Gerotalk : Business

The Microeconomics of Long-Term Care Can Cause Problems

Brian Garavaglia — Thu, 06 Aug 2009 13:40:00 GMT

It is no secret that our country is currently going through some very difficult economic times. With job losses increasing, the subprime problems leading to many issues of foreclosure, and many financial institutions failing or needing to be bailed out, many people hold the misconception that health care as an industry is immune to the larger economic problems that are found in society. I often hear many individuals saying that if you work in the health care industry, you do not have to worry about your job. It is interesting how many people feel that the health care industry is somewhat disconnected from the larger problems of society and are inoculated from many of the problems that other face in today's world. Health care, including long-term care, has to deal with issues that are faced by the rest of society. Yet, in doing so, one would hope our industry addresses them prudently due to the lives that are often dependent on our decisions.

The economic climate of long-term care has always been an important consideration for administrators. It is amazing how many think that nursing homes are making a large amount of money in the business of caring for the elderly. On the basis of fact, most nursing home's margins are often not very far from zero, being at times slightly above or slightly below. However, the reality is that nursing home care has always been about just that, care.

Yet, even though these facilities have been predicated on caring for those that have not been able to care for themselves, many facilities nevertheless have tried to maximize their profit margins. Strictly speaking, there is nothing wrong with this, especially since health care is a business. However, the problem begins to rear its ugly head when management losses sight of the special business they are in, which is caring for the elderly, and starts to evaluate their entire business on the basis of the economics of the facility. If they attempt to maximize their profit margin at the expense of resident care, it is here that the problem exists. Unfortunately, and all too often, health care management, including long-term care managers and administrators, fail to understand that conducting business is not the same as conducting other forms of business. In the business of long-term health care the lives of frail and dependent individuals are reliant on the decisions you make on a daily basis.

We have witnessed that many forms of reimbursement have not kept up with the rate of inflation in the medical industry. Because of this one of the most common ways that administrators use to control their economic environment is to target the workforce of the nursing care facility. In fact, health care organizations have introduced many tools to be used for control, such as various metric systems that informs management staff how many workers are needed for a given number of residents. Also common in the nursing home environment is using the metrics of hours per patient day, often referred to as HPPD's. Using measurements to help control excesses in any area are important. However, the administrator has to be aware that these numbers are not etched in stone and that in addition to staff-patient/resident ratios, one has to also calculate many of those intangibles that often do not lend themselves nicely to quantitative analysis. For instance, the acuity of an environment, based on wounds, bariatric issues, the number of acute illnesses that are currently exacerbating chronic conditions, or the increased number of roaming and confused residents, just to name a few, have to be considered and factored in to the control area. Again, as one can see these are not always easy to capture through a measurement device. Beyond attempting to post positive bottom line numbers is the need to post positive bottom line care. This must be first and foremost in the mind of administration.

Also, during our current macroeconomic hardship that society is facing, the impact that it has on many businesses, including nursing home care, is prominent. As mentioned previously, health care organizations are not divorced from the larger economic problems in society as many have come to believe. On a daily basis workforce reductions are happening in all areas of society, including healthcare. Although long-term care often has some resistance towards engaging in this type of activity, especially with nursing staff, the problems of workforce reduction still exist. In some cases workforce reduction may be needed, but again, one has to be quite prudent in using this type of financial control mechanism. Administrators have to be aware that although they may be reducing overall labor costs that may have an important impact on the economic environment of their nursing home, here again, one has to be aware of many costs that cannot be measured, those intangible costs of losing social capital. Making workforce reduction often entails losing important social capital, such as those qualities of knowledge, experience, care, and quality that again are not easily quantifiable. Although reducing the workforce by two or three tangible and measureable units may come to save the administrator those measureable costs found in their income statement, the two or three tangibles units reduced could actually entail intangible social capital losses that may amount to really losing five, six or seven units of quality care.

The business mindset, especially during difficult economic times, is often based on reducing those tangible and measureable units to bring greater harmony to those financial instruments that are often used in measuring the performance of a business entity. However, administrators and long-term care organizations that want to manage a health care organization exclusively in this manner are really deadwood. Unfortunately, health care administrators and health care organizations engaged in long-term care attempt too often to manage on a strictly business-based mindset. As we have witnessed currently in our society the common classical and neoclassical economic principles do not always work and attempting to use tangible economic measurements without paying attention to those intangible behavioral economic features has caused considerable problems for our society. This also applies to health care, including long-term care. Attempting to navigate difficult economic times by using these so-called time honored traditions of managing microeconomic environments can ultimately impact quality care, which is the ultimate goal of any health care facility, in a negative manner.

Additional Staff Training Must Accompany the Increasing Complexity of Care

Brian Garavaglia — Mon, 22 Jun 2009 13:48:00 GMT

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

According to AHCA, many long-term care organizations are increasing the levels of services they provide:

More than 36 companies are adding rehabilitation suites or units."
16 are planning to add new services such as Alzheimer's care, secured units, and respite rooms.
23 providers will start offering ventilator services.

At first blush this shows the increasingly progressive nature of many long-term care environments. It also demonstrates the need for many companies to attempt to capture higher reimbursement rates that these services potentially hold. However, although these services provide a greater potential for increased revenue as well as heighten the level of professional services offered, they do not come without a cost.

There is a monetary cost based on the capital expenditures that definitely needs to be considered. Equipment such as respirators, special safety devices for Alzheimer's residents, rehabilitation equipment that is purchased, as well as the construction costs all incur hefty capital outlays.

This is during a period of time when state and federal reimbursement is facing potential declines. State governments are looking to make cuts during these difficult economic times in numerous areas that will affect Medicaid reimbursement and the Centers for Medicare and Medicaid are also looking for possible reduction in funding for skilled nursing care centers.

So even as the skilled nursing care environment becomes increasingly competitive, with many companies looking to gain an edge on their competitors by adding more skilled services, the financial cost in doing so will be considerable. As mentioned, in an era where many decisions to reduce reimbursement have been made, many companies have to make sure and be cautious in approaching this type of expansion. A good example of this can be found in the hospital industry, where many hospitals that also are part of a highly competitive environment, have actually put out incredibly great capital outlays, just to find out that they often have poorly calculated payback periods.

However, there are other costs that will need to be examined as well. The staff that needs to carry out many of these services will definitely need to be upgraded as well. For instance, introducing a ventilator unit in a facility will entail hiring an optimal number of respiratory therapists that are on staff for 24 hours, seven day a week. Furthermore, many of the nurses that nursing care facilities rely on are typically licensed practical or vocational nurses. With ventilator units, often you need more nurses that are registered nurses and also specially trained with advanced cardiopulmonary training. Many facilities that decide to add neurological units will in turn need advanced nursing care and training among their nursing staff.

Upgrading training will not only be important for nursing staff, but it will also be necessary among social workers, activity professionals, rehabilitation staff, and in particular among certified nurse assistants. Since most clinical care is provided by certified nurse assistants or CNA's, this group of workers will need greater periods of training. Most certified nurse assistant training is short and generalized, being focused on the traditional nursing care issues that are often found among the frail clientele of nursing care centers, such as providing basic care and assistance with the activities of daily living.

With the provision of more complex clinical services, this group, which is often recipients of a very short period of training, will need to obtain greater levels of specialized training to address many of the more complex clinical needs that they will face. There are many that currently think that certified nurse assistant training is too short as it is. Therefore, with the introduction of specialized Alzheimer's services, ventilator care services, or neurological care services, certified nurse assistants will definitely need greater training to support the needs of the higher complexity of residents they will be working with daily.

With increased training and the level of work that many of the specialized areas will lead to, remunerating workers so that their wages are commensurate with their training and workload with also enhance the cost for a facility. Again, one has to be mindful of the current economic climate in which government subsidization for services are being lessened rather than increased. Furthermore, one has to also be aware of the potential for increased liability, which will definitely increase as resident acuity increases. Therefore, to minimize the risk, proper training and education of workers in these new specialized areas will be mandated, all escalating the cost to the nursing care center and for nursing services that will be provided to residents.

As the culture of nursing homes continues to change, moving toward acceptance of a higher acuity clientele, and concomitantly more complex services, it will lead to not only greater costs for the long-term care industry, but much greater levels of training that many companies may not have totally envisioned. As nursing care centers will address the needs of residents with greater clinical complexities than has been traditionally seen in long-term care, it will become imperative that many of the frontline individuals involved in the provision of clinical care will obtain greater levels of training.

Long-term care companies that envision enhancing the clinical complexity of its nursing care environment, as well as enhancing their revenue base through increasingly specialized services, will need to realize that the core element of these services, its professional staff, will also need to be part of these changes.

It's All About Connections

Brian Garavaglia — Wed, 11 Feb 2009 19:56:00 GMT

Nursing home administrators face an important dilemma: They need to lead and at times be firm, yet they need to remain connected to their workers.

Many administrators and managers think they cannot be leaders and be connected to their workers. A frequent management ideology is that one must remain distant from their staff to produce the most objective form of management. In other words, remaining distant, aloof and uninvolved is frequently viewed as the necessary means for managing people in long-term care facilities. However, quite to the contrary, this can be a very hazardous management style to employ. It may not only lead to a more contentious work environment, but it may also lead to lower levels of productivity among the staff.

Connectivity does not necessarily mean that the administrator has to establish a buddy system. Connectivity means that there is a feeling by the workers that they are attached to the larger environment. Individuals with a sense of connectivity feel that they are productive members of the larger nursing home environment.

Feeling connected to something is very important. Studies have found that those that feel connected to their school excel at greater levels. Those connected to their community demonstrate lower levels of deviance and crime. And those connected to their workplace have lower levels of turnover and higher levels of job satisfaction. An important element of leadership is nurturing the connection of the workers to their work environment. However, administrators that are dictatorial, aloof and disconnected themselves create a fragmented environment.

Empathy and Connectivity

Empathy is an important emotion that helps to build feelings of connectivity. Empathy, contrary to sympathy, is an emotion that helps you feel what another person is feeling. Empathy is so fundamental that without it individuals can commit unthinkable behaviors.

However, it is also sometimes felt that empathy can be detrimental for sound administration. I have frequently heard many individuals say that in a higher management or administrative position you have to leave your empathy at the doorstep. The thinking here is that empathy will prevent an administrator or manager from successfully disciplining workers and making them work in a productive manner.

However, in reality, nothing could be further from the truth. Workers often want to feel that they are being understood. In a nursing facility, an administrator is often faced with many workers that will frequently want to have the administrator's ear. Coming off distant, aloof, uncaring and unfeeling can make workers feel that their concerns and feelings are not important. Empathy is an important emotion that helps administrators and managers connect with their workers, helping them understand what their employees are feeling.

Being an empathic administrator does not mean you will become "soft," unable to lead firmly and without conviction. However, it does mean that your leadership will be predicated upon a greater knowledge of your workers, and with it, a greater intersubjective understanding of your interaction as an administrator with those that you lead.

The Importance of Listening

Listening is a very important part of communication. All too often when communication is discussed the transmission of the message, especially verbally, is emphasized. Being a good listener helps to establish a connection with your workers. One of the most common complaints that workers in nursing care facilities have is that they are not being listened to by management.

When workers feel that they are being listened to, they feel a sense of connectivity. It should also be mentioned that productive listening skills are based on "active" listening, which is different than "passive" listening. Active listening leads to feedback and questions that are used. When an administrator, manager or regional director is listening to their workers and providing feedback as well as asking questions, workers feel a sense of connectivity. They are aware that the person they are interacting with is not only hearing them, but listening to them as well. They feel that the person who is actively listening to them is taking their entire "self" into consideration. This is quite different than the passive listener, who may just stare and hear what a person is saying, but is really not listening intently to the worker. Workers often are quite aware of these types of listeners and come away feeling disconnected and unappreciated, not only as workers, but as a person.

