Why the DON Role Matters More Than Simply Filling a Position
“In skilled nursing, hiring someone to fill a position is not the same as hiring the right leader for the position. A vacant DON position creates challenges. But placing the wrong person in the DON position can create additional challenges that extend beyond the nursing department.”
In skilled nursing, hiring someone to fill a position is not the same as hiring the right leader for the position.
This is particularly important when selecting a Director of Nursing (DON).
The DON is a critical member of the facility’s clinical leadership team and plays an important role in coordinating nursing operations, clinical processes, staff accountability, regulatory expectations, quality improvement, and resident care.
Too often, organizations can become focused on filling a vacancy quickly without taking sufficient time to determine whether a candidate has the experience, leadership ability, clinical knowledge, credentials, communication skills, and organizational fit necessary to succeed.
A vacant DON position creates challenges. But placing the wrong person in the DON position can create additional challenges that extend beyond the nursing department.
Why the DON Position Requires Strategic Hiring
The nursing department is generally one of the largest operational departments in a skilled nursing facility and provides around-the-clock resident care.
The DON therefore needs more than clinical credentials. The individual needs to understand how to lead people, manage systems, recognize clinical risk, communicate with interdisciplinary leaders, respond to changes in resident condition, prepare for surveys, monitor clinical outcomes, and hold staff accountable.
A strong DON should be able to move between the clinical details and the larger operational picture.
A narrow question driven by the urgency of coverage, prioritizing immediate presence over long-term clinical stability, cultural alignment, and risk foresight.
Evaluates whether the candidate can develop the nursing team, drive staff engagement, navigate regulatory audits, and ensure consistent standards of resident-centered care.
A KCG Case Study: When Filling the Position Is Not Enough
Consider a skilled nursing facility experiencing several common, interconnected operational challenges:
The organization needs a DON. The immediate temptation may be to fill the vacancy as quickly as possible.
However, hiring based primarily on availability can create a second problem if the selected leader does not have the experience or leadership skills required by the facility.
What Happens When the Right DON Is in Place?
A strong DON can help establish structure and accountability within the nursing department. This transformative impact unfolds across seven foundational pillars:
Clear Clinical Expectations
Staff should understand what is expected of them regarding resident care, documentation, communication, policies, procedures, and escalation of concerns.
Stronger Staff Accountability
A DON must be willing and able to address performance concerns consistently while also providing staff with education, coaching, and appropriate support.
Better Communication
Clinical leadership influences communication between nurses, CNAs, physicians, residents, families, rehabilitation, social services, dietary, administration, and other departments.
Regulatory Readiness
Survey readiness should not begin when surveyors arrive. A strong DON can help make compliance part of daily operations by monitoring clinical practices, identifying gaps, educating staff, and following through on corrective actions.
Quality Improvement (QAPI)
Clinical leaders play an important role in identifying trends and participating in Quality Assurance and Performance Improvement (QAPI) activities. The goal should not simply be to respond to problems after they occur. The goal is to identify patterns early and develop sustainable interventions.
Staff Development
A strong DON understands that hiring staff is only the beginning. Nursing employees need orientation, competency validation, education, coaching, feedback, and ongoing support.
Resident-Centered Care
Ultimately, clinical leadership should remain connected to the reason the nursing department exists: providing safe, individualized, dignified care to residents.
The Connection Between Clinical Leadership and Facility Performance
CMS’s Five-Star Quality Rating System currently evaluates nursing homes through three major domains:
Health Inspections
Evaluates findings from the three most recent state standard surveys and the last 36 months of complaint and infection control inspections.
Staffing Domain
Incorporates RN hours per resident day, total nurse staffing hours, weekend staffing, total nursing staff turnover, RN turnover, and administrator turnover.
Quality Measures
Calculated from a subset of clinical MDS assessments and Medicare claims data measuring clinical outcomes, prevention, and functional status.
CMS provides separate ratings for each domain as well as an overall rating. The staffing domain incorporates measures including RN hours per resident day, total nurse staffing hours, weekend staffing, total nursing staff turnover, RN turnover, and administrator turnover. The quality-measure domain incorporates multiple clinical measures derived from clinical and claims data.
These measures demonstrate why effective clinical leadership matters.
Precision in Clinical Leadership Attribution
However, it is important to be precise: a DON does not independently determine a facility’s survey results, quality measures, staffing rating, or overall Five-Star rating. Facility performance is influenced by many factors, including executive leadership, staffing, clinical systems, resident population, resources, interdisciplinary collaboration, regulatory compliance, and the effectiveness of quality-improvement processes. The DON is one important component of that larger system.
What Should an Organization Look for When Hiring a DON?
Before making an offer, leadership should evaluate more than a resume. Use this rigorous checklist across five dimensions:
1. Experience Checklist
8 Indicators2. Leadership Checklist
8 Indicators3. Clinical Knowledge Checklist
8 Indicators4. Regulatory & Quality Checklist
8 Indicators5. Cultural Fit Inquiries
6 Alignment InquiriesInterview Questions for a DON Candidate
Organizations should move beyond general interview inquiries and evaluate candidates on concrete operational scenarios. Organizations should consider asking:
Tell us about the nursing department you currently lead or most recently led.
What were the biggest clinical challenges you inherited, and how did you address them?
How do you hold nursing staff accountable while maintaining staff engagement?
How do you prepare your department for an annual survey?
Tell us about a significant clinical deficiency or concern you encountered and how you addressed it.
How do you use audits and data to identify clinical trends?
How do you approach QAPI?
How do you address repeated staff performance concerns?
How do you handle conflict between nursing staff and other departments?
What would your first 30, 60, and 90 days look like in a new DON position?
What support do you need from the Administrator and regional leadership to be successful?
What do you believe separates an average DON from an effective clinical leader?
The Benefits of Getting the Hire Right
Hiring the right DON does not guarantee a particular survey outcome, staffing result, or quality rating. However, effective clinical leadership can provide an important foundation for managing the nursing department.
CMS specifically identifies staffing as one of the three domains used in the Five-Star system, and its current staffing methodology includes nursing hours and turnover measures.
CMS also reports that increased nursing staffing levels are commonly associated with improved quality of care and quality outcomes, while lower nursing staff turnover is associated with improved quality of care.
Don’t Just Fill the DON Vacancy
A DON vacancy creates pressure. The organization needs coverage. The temptation is to hire quickly.
But an important leadership question should always be asked:
“Are we filling the position, or are we selecting the leader our nursing department actually needs?”
The answer can have significant implications for the nursing team, residents, families, survey readiness, and the organization’s overall operations.
At Kay Consulting Group, we believe leadership placement should be approached strategically. The right leader needs appropriate experience, clear expectations, resources, accountability, and ongoing support to succeed.
Hiring the right person is only the beginning. Developing, supporting, and holding that leader accountable is what helps create sustainable performance.
Final Thought
A strong DON does not operate in isolation.
The DON needs an Administrator who supports clinical leadership, an executive team that provides appropriate resources, a culture of accountability, adequate staffing, and an interdisciplinary team committed to resident-centered care.
When organizations invest in appropriate clinical leadership and provide that leadership with the tools and support necessary to succeed, they create a stronger foundation for quality, compliance, staff development, and resident care.
Navigating Leadership Transitions or Clinical Vacancies?
Kay Consulting Group, LLC provides seasoned interim healthcare leadership, clinical stabilization, and executive operational advisory to skilled nursing facilities across the nation.
References
- Centers for Medicare & Medicaid Services (CMS). Five-Star Quality Rating System. Updated September 21, 2026.
- Centers for Medicare & Medicaid Services (CMS). Provider Data Catalog: Nursing Homes: Technical Details. Includes current Five-Star calculation methodology, staffing measures, turnover measures, and quality-measure methodology.
- Centers for Medicare & Medicaid Services (CMS). Nursing Homes Including Rehab Services: Quality Measures. Provides current nursing-home quality measures and information regarding staffing and quality outcomes.
- Centers for Medicare & Medicaid Services (CMS). Quality Measures. Provides information regarding the quality measures used in nursing-home quality reporting and the Five-Star system.