So Others Can Follow

It was the final days of his senior year in high school when Agustin Ramos faced his first great challenge in leadership.  The year-long competition among the four houses of his British-style K-12 school in Argentina was drawing to a close, and Agustin was the captain of House Yellow.  With two days of intense contests in sports remaining before the winning house was announced, Agustin had to face one simple fact that could not be denied: in the school’s thirteen year history of the house competition, House Yellow had never won.

“When the final day of sports came,” Agustin recalls today, “I was everywhere.  I remember running to every single event and talking with the little ones in elementary, all the way up to the senior students.  It was like coaching.”

At the end of the day, the scores were tallied.  Agustin’s enthusiasm and natural leadership ability pushed his house to play their hardest, and for the first time in thirteen years, House Yellow had won the sports.

“It was a defining moment and is still a potent memory,” Agustin says.  “Seeing the faces of the House Yellow students after the results were in was an incredible high.  Everybody was looking at each other.  All the houses were shocked.  Yellow, really?  We were euphoric.  It was amazing for everybody since it was the first time for Yellow to win, and it was amazing for me because it was my first encounter with building a team and leading them to success.  I could empower people to win in whatever they were doing.  Everything counted.  If you really talk to people and make them aware of how important it is, and show them how good they will feel if they win, then you can reach them and give them what they need to succeed.  On that day, going around talking and cheering and connecting with people…  I was exhausted, but we won.”

Agustin’s experience all those years ago was instrumental in shaping his sense of himself as a leader.  “Maybe after thirteen years, House Yellow was due to win,” he acknowledges.  “But what matters is that I was their captain when it happened—I saw the joy on their faces, and I felt it.  Maybe the right question to ask is: Who wants to be the captain of the house that had never won?”

Articulate and introspective, Agustin is eager to ask these questions of himself, just as he is eager to take on the unknown.  This drive to ask the hard questions and challenge himself has led him from winning the house competition in high school to pursuing aggressive success in numerous and varied industries.  Novelty-seeking and always after a challenge, Agustin chased a path through architecture, marketing, real estate, and retail before he finally found his greatest and most fulfilling challenge yet.  On the verge of returning to Argentina after a year-long consulting project in the United States, he took a daring leap of faith that has taken him from an entry level position seven years ago to becoming the Chief Operating Officer of NMS Healthcare today.

NMS Healthcare, formed by Matthew Neiswanger in 2003, owns and operates three cutting-edge long term care facilities in Maryland serving more than five hundred patients daily.  “We do not run long term care the classic way,” he says.  “If you look at long term care or a nursing home, you think of elderly people who are in this place because they can’t care for themselves, which can broadly include assisted living or a skilled nursing home.  We differentiate ourselves by really going after high acuity cases.  Of the 250 beds in our Hyattsville facility, 50 are pulmonary care beds. We host over 70 dialysis patients with 24 of them in need of both dialysis and mechanical ventilation simultaneously.  Our patient demographic is all based on acuity.”

It’s not possible to tell Agustin’s story at NMS Healthcare without telling the story of its founder.  “Matt worked his way up in the long term care industry from the very bottom as a geriatric nursing assistant,” Agustin says.  “He worked all through his undergraduate and then master’s degrees.  Eventually he became an administrator, running a facility.  One day he had the opportunity to buy a skilled nursing home that was in distress.  He put everything he had into forming a partnership to take over the building.  The guy is kind of a genius when it comes to nursing homes.  He had a very good vision of what was needed for a long term care facility to be successful in an industry where most of them struggle.”

With the foundation of Matt’s nuanced knowledge base, NMS bought its first building and turned it around completely.  In a few short years, one building led to two, then three, and 220 beds became 532.  “We have invested over $16 million in the portfolio to build what is a niche between a hospital and a skilled nursing home,” Agustin says.  “A hospital often retains patients like ours because there is no next setting in which to discharge them.  Well, that’s where we come in.  Our model addresses this gap.”

When Agustin first met Matt, he was interviewing for a job at NMS, and the long term care visionary told the novice he could offer neither a salary nor a position that was commensurate with Agustin’s kind of experience.  “I told him that it was alright, that I had heard great things and it was a pleasure to meet him,” Agustin remembers.  “He told me to give him a call before I decided definitely to return to Argentina.”  Two months later, Agustin was certain he would make the move, so he called Matt to set up another meeting.  “He offered me a job and said that if I accepted, I could end up running one of his companies one day, but I’d have to learn the business first,” says Agustin.

With that, Agustin started as Director of Quality Assurance, putting all his chips on the comment Matt made.  His family was skeptical, but Agustin was drawn, as he describes it, almost irresistibly to the challenge.  “Part of what drew me was that it was something I didn’t know,” he explains.  “Matt did just what he said he would do.  Not too long after I started, he offered me the opportunity to run the Dialysis Center, his smallest business. Three years later he promoted me to Vice President of Operations of the long term care portfolio where I learned the whole business from him.”

Agustin has been with NMS for seven years now, the longest he’s been with any one company.  In his tenure as COO, he achieved the Health Facilities Association of Maryland (HFAM) Presidential Leadership Award in 2011 “For outstanding leadership and service in providing quality care for Marylanders most in need and for tireless service to the HFAM provider community, advancing the critical issues of eligibility determination and guardianship.”  And the constant that has kept him so thoroughly engaged has been the freedom he has to tackle challenges.  “I’ve had the opportunity to innovate and to implement new ideas at NMS Healthcare, and I’ve been able to experience the joy and exhilaration of leadership.  It’s been a perfect fit for me.”

The appreciation is mutual.  Indeed, Agustin’s agile nature and swiftly adapting approach have made him an ideal leader in an industry undergoing intense change and scrutiny.  But one of his greatest assets, paradoxically, has been his lack of experience in healthcare.  “I was and am very naïve,” he explains.  “But that means my barriers are very low for creativity and exploring new things.  You put all of that into the equation, and it’s a good mix.  It has allowed me to grow as a leader, to grow the company, and to become one of the first long term care portfolios to run 100 percent paperless in the nation.”

Long before the public started reading headlines about electronic health records in the Affordable Care Act, NMS Healthcare was already paperless, thanks to Agustin’s initiative to transition NMS’s medical records paperless.  At the time he enacted it, the initiative was bold and expensive, representing an immense training challenge.  “We had people who did not know how to turn on a computer,” Agustin says.  “Even Matt said, ‘I’ll be dead before I see a nursing home go paperless.’  That was a trigger for me.  I was certain he would be very much alive when I was done with it.”

It took over two years to become fully paperless, and along the way, Agustin and his team encountered plenty of difficulties.  “One lady, a nursing assistant, was trying to document in the computer system,” he recalls.  “She was having trouble and getting very frustrated, until she started shouting at the computer and banging on the desk, saying she was doing what she was trained to do but it wasn’t working.  Of course it turned out that she was holding the mouse upside-down.”

Agustin’s determination and leadership ability pushed NMS to set a new standard in the industry for record keeping.  “We are always trying to be the first ones,” he affirms.  “We try to mark the path so others can follow. We’ve done it with paperless documentation, with mechanical ventilation, and with vent-dialysis. This year the goal is to launch the first bedside dialysis program in a long term care setting.”

Entering the healthcare industry not only meant a tremendous shift in Agustin’s technical focus, but also in the philosophical underpinnings of his drive to succeed.  “I entered a setting that was completely foreign to me,” he says, “but that I knew carries great meaning.  After I came into healthcare, the ‘why’ for me became deeper.  The impact of our work is on people that are in need.  They are not in a position of choice, and that simple fact changes the urgency for me.  It’s about helping people.  It’s about leading a team to success, and having that success mean real improvement in real people’s lives.  That’s what has kept me in healthcare for seven years now.  It’s very fulfilling and rewarding.”

Agustin’s grasp of his own leadership may have been ignited on that last day of the house competition, but his love of building can be traced back even earlier to the days he would observe his father’s business in Argentina.  “As a child and teenager,” he says, “I saw what my father was doing as an entrepreneur.  I would always ask him to take me down to the construction sites to see what was going on.  Sometimes he would build from new, and sometimes he would take something old and change it.  I was amazed with that.”

The young boy was so amazed, that his first interest in university would be architecture.  But before long, he would realize that he was much more strongly drawn to business.  His life’s work would be more than just designing the building itself.  He wanted to have a hand in a business’s conception, financing, and execution as a much larger project, with ever greater challenges and different kinds of rewards.

Agustin’s inclination to introspection and deep mental challenge is a thread that permeates his childhood as well, expressed as his passion for playing music.  “My family always had a piano at home,” he recalls.  “My parents made sure of that once I started piano lessons when I was eight.  As I got older and began to set out on my own, every time someone would ask me what I wanted as a gift, my answer was a baby grand piano.  I wanted that sound.  And after many years, I finally got my first baby grand in 2012 as a birthday present from my wife.”

On the one hand, the baby grand represented something that Agustin had always wanted but could never afford.  On the other hand, it also represented something he would never master.  “There was a time when I would read musical scores and jazz chords,” he recalls.  “Now, I just play whatever comes to me.  Every time I sit at a piano, I’m not trying to play someone else’s tunes.  I’m just playing what comes out.  In doing so, I can feel my limitations—I can hear what’s in my head and see how my hands can’t quite translate it to reality.  It’s something I really cannot master or dominate, and it’s a constant attraction to me.  Golf is the same for me.  I like golf because I’m bad at it.  I find intriguing things that I cannot ever truly master.”

Agustin’s piano also represents a connection to his family.  “I see my children taking the same interest in it, but with hugely different results,” he says.  “My daughter is mastering the pieces she pursues.  She can come back from a class, sit down with the score, and sight read—it’s amazing.  It’s something I really admire.”

Agustin’s deep relationship with his piano offers a unique window into the mind and also the leadership style of an inventive and forward-thinking innovator.  When he has an idea forming that needs to come out, he sometimes turns to his piano as an instrument not just to produce sounds, but to entice his very thoughts from their formative place in his head.  “If I need to think about something, I need to not think about it,” he says.  “Once you have one idea of how to solve a problem, it’s very hard to go around it or find other possible solutions.  If I have some vague idea of what I want, my process is to always question it first, then let it go.  If you keep thinking about the same thing, you can’t get away from whatever your original conception was.  You have to take the idea and place it somewhere in the back of your mind, and then completely disconnect and let it work.  The answer will come, hopefully with more thoughts of possible solutions that you can put through a process of elimination.  It’s a habit I inherited from my mother!”

Agustin strives to extend this philosophy to his leadership style.  “I do try to do the same with my staff, which can be difficult,” he says.  “My team can sometimes feel like I’m always questioning their ideas or never accepting their thoughts, but it’s the same way I treat my own ideas.”

Agustin’s leadership style also focuses on robust analysis, the value of which he learned personally when a project he was working on in Argentina hit a glitch.  “The project itself did go very, very well,” he says.  “But internally, the partnership fractured, and suddenly I had a taste of how badly things can go.  I lost a friend because of business, and I learned what makes a risk a huge risk.”  This crucial experience taught Agustin to be more cautious.  “I had a huge blind spot, and I learned that you can hit the wall because of it.  And when you hit it, you hit hard.  But you just have to get up, learn from it, and try again.”

When Agustin hit the wall in this manner, his father told him it was probably good for him.  “Up until that point, I had had nothing but success in my career,” he admits.  “I always got positions that should have gone to candidates with more experience.”  Setting out with a degree in marketing, Agustin had become the regional marketing manager for Burger King in Argentina when he was only 21.  Later, when he became a product and brand manager for SanCor, the biggest dairy producer in Argentina, he was a mere 24.  From there he had finished his Master’s in Strategy, created his consultancy and set out on his own, and until then had seen only success.  “It was an important lesson,” he affirms.

In the wake of that experience, Agustin’s leadership style has been more inclusive, prioritizing information sharing among all team members.  “If you’re very charismatic, you can maybe get away with telling people what to do.  But that’s not me,” he says.  “I’m more someone who encourages people to make decisions.  I push them to do better every day, not by telling them what to do, but through sharing information and making them aware of what’s going on so they can then make the right decisions by themselves.  My management and leadership style is built on trust.”

In considering the people who have performed the best under his leadership, and in recalling his own experience, Agustin’s main point of advice for recent graduates is to urge them to explore and to always be ready to adapt.  “Prepare yourself to blend with your environment,” he says, “but do what you do with conviction and stay true to yourself.  Stay focused on the things you can control and keep a very open mind to changes around you.  Things change, so you have to adapt.  And have fun doing what you do.  If you are not having fun, change it.”

This approach stems from his childhood when, at the age of four, Agustin and his family moved to France and then Spain for a total of four years, fundamentally shaping his character.  “The fact that I was born in Argentina, moved to France, and then to Spain and back at such an early stage of my life could have helped my ability to adapt to a new environment,” he reflects.  “Business is about adapting.”

His family may have moved several times in a short span, but when they were in Argentina, the unifying atmosphere of his house played a prominent role in his daily life.  “Home was the center of everything,” Agustin laughs. “If you were sitting having coffee with my parents in the living room, you would see so many people coming and going—friends, boyfriends, girlfriends, relatives.  There was always movement.  Everyone met at home.”

Today, Agustin and his wife, Victoria, have two children of their own: Micaela (9) and Lucas (5).  They were high school sweethearts who met when they were fifteen, and this year will celebrate their thirteenth wedding anniversary.  “She has supported me unconditionally in everything that I have done,” he says.    “She even had to leave her job and give up her career when we moved to the U.S., and for that I still owe her.  I could have not accomplished this much without her.”

As Agustin looks forward, he aims for growth—for both NMS Healthcare, and for himself as a person and leader.  And if past is prologue, that growth is coming.  With each time he sits down at the piano to unearth his next great business vision, and with each initiative he pushes ahead of the curve, Agustin has committed to pursuing the best ideas and the best path forward so others can follow to a better future.

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