The Secure Base

Psychologists, especially those that study attachment, have known for some time that establishing a "secure base" is very important to feel a level of connectivity. Psychologists have studied the importance of creating a secure base in childhood, as well as in adulthood. This also applies to the workplace and in particular, the nursing home environment. Those that have a secure base feel a sense of security and trust.

This is very important, especially during these volatile economic times. However, workers that feel that their environment is fraught with insecurity will fear speaking or interacting with the administrator or other managers for fear of what it may lead to. The nursing home environment becomes one that individuals feel they need to tread very gingerly in due to the perception that management is disconnected and not caring about their workers.

Contrary to what most individuals have come to assume, nursing home management is predicated upon maintaining a strong level of connectivity. This attachment or connection to workers in the nursing home environment is critical. Workers that feel disconnected also will typically have lower levels of productivity, feel lower levels of job satisfaction, and experience higher turnover rates.

Workers need to feel that their concerns and feelings are being taken seriously, that they are being listened to, and that their environment is one that builds on feelings of trust and security. An uncaring and disconnected administrator or manager can lead to an environment that leaves the workers disconnected and subsequently uninvolved. When this happens it further spirals into a work environment that not only leads to worker dissatisfaction, but it also compromises the care that is so paramount to the nursing care facility.

Escalation of Commitment After Costs are Sunk

Brian Garavaglia — Mon, 22 Dec 2008 15:22:00 GMT

None of use like to loss on something. Having a financial, psychological or emotional investment in something makes it that much more difficult to walk away from. This is a common occurrence in the daily lives of many individuals. In health care the same issues are found. We make business investments and sometimes we get the business.

In long-term care this is often found. We make a decision, an investment ensues, and on many occasions the correct decision has been made. However, what happens when the decision is made, an investment ensues, and then it does not work out. How long do you stick with a decision and continue to add more costs to an already unsuccessful project?

First, we have to understand the concept of sunk costs. This is a cost that has already been incurred. Money has been invested in a project and this money cannot be brought back. So the cost is sunk. Therefore, with the cost being sunk your decision to continue a project needs to be based on what can be anticipated in the future. With a sunk cost, determining whether a decision needs to be made for a project to continue needs to be held in abeyance. Past costs or costs that have already been spent now become irrelevant to any future decision.

The decision now must be based on what costs will be incurred in the future versus what positive results from the project you anticipate receiving. The sunk cost becomes irrelevant for determining whether you want to continue with the project since what has been lost is no longer retrievable and your decision currently has to be focused on whether it is viable from this point on to continue with a project that will be viable.

It is always difficult to make a decision about whether a project should be discontinued when it is not currently doing well. However, many individuals muddle the decision by bringing sunk costs into play, which makes it even more difficult to determine what decision to make. When costs are sunk, for all intent and purposes they become irrelevant to your decision for the future.

However, this type of rational thought is easier said then done. One of the reasons is that we often have psychological and emotional costs tied to our financial costs. Therefore, even when we attempt to disengage from the material financial loss, it becomes quite difficult to also disengage from our psychological and emotional commitments that are associated with our sunk financial costs. As many who work in long-term care administration read this they can probably appreciate this predicament.

Because decisions in which financial investments have been made are also fueled by psychological and emotional investments, it becomes difficult to disengage from a failing proposition when the emotions of the person and the psychological needs of the person are involved with the decision. Long-term care administrators, wanting to justify their position and definitely not wanting to say they made an investment for naught will at times engage in the escalation of commitment phenomenon.

This leads many to continue to commit to a course of action, even when it is not successful, due to the sunk costs that have already been incurred. As we mentioned above, the determination of whether a course of action should be continued cannot take sunk costs into account since they already are spent and are no longer retrievable. Yet, with the escalation of commitment, individuals fail to look at the course of action based on future benefits minus costs, but on what has retroactively been already sunk into the project.

The psychological and emotional factors that are driving this phenomenon are great. Psychologically, not wanting to see oneself as leading a failed project and emotionally being closely tied to the project, as well as engaging in self-justification, where they are attempting to convince themselves that they made the correct decision are primary forces motivating many administrators to continue with the wrong course of action. All of us like to save face and in an attempt to not loss face, we escalate our commitments in the hope that they will finally pay off and achieve the goal that we set out to accomplish. However, we can see how this can be a pernicious thought pattern. Yet, how many of us have been caught in its grasp, where we attempted to save face and continue to escalate our commitment. Being wrong is hard to swallow and even more difficult to admit to others.

I hope that the person reading this has gained a better understanding of sunk cost and escalation of commitment. Both work hand-in-hand, and they can impact on the decisions that many long-term care administrators make. Financially, sunk costs are all too often factored into decisions regarding future investments. This can become imprudent for decision-making.

However, even more problematic is extricating the emotional and psychological investments that we incur in many courses of actions that we hold firm to in a stubborn, pertinacious manner. If we were robots, devoid of these processes, we could understand how we could extricate ourselves from sunk costs. However, because we are human beings, vested with these important processes, those who work with important business decisions, including those found in long-term care administration, have to be particularly sensitive to how these factors can lead to improperly engaging in an escalation of commitment.

We Still Have A long Way To Go

Brian Garavaglia — Wed, 19 Nov 2008 18:24:00 GMT

With all the changes that nursing homes have undergone during the last 20 years, we still have a considerable way to go. Even with nursing home reform that started slightly over 20 years ago, especially the movement to make the nursing home environment more homelike, the changes that have been introduced still have not eliminated the institutional setting that exists in nursing homes in the United States.

As I enter many nursing homes I have noticed different levels of accommodations. I have noticed nursing homes in communities that have higher socioeconomic levels having more resources and coming closer to many of the goals that the industry has set for the nursing home industry. However, at the other extreme, as I have toured nursing homes in lower socioeconomic level communities, and I have witnessed not only deprivation within the community but also within the nursing homes that are found in these communities. During our election year it sometimes makes me wonder that although we espouse democracy and equality, we still face considerable obstacles in perfecting these major concepts found outside as well as inside long-term care environments.

As I walk through many of these nursing care facilities I often wonder why there is so much inequality in resources and care found in these health care facilities. Sociologically, I have to say it intrigues me that the provision of care that exists in many long-term care facilities is predicated upon the deferential level of resources that is found from one long-term care facility to another. This interests me because it reflects many of the same inequalities that are found in our larger society. However, at the same time that it interests me as a researcher, it also saddens me to think that this type of inequality continues to exist at a time when it should not.

An interesting sidebar that exists is that we attempt to monitor and engage in regulatory oversight using the same standards for all nursing homes. However, how can we apply a universal regulatory standard to all nursing homes when there is such disparate features found among nursing care facilities in the United States. How can we apply the same standards to a long-term care facility that may have abundant levels of financial resources and say that the same standards should be applied and exist among nursing care facilities that have very few resources.

Often we attempt to delude ourselves so we fail to realize the harsh realities that continue to exist in our world. We do so at times to distance ourselves from the true reality and pain that we would come to feel if we were to let ourselves comprehend the complexity and less than humane circumstances we face in daily life. As we continue to deal with the harsh inequalities that are found in society, we have to come to realize that health care facilities, as institutions of society, face the same endemic problem.

Therefore, it should not come to surprise me, or anyone else for that matter, that the disparity that is found in long-term care facilities continue to exist. It should not surprise us that the ideals for a homelike environment are more closely found among certain facilities and far from it in others. Moreover, it should not surprise us that there is differentials in the type of care that is provided among nursing care facilities based on a large differential in the resources that they have available.

What should come to surprise, if not astonish us however, is that we continue to delude ourselves by thinking that many of these differences fail to exist. Furthermore, what should surprise us is that we as a society can employ the same standards for all nursing facilities, deluding ourselves into believing that they are all playing on a level playing field.

Not only do we have to recognize that the inequality of long-term care facilities mimics that found in larger society in general, but we also have to recognize that we cannot continue to employ universal regulatory standards to all nursing care facilities as if they were all equal. If we fail to recognize the great disparity in resources that is found in long-term care, or bury our heads in the sand and say that it is not financial resources that matter, but the personnel that exist in the facility, or say that oversight needs to be equal when that entities that are being overseen are not, we will fail to be able to further enhance our industry. As one can see we still have a long way to go.

Matching Residents to Facility Resources

Brian Garavaglia — Fri, 29 Aug 2008 14:41:00 GMT

It is no surprise to anyone who works in health care that census is always a critical issue for long-term care facilities. This especially is an important focus for many skilled nursing care facilities. As more assisted living facilities are now taking many residents that at one time was the purview of nursing facilities, many nursing facilities today are in competition for residents that are being more difficult to get to help bolster their census numbers. However, because census is such a driving force for nursing facilities, and since many facilities are in competition with many other nursing care facilities for the same residents, a common error often happens: Many facilities attempt to take anyone they can obtain in the referral process. This is a critical error than can come back to haunt the nursing facility.

A few principles need to be adhered to regardless of whether the facility is a for-profit or a not-for-profit facility. First, the facility must remember that they are there to service the resident to the best of their ability. The ethical principle of beneficence has to be always followed here. Although census is a key driving force for the sustenance of the facility, so to is following this important ethical principle of doing no harm to help further the resident and their health status. Taking residents that you cannot support with the skill level of your facility is unethical and inappropriate.

Another major principle that follows from this is that the administrator and other administrative personnel such as the director of nursing, have to know their staff, the knowledge capital that is found in their facility, and the supplies and other supportive factors that will enhance their ability to provide the appropriate level of care. For instance, if a person comes in with a significant level of wound care that is needed as well as a wound vac, and your facility fails to have a sound wound care personnel that can address this issue, your facility can face great liability in this area. When you admit a resident it is implied understanding that you have reviewed the case and feel comfortable with the ability to care for the resident's needs.

Revenue is very important on the business or administrative level in long-term care. However, this often is at variance with sound clinical judgment on taking a resident. Another important principle that needs to exist is never let your bottom line business mentality become so myopic that it clouds your ability to see the larger context of the resident care environment. Many individuals will often try to close the sale of a resident, similar to that of a car sales person. A sales or marketing plan in long-term care is always dealing with human beings and not inanimate widgets.

Making sure the proper people, skills, accoutrements and such are in place all need to be considered. Admissions decisions are too often driven from a purely business point of view-how can we increase our census and with it, our revenue. Administrators and other nursing home administrative personnel who manage on this level often fail to understand that management happens within a larger context, both internal to the facility and external to the facility, and both factors have to be considered in the larger context of appropriate resident to facility fit.

Quality care and resident population stability is driven by making sure that the resident to facility fit is appropriate and conducive for not only the resident, but also the staff. If the resident has care issues that exceed the facilities resources it can be quite problematic. On one level it may actually be so expensive to care for such residents that the bed that they are occupying, nevertheless, is causing the facility to incur a tremendous financial hardship. Furthermore, the clinical complexity of the resident may actually outstrip the knowledge capital and resources in the facility.

However, more often than not, the staff feels the pressure and stresses of not having the appropriate skills to care for residents that are not a proper fit with the skill level of the facility. Take for instance a nursing facility that chooses to admit more residents with psychiatric issues that many nurses, or physicians, may not feel comfortable with in treating since they have not worked with this type of clientele before, or very sparingly. Can nurses and certified nurse assistants be trained to address the unique concerns that some of these residents have? Yes, but remember there is a learning curve. Is it fair to say to improve our census we will take more individuals with behavior problems even though our staff is not comfortably trained with this type of resident. Definitely not! Not only is it not serving the resident well, but having staff work in apprehension because they know their skills are not appropriate to care for these types of residents on a wider scale will often lead to errors and poorer levels of care.

Furthermore, it is a hardship for many residents. They need to feel comfortable with the facility and skill level of those that take care of them. Residents and family members often become cognizant of a facility and staff that lack the skills to appropriately address the resident care issues. Not only does this taint the reputation of the facility, but the legal liability that exists here can be quite costly.

A final principle that needs to be stated is that quality is the driving force for nursing care facilities. Although everyone is looking for a quick fix to their census problems, quality drives census in a number of areas. Understanding your facility's capabilities shapes quality. Tailoring your residents to the fit of your facility shapes quality. These in turn lead to a facility having a strong reputation in the community. The reputation of the facility leads to census development. However, the leaders of the facility have to be realistic about what their capabilities are and where their strengths lie. Exploiting the strengths of the facility will lead to better quality of care, which subsequently leads to a strong reputation and better census growth and stability. Conversely, one has to also understand their weaknesses. All facilities have weaknesses, yet attempting to enhance their census be admitting residents that fall into these areas of weakness is a recipe for disaster.

It is a categorical imperative that nursing care facilities understand the importance of matching residents to the facility's strengths and therefore proper facility fit. If you find yourself saying that "I think we can take care of this resident," this often is a sign of attempting to place a round block in a square peg. If the fit fails to exist and you are not able to knowingly and adequately address the resident's needs, then you need to be conscious of this and let that resident be admitted to a facility that is more able to do so. Just because many skilled nursing home are called ‘skilled," does not mean the same skill level exists in all facilities. Skill is not a constant, but is a variable that has to be closely monitored to provide appropriate and quality resident care. Continuing to view census myopically, viewing just the numbers and failing to understand the larger qualitative context of the resident to facility fit is often a major error that is learned by many the hard way.

Can Apples & Oranges Be Compared?

Brian Garavaglia — Mon, 30 Jun 2008 14:20:00 GMT

The Bush administration advocated the need to rate nursing homes on a similar ranking system to that found in the hotel and restaurant industry. At first blush this seems an intuitively simple and consumer friendly system. Why not have consumers that are looking to place their loved ones in nursing homes have a simple system of one through five stars to help with their search. It appears to be a completely simple and adequate system that can be put in place quickly to assist the public with nursing home quality. However, remember when your algebra teacher said you cannot add apples and oranges? Can the rules be overlooked here? Can nursing homes be ranked similarly to hotels and restaurants? I think this question begs further consideration.

Currently there are a number of tools that are used to rank nursing homes. Probably the best known is the Medicare site that compares nursing homes on the basis of their number and type of citations. The information for this site is compiled from surveys of nursing homes conducted by surveyors. Yet, what is known about the system as it exists is it is far from perfect. In fact, there is a considerable level of subjectivity that is found in the survey process. Surveyors often make judgments about facilities prior to entering the facility. Furthermore, there is considerable variation from one surveyor to another as well as from one survey team as compared to another. In addition, states demonstrate a considerable level of variation among their surveyors. Surveys and the level of stringency found to exist in the survey process from one state to another differ considerably. Therefore, the system as a whole is filled with considerable variability that often is difficult to account for and would dramatically influence a supposed standardized rating system.

Another problem that exists is that hotels and restaurants do not have to rely on Medicare and Medicaid funding, or other third party funding, as do most nursing care facilities. Consumers in these other industries often pay up front with a fee set by the establishments. This allows hotels and restaurants to know their revenues and cash flows up front. However, in the nursing home industry, state and federal entities and third party insurance regulations place great restrictions on what earnings are actually realized. Most nursing homes operate on very small margins and therefore, many fail to have the funds to engage in extensive renovations as well as have the comfort to pay out large amounts of money for extensive and specialized staffing. In fact, there is also considerable statistical variability between nursing homes and the companies that own them, with larger companies often able to incur much greater capital expenditures to achieve the homelike environment that many seek.

So you may ask, what does all of this have to do with ranking nursing homes? As I hope has been illustrated so far, the complexity for a simple rating system is simply, not that simple. Even with hotels and restaurants, this simple five star system is not so simple. First, how many of us have been in supposed five star restaurants and hotels, only to come away quite disappointed in the food or service we encountered. Also, how many of us have come away saying that I wish I would have went instead to the smaller community restaurant or hotel where I get better quality and more food to eat for the money or better and higher quality customer service.

Yet, these hotels and restaurants, which are smaller and less spacious, are often viewed as the red-headed stepchild of the hotel and restaurant industry, especially when compared with their four and five star competitors. The same holds true for the nursing home industry, where the commodious environment of new, modernized, and large-scale facilities hold a primacy effect on those that rate these facilities.

For a true nursing home rating system to work, the rating system must be multifaceted and use many different indices for measurement. If the rating system is only going to be based on facility survey results, a less than true picture of the facilities that are being rated will result. This is not to say survey results should not be used. For sure survey results are an important indicator of the health of a nursing home facility. However, as was mentioned above, it does have its flaws and our current survey system, which has improved over the pre-OBRA years, is still predominately a subjective system. So with the subjective nature of the survey process, coupled with considerable differences found among state survey agencies as it relates to the level of nursing home survey stringency, other factors have to be considered in ranking nursing homes.

One important consideration is the type of people working in the facility and not just the number. Often, facilities are examined for having an adequate number of staff to residents. However, the quality of the staff is also important. What is the level of training, years experience, education, and level of specialization found among nursing home staff. Just as hospitals are viewed as progressive environments, predicated on the quality of their staff, so to should nursing care facilities be examined in the same manner.

In addition, how does acuity play a role in rating nursing homes? For instance, a facility that provides more extensive and intensive services such as bariatric care, dialysis, or ventilator care often have more critical residents with concerns that are more easily targeted during the survey process. However, they also typically have a clinical skill base that is higher as well. This also needs to be factored into the rating system of any nursing facility.

Moreover, is the nursing care facility a learning, teaching and training environment? Is it a place for training physicians, nurses or other long-term care professionals? Is research conducted among individuals within the long-term care environment? Is it a progressive environment that explores new strategies and techniques, especially toward advancing the care of long-term care residents? Many at this point may be saying you have to be kidding; these are nursing homes and not hospitals. However, many long-term care environments are now involved in many of these areas as well.

There can be more that can be targeted in creating a nursing home rating system with greater levels of legitimacy to help assist consumer knowledge in this area. However, just using survey results is not enough and I hope I was able to emphasize the importance in creating a multifaceted rating scale for nursing homes. Furthermore, I hope I was able to demonstrate that creating a rating system for nursing homes, based on and similar to the one used in the hotel and restaurant industry, would be very difficult. These industries are apples and oranges, and as your elementary algebra teacher explained to you early on, apples and oranges cannot be added together.

That being said, a system of rating nursing homes can be created, however in doing so one cannot create a valid system that is overly simplistic and based on a one-dimensional scale of measurement. It must be a system that adequately captures and reflects the complexity of the long-term care environment. Because of the complexity of the systemic nature of long-term care environments, capturing the complexity in creating a valid rating instrument for measuring nursing homes will be more difficult than for rating hotels and restaurants.

For more information: New Rating System in the Works for Nursing Homes

The Social and Economic Impact of Census and Resident Mix in Long-term Care

Brian Garavaglia — Wed, 30 Jan 2008 21:01:00 GMT

The long-term care landscape has changed and will continue to change. One of the greatest changes that have been found in long-term care is in census, or the residents that are found in long-term care, often referred to as resident mix. As census has changed, so has the social and economic impact found in long-term care, and the implications in this area will continue in upcoming years. Therefore, some of these important changes will be examined to highlight the myriad of social and economic factors that are involved in census change.

Census has always been a driving force for maintaining a financially viable facility. Furthermore, administrators are always examining revenue, expenses, cost control measures, RUG score utilization, and reimbursement rates for Medicaid, Medicare, and third party insurers to find where their facility stands at any given period of time financially, and to understand how the economic landscape will influence their facility in the future. Census and occupancy rates have always been one of the first things that are examined. Moreover, traditionally nursing care facilities were driven by a census and demographic profile that was typically made up of those over 65 years of age. For the most part, a great deal of this population still exists, but change is happening and will continue to happen for long-term care facilities.

Although seventy percent of nursing care reimbursement comes from Medicaid, in years past this was almost an exclusive reimbursement for those elderly that needed continued nursing home care and exhausted the rest of their financial resources. However, today the demographic profile of many nursing care facilities has shifted and more members of the younger population have now entered the resident mix in nursing homes. There is an economic exchange here that has also happened, which has led to a net financial loss in many instances. Not only are older adult Medicaid recipients being replaced by younger Medicaid recipients, older adults often come to the facility with Medicare after a qualifying hospital stay where younger individuals, many of whom are poor, come to the facility with no Medicare or private third party insurance prior to being established on Medicaid. So the net result is not a one-to-one redistribution, but a financial loss of Medicare or other third party payment that often is part of the early stay for many older adults.

As demonstrated above, one can see how social changes in census can have a powerful impact on the economic factors found in the nursing home industry, and in particular, on the financial climate of any one nursing care facility. Also, some long-term care facilities have attempted to place themselves into a rehabilitation niche, to take advantage of short-term rehabilitation and extend themselves as post-acute care facilities. For some this has worked, capitalizing a both a younger and older adult population that will come to them with Medicare or very good third party reimbursement. However, for many facilities, and in particular many inner-city or rural area nursing homes, facilities that are often older and are reliant on hospitals providing them with poor older and younger residents, the social changes in census have a powerful impact on the financial status of these facilities.

Many of these facilities are unable to take advantage of better financial resources that certain residents in suburban facilities have at their advantage. When this is coupled with older buildings that have greater primary and preventative maintenance costs and a higher percentage of Medicaid to Medicare/private insurance residents, it should be clearly understood why many of these nursing care facilities are very financially strapped.

However, even the suburban nursing care facilities are starting to feel the economic impact of the social changes in census. Because the nursing care environment is quite competitive, with many facilities competing over the same residents, and since any empty bed is a major cost for the facility, many suburban facilities are also now taking younger residents, something that they often would not have done in the past. As the competitive market for Medicare and private third party payers has increased, concomitantly with the need for some level of cash flow to cover those empty beds and also forestall further reductions in Medicaid payments for not being at a certain census, many facilities now need to accommodate to the new resident mix that is found in their census.

As the mean age of many nursing care facility’s census has been reduced with the addition of younger members, the economic impact of dealing with a more diverse age population with often markedly different clinical profiles also needs to be considered. Accommodating the needs and acuity levels of all age groups with the level of heterogeneity that is presented in a facility can lead to heightened costs for staffing, training, supplies, therapeutic invention and medications, just to name a few. This, mixed with many states having to make budget cuts that can affect the reimbursement rates for Medicaid, can lead to a very problematic financial situation for nursing homes. Regardless of facing strict cost control measures, it is often easy for the needs of a heterogeneous age-based nursing home population to grossly extend their costs that far and exceed the ability to even break even.

Today’s nursing homes are no longer the old-age homes of the past. Variability in services rendered, age of the population, types of issues that are found among the census of residents, as well as even the type of staff who exist in long-term care, are quite different. Many long-term care facilities are now an extension of the acute care hospital environment, offering heterogeneous resident mixes, shorter stays, with greater levels of acuity and rehabilitation needs. Furthermore, even those that are unable to take advantage of positioning themselves as a post-acute care facility still have to address the needs of a younger population with wants and desires that they are still going to have to accommodate. Therefore, the social changes of our nursing home environment are driving many of the economic and financial features that are found in the industry.

In many ways our state and federal governments need to also become increasingly aware of how the social impact in the nursing home environment drives our industry’s economic changes. When we look at the greater variability found in the nursing home census of today, attempting to subsidize a population just based on apples, when in reality apples and oranges exist, leads to an unmistakable error in financial reasoning. As the social forces propelling this change continue to become more marked over the upcoming years, advocates in the field of long-term care as well as state and federal government officials will have to determine whether they would like to fund for quality or mediocrity. Please share your thoughts.

Hot Button Topic: Is the Type of Nursing Home Ownership Important?

Brian Garavaglia — Tue, 22 Jan 2008 15:27:00 GMT

A recent September 2007 New York Times article entitled, At Many Homes, More Profit and Less Nursing, discussed the issue of profit and ownership, especially by private equity firms. This article especially was quite critical of many companies that reduce important nursing staff to enhance their profits. For those nursing homes, especially those owned by companies that know little, if anything, about health care, this can become a very important problem.

However, the reality is that although the nursing home industry is one of the most regulated industries in the United States, with a plethora of state and federal regulations that govern the daily operations of nursing care facilities, there are very little regulatory requirements for those who want to get involved in ownership of long-term care facilities. Because of this, many soon-to-be-owners enter the industry to obtain a bottom-line profit, coming from numerous areas and professions with little understanding of the nursing home industry and the regulatory requirements that govern this industry.

For the administrator this can be quite disconcerting. As a person that has to not only understand the financial situation of the nursing care facility, but also hold the responsibility for making their nursing home attain quality care standards toward servicing their residents, administrators are often placed into a bind of attempting to minimize costs, enhance their revenue, and still provide sound care. The resounding impact of the New York Times article was felt back on capital hill where our country’s legislators have started to talk about investigating this issue further.

However, should we be so surprised that these problems exist in the nursing home industry, especially when private equity firms and other group investors who become involved in the long-term care industry think doing business and closing sales in health care is similar to that found in the retail or restaurant industry. Moreover, administrators and other long-term care staff often face conflict between what they know is correct and best practice in servicing the nursing home population while at the same time having to address the myopic bottom-line concerns of many owners who want to maximize their profit.

Last year, Consumer Reports found that not-for-profit nursing homes often service the nursing home population better than for-profit nursing homes. Furthermore, independent nursing homes have been found to provide superior care than larger chain-owned nursing care centers. However, this is not news that is new. Numerous studies have found similar results. In reality this makes a great deal of sense. Nursing homes were never meant to be profit centers, leading investors to maximize their returns. The very nature of these health care facilities have been built around servicing frail and infirm individuals that often need extended care or extended levels of rehabilitation.

Also, by placing individuals who know very little about health care in high authority positions with values that dictate profit at the expense of quality care, an inherent contradiction is now in place that in turn creates potentially harmful consequences as reducing nursing staff as was found in the New York Times article.

The major dilemma that results is when the capitalistic business values of our society collide with the values of our health care sector. Health care deals with human lives and not selling widgets. Reducing costs through eliminating staff, supplies, or key positions within nursing homes are not the same as doing so within a retail sector that does not deal explicitly with sick, ill, and frail patients. The variable costs dealing with the types and levels of acuity of residents that nursing home’s service cannot or should not be equated with the fixed volume of inventory found on car lots. Furthermore, nursing homes, the acuity of the residents they serve, and the number of skilled personnel that they must have, can change dramatically on a daily basis, which is something that is typically not found in other business sectors. This in turn leads to volatility in variable cost factors in long-term care that is not typically found in non-health care sectors.

Given all that has been mentioned, the reader should not interpret that nursing home administrators should fail to be adroit health care administrators. They need to reduce unnecessary costs and enhance their revenue if possible. However, this should never be at the expense of the care that is provided to residents. Streamlining the business environment in nursing homes aimed toward achieving greater efficiency is still as important as it is in other types of business.

Yet, since nursing homes deal with human lives that often need to be serviced to a considerable level, the business environment of nursing homes is also quite different than the traditional business environment. Cutting costs become more difficult when the acuity of resident care is raised considerably. Companies or owners that get involved in nursing home care failing to understand this unique feature of the nursing home industry are bound to fail. Furthermore, the types of cost control that they may institute, similar to the types of control that they have instituted in other business sectors, could lead to deleterious results when applied to patient care.

Therefore, how does the administrator, who may be sandwiched by the company advocating bottom-line profit and strong operating margins versus providing for the needs of their residents even at the expense of reducing profits reconcile this very difficult dilemma? It becomes a source of ethics. As mentioned previously, the administrator is always entrusted with understanding the larger picture of the nursing care facility that they oversee.

The administrator should never just see himself or herself as a businessperson, but hold firm to viewing their primary role as the chief advocate of the residents they serve. This may not always be a comfortable fit with those who run the company, but reconciliation should never mean compromising the integrity and ethics of the administrator. Good businesses and good business people will recognize that, not just in words of mouth, but also manifest through their behavior.

As Edwards Deming preached, if you focus on servicing customers, or in this case residents, achieving positive bottom line results will come, but they should never be the end in themselves. Unfortunately, as brought to the attention of the American public by the New York Times, too many companies in nursing home care today are uncompromisingly and myopically focused on the bottom-line profit margin at the expense of care.

In conclusion, nursing homes were never meant to be major areas of investment but providers of an important type of health care. It should also be mentioned that there are some very good companies and nursing care facilities that have a firm understanding of their values and the reasons they are involved in the practice of nursing care.

However, as has been mentioned in this article and in the New York Times expose, there are also some that have questionable values that need to be re-examined. Nursing home administrators have to take a clear stance at demonstrating the roles and values that should be emblematic in nursing home care. They are more than just business administrators, but health care administrators vested with the responsibility of protecting and advocating for the sick and infirm they ultimately service.

Root Cause Analysis as a Process, Part 3

Brian Garavaglia — Thu, 20 Dec 2007 19:58:00 GMT

In the first two parts of this series, I expounded upon the need to develop a sound problem statement and to understand and not be misled by terms such as facts, validity and truth often used superficially in examining issues. In the third part of this series, a discussion on the process of root-cause analysis will follow. The key term here is process. Root-cause analysis is not a static or compartmentalized element, it is a dynamic process that looks to define the problem, search the data, analyze the data and come up with solutions to deal with a current issue and hopefully forestall future issues. Therefore, as was mentioned earlier in the series, it is a process that needs to be practiced toward developing sound analytical skills, which aid in narrowing down and specifically targeting the problem.

Anderson and Fagerhaug write that the process of root-cause analysis should focus on seven major areas: Problem understanding, problem brainstorming, data collection, data analysis, identification of root cause, eliminating the problem and implementing a solution. Notice that they also agree that one needs to start off with a well-developed understanding of the problem. Also notice that root-cause analysis is typically based on the group, brainstorming ideas, many of which may go unnoticed if a single person is involved exclusively in the problem solving approach. This is important because on a sociological and social-psychological level, studies have demonstrated that bringing people together often helps to generate ideas that they would not have developed in exclusivity.

Following the brainstorming period data collection, data analysis, and root-cause identification should ensue. However, it must be emphasized again that appropriate data collection, sound data analysis, and subsequently a targeted root cause is only as good as the problem statement that has been formulated. If you start off with the wrong problem, no matter how good your data collection, analysis and identification is, it will be all for naught. As was mentioned in the first series, a clearly identified problem drives everything that follows. Therefore, it will determine what data you collect, the analysis that you use, and the identification that follows. If you determined that problem X is the issue, when it is really problems Y or Z, the data, analysis and identification will become futile procedural elements that have not aided your endeavor in finding the truth, and ultimately the cause, associated with a particular issue.

Finally, as the process continues, root-cause analysis looks at more than just identifying the cause, but also eliminating the problem and instituting a well developed solution to 1) deal with the current issue and 2) prevent future issues of a similar nature. The process also should not be viewed as a perfectly fluid process with no glitches. Because it is analytical and deals with individuals as a group looking to add ideas toward finding cause and ameliorating the particular issue, there are often many hills to climb among the group members.

A question often arises about what type of analysis should be employed. The answer to this question is that there is no one correct type. There are two major types of analyses that are often employed: quantitative analyses based on numbers, statistics and mathematical equations and qualitative analyses based on non-numerical data analysis. Neither is necessarily superior to the other, and skilled practitioners will often determine the analytical tool based on the problem and the type of data collected. There are literally hundreds of techniques for both qualitative and quantitative data analysis that can be used. However, due to the brevity of this article, none will be covered. This needs to be reserved for a more thorough discussion of data analysis. But, it should help to illustrate the complexity of root-cause analysis; a process that due to its complexity cannot be entered in a hasty and unpracticed manner.

In the third part of this series I covered many of the steps that are involved in the process of root-cause analysis. It is an iterative process that is shaped by those involved in the process and by the type of problems that are being addressed. Moreover, it is an analytical process that is highly useful to those in long-term care, which can help target and address problems in a constructive manner. However, it must be stated that many problems are quite multi-dimensional and for some of these problems finding the cause is not always feasible. Therefore the term root-cause analysis in itself can be misleading, with the reader thinking that if they followed the appropriate algorithm, a cause will always be ascertained. It is because of this that a final installation on root-cause analysis will be written to explain why correlation, and not causation, is at times the best we can hope for in solving very complex issues that arise in long-term care. I look forward to any comments you may have.

Reference

Anderson, B. & Fagerhaug, T. (2006). Root cause analysis-Simplified tools and Techniques. Milwaukee, ASQ Quality Press.

Root Cause Analysis—Facts, Validity, Truth, and Consequences, Part 2

Brian Garavaglia — Thu, 20 Dec 2007 19:54:00 GMT

In part one, the emphasis was on attempting to make sure that a problem was adequately and soundly delineated before root-cause analysis is implemented. In part two, examining the illusory concepts of facts, validity and truth will be examined. Here again, just as with the problem statement, individuals often take these concepts for granted. But again, as with the problem statement, these apparently simple concepts often hold a considerable level of complexity that is often not understood. It is that which we will concern ourselves in the next few paragraphs.

Frequently not just in long-term care, but in many areas of life, I will hear people say, "you cannot dispute it; it is fact." Many often think that fact is tantamount to truth. However this is far from true. A fact is something that exists, but facts do not hold anything inherent in them that make them true or false. Let us use a few examples from the typical long-term care environment to further illustrate what is being stated. In the first scenario resident Jane Doe has an ulcer on her leg, but does that mean the staff has not provided good, sound care?

Quite possibly this could be true but it could also be false. The fact that exists is that she has acquired an ulcer on her leg that measures 3 centimeters by 2 centimeters and has been staged as a stage III ulcer. That is the only fact that we know at this time. Although decubiti are often associated with poor care, anything that extends beyond the facts just mentioned is speculation. Upon further examination Ms. Jane Doe is turned every two hours, gets frequent skin message from the staff and has excellent care provided to her. However, her diabetic and cardiovascular condition has led to an unavoidable stasis ulcer that is due to the severe vascular occlusions found in her peripheries. Here the fact is that she acquired an ulcer. Is the ulcer due to poor care? Other facts have to be ascertained. In this example she 1) had very good care and 2) had physical conditions that led to an unavoidable occurrence.

Scenario two deals with an administrator who gets a call and is informed by the president of the company that his operating margin for the month is a negative 19 percent! The administrator says that this cannot be true and that his numbers show that his operating margin was a positive 15 percent. The president adamantly says that the accounting facts show this is not the case and that he must demonstrate dramatic improvement in the next month or else. The administrator goes back and checks the financial data that he has and compares it with the financial data that the president had and he finds out that there is $200,000 instead of $20,000 in entries that were not coded properly to wage expenses, including his director of nursing who had an erroneous monthly wage expense posting of $100,000. As one can see the facts on paper existed, but they did not reflect the true reality.

Often facts do not reflect the true reality of a situation. In both of the situations above, a root cause analysis had to be employed to determine further facts. Moreover in both cases the analysis found other facts that countered the abrupt and often quick attributions that others made regarding the initial set of facts. Furthermore, at times people will mistakenly use the concept of validity to buttress their conclusions about a particular finding. In reality validity only means that the extrapolation of the data fits with the initial problem or premise that was formed. For instance, here is an example of something that has validity, but does not demonstrate any truth.

All dogs have three legs,

Lassie is a dog,

Therefore Lassie has three legs.

This is a perfectly valid argument that is logically sound, but due to the initial premise that was incorrect, so was the final conclusion. Or using a long-term care example:

All skin ulcers are the result of poor care,

Jane Doe has an ulcