous quality improvement. Finance and regulatory compliance are additions drawn from the realities of the DON role, where budget reviews and survey cycles test leaders constantly. Staffing and workforce carries the most weight, given the cited link between leadership commitment to staff well-being, nursing staff turnover and quality ratings.
| Competency | What It Looks Like for a DON | Where to Build It In (Hiring, Evaluation, Development, Succession) |
|---|---|---|
| Person-centered culture (named in proposal) | Rounds with residents and families, builds care plans around resident preferences, coaches staff to ask before acting | Hiring: behavioral questions on resident-choice dilemmas. Evaluation: resident and family feedback. Development: culture-change training. Succession: include successors in care-planning meetings |
| Accountability (named in proposal) | Owns survey findings and incident follow-up, sets clear expectations for unit managers, closes the loop on complaints | Hiring: ask for a past error and how it was fixed. Evaluation: track corrective-action completion. Development: coaching on difficult conversations. Succession: assign successors ownership of a plan of correction |
| Continuous quality improvement (named in proposal) | Leads QAPI meetings, tracks falls, pressure injuries and infections, runs root-cause analyses | Hiring: request a QI project example. Evaluation: tie goals to measurable quality indicators. Development: QI methods training. Succession: have successors lead a performance improvement project |
| Finance | Builds the nursing labor budget, manages overtime and agency use, matches staffing to census and acuity | Hiring: test budget literacy. Evaluation: review variance to labor budget. Development: healthcare finance coursework. Succession: involve successors in budget preparation |
| Regulatory compliance | Keeps the building survey-ready, interprets federal and state requirements, trains staff on documentation and infection control | Hiring: scenario questions on survey response. Evaluation: survey and mock-survey results. Development: regulatory updates and mock surveys. Succession: successors shadow the survey process |
| Staffing and workforce (workforce support named in proposal) | Builds stable schedules, monitors turnover, supports staff well-being, grows charge nurses into managers | Hiring: ask how candidates retained staff. Evaluation: turnover and retention trends. Development: mentoring and leadership programs. Succession: name and develop a ready backup for each manager role |
The temptation in a staffing crisis is to jump straight to succession plans and skip the groundwork. ACHCA's letter to the WHO argues for the opposite order, and it translates well to a nursing department. Our version adapts ACHCA's phasing for directors of nursing. It is not an official WHO tool, and the WHO has not adopted it.
ACHCA's first phase designates one accountable leadership role with core duties and a defined workflow. In practice, that means deciding who owns clinical quality, staffing decisions and escalation, and writing it down.
The next phase adds structured leadership evaluations, followed by risk and quality assessments. Evaluations tie hiring, performance reviews and professional development to the same competency set.
The final phase is formal succession planning. ACHCA's letter cited research that leadership commitment to employee well-being reduces nursing staff turnover, so succession and retention belong in the same conversation.
Two failure points come up repeatedly:
A useful check is to ask whether a named successor could run tomorrow's morning huddle. If the answer is no, the plan is still on paper. ACHCA also tied administrator turnover directly to lower nursing home quality ratings, which is reason enough to treat these phases as operational work rather than paperwork.
Bench strength means you always have a named successor for the director of nursing chair, plus two or three nurses who could step into a unit manager or clinical coordinator role within a year. Building it is less about finding a program and more about matching each rising nurse to the option that fits their schedule and your budget.
Each option maps to the continuity phase of the phased roadmap: mentoring builds the internal pipeline, Future Leaders and DELP create external exposure, and the Academy supplies the competency language you can drop into performance evaluations.
A 2026 systematic review of 18 studies found that leadership development programs improved relational leadership, job satisfaction and commitment while reducing emotional exhaustion, with active learning methods (simulation, role-play, reflective practice, 360-degree feedback) producing the strongest engagement. The evidence for direct turnover reduction in long-term care specifically is still thin, so treat retention gains as a reasonable expectation rather than a guarantee.
An MSN builds your skills, but a state license gives you the legal right to run the building. The two are not interchangeable, and no master's degree satisfies state licensure requirements on its own.
There is no single national nursing home administrator license. Each state board sets its own education, supervised training, exam, age and experience rules.1 Most states use the NAB NHA and CORE exams, and some add a state exam of their own, including Kansas, Texas, Oklahoma and Pennsylvania.1 Passing the NAB exams does not make you licensed.
A bachelor's degree is the most common education minimum.1 Some states accept an associate degree, usually in a health or business field and paired with more experience. Oklahoma is one example.2
Administrator-in-training (AIT) requirements vary widely, so never assume another state's numbers apply to yours.
South Carolina takes an experience-based approach, requiring one to three years of practical experience depending on degree and field.8
An MSN in health systems management is strong preparation and a real differentiator. It covers finance, regulatory strategy, operations and workforce leadership, the areas where nurse leaders often feel least ready. Some boards recognize a master's in specified fields as meeting the education requirement. Even then, the board may still require an experience or AIT pathway, as Pennsylvania does.9 The degree field and whether the program includes an internship can change the outcome.
Before you enroll anywhere, check your state licensing board and confirm its education, AIT and preceptor rules. If you plan to move, check the destination state too, since the same degree can lead to very different training hours.
Most long-term care nurse executives climb the same five rungs, picking up credentials along the way. The ladder below shows where an MSN, nursing home administrator (NHA) licensure and specialty certification typically enter. Real paths vary by state licensing rules and by employer, so treat this as a common pattern, not a fixed sequence.
The director of nursing (DON) is the registered nurse accountable for clinical care, nursing policy and the nursing workforce, while the nursing home administrator is the state-licensed leader accountable for the entire facility, including finances, regulatory compliance and operations. In most nursing homes the DON reports to the administrator, and the two work as a clinical and operational partnership. Salary figures below are approximate averages from McKnight's Long-Term Care News 2025-2026 compensation reporting; for broader context, the U.S. Bureau of Labor Statistics puts the May 2025 median for medical and health services managers, the federal category that includes nursing home administrators, at $123,860.
| Role | Core Focus | Typical Credentials | Reporting Line | Typical Salary Range | Typical Years to Reach |
|---|---|---|---|---|---|
| Director of Nursing (DON) | Clinical quality, nursing staffing and scheduling, care policies, survey readiness and nursing staff development within one facility | Active RN license; many employers prefer a BSN or MSN; long-term care DON certification is common | Administrator or executive director | About $117,000 per year (industry report, 2025-2026) | Varies; usually follows charge nurse, unit manager or assistant DON roles |
| Nursing Home Administrator | Overall facility operations, budget, regulatory compliance, staffing strategy and resident and family relations | State nursing home administrator license (NAB national exam plus state requirements); bachelor's degree commonly required; some add an MHA or MSN | Owner, governing board or regional operations leader | About $133,750 per year (industry report, 2025-2026) | Varies by state; licensure typically requires an administrator-in-training period |
| Executive Director | Leadership of a community or campus, often blending licensed administrator duties with business development and multi-service oversight | Often a licensed administrator; bachelor's or master's degree (MHA, MBA or MSN) common | Regional vice president or governing board | Not reported in the sources reviewed | Varies; usually follows administrator or senior operations experience |
| Regional Nurse Executive | Clinical quality, compliance and DON support across multiple facilities, including survey preparation and leadership coaching | Active RN license; BSN or MSN typical; prior DON experience usually expected | Corporate chief nursing officer or vice president of clinical services | Not reported in the sources reviewed | Varies; generally follows successful tenure as a DON |
Before launching any mentoring or succession program, pull a 12-month baseline for each metric below, then review the same measures every quarter so leadership investments can be tied to real movement. Nursing homes have reduced total nursing and RN turnover by nearly 11% since mid-2022, according to the 2026 AHCA/NCAL Nursing Home Workforce Report, so measure against current benchmarks rather than pandemic-era highs. To put dollars on the gain, NSI's 2025 report puts the average cost of losing one staff RN at $61,110. The same report estimates that each 1% change in RN turnover is worth $289,029 a year in added cost or savings for an average hospital.
| Metric | How to Calculate | Data Source | What Improvement Looks Like |
|---|---|---|---|
| Nursing-home RN turnover | RN separations in the period divided by average RN headcount, times 100 | HR and payroll records; CMS Payroll Based Journal; Skilled Nursing News 2025 benchmark | Falling below the 2025 nursing-home RN benchmark of 36.53% |
| LPN turnover | LPN separations divided by average LPN headcount, times 100 | HR and payroll records; Skilled Nursing News 2025 benchmark | Holding at or below the 2025 benchmark of 35.29% |
| CNA turnover | CNA separations divided by average CNA headcount, times 100 | HR and payroll records; Skilled Nursing News 2025 benchmark | Moving below 42.34%, the 2025 benchmark (down from 44.16% in 2024) |
| Combined nursing turnover (CNA, LPN, RN) | Simple average of CNA, LPN and RN turnover across four reported quarters | CMS Payroll Based Journal data, as used by the New Jersey Department of Human Services | Reaching New Jersey's quality incentive target of an average at or below 30% |
| New-hire retention at 90 days and 12 months | Hires in a cohort still employed at 90 days and at 12 months, divided by cohort size | HR onboarding and separation records; NSI 2025 report | Rising retention; NSI reports first-year RN turnover at 22.3% |
| DON and administrator tenure | Months in role for the DON, administrator and other top leaders; track leader separations divided by leader headcount | HR records; Skilled Nursing News 2025 benchmark | Longer tenure; top-level executive turnover fell from 31.97% in 2024 to 22.12% in 2025 |
| Quality star ratings | Track overall, staffing and quality measure star ratings each quarter | CMS Care Compare | Stable or rising stars; ACHCA links administrator turnover to lower nursing home quality ratings |
| Agency spend | Agency nursing labor dollars divided by total nursing labor dollars | Payroll and accounts payable | A declining share of nursing labor spend going to agency staff |
| Time to fill vacancies | Days from requisition approval to accepted offer, averaged by role | HR applicant tracking system | Fewer days to fill, especially for charge nurse and unit manager roles |
| Succession readiness | Key leadership roles with a named successor ready now or within 12 months, divided by total key roles | Internal talent reviews and succession plans | A rising share of DON, ADON and unit manager roles with a ready successor |
A global standard written in Geneva has no direct authority over an American nursing home, and nobody involved is pretending otherwise. ACHCA board chair Mark Prifogle told McKnight's Long-Term Care News that it is unclear how the WHO framework would influence domestic US policy, given that the Trump Administration withdrew the United States from the organization earlier this year.1 That is the honest answer, and it deserves repeating plainly.
The executive order directing withdrawal was signed January 20, 2025, formal notice followed on January 22, 20251, and CDC materials describe the withdrawal as completed January 22, 2026.2 US funding to the agency has been terminated, personnel have been recalled, and official participation in WHO committees, governance bodies and technical working groups has ceased. WHO's own statements frame the date as the effective point of the notified withdrawal. Available 2026 federal materials do not identify any change to Medicare or Medicaid requirements, nursing home regulations, assisted living policy or long-term care workforce rules arising from the withdrawal.1
The substance of the proposal, leadership competencies, culture and continuity, targets problems your surveyors, your owners and your residents' families already judge you on: administrator turnover, nursing staff turnover and the quality ratings both feed. None of that waits on a vote in Geneva.
One concrete move this quarter: name a single accountable leader for each core clinical workflow and write that accountability into the job description.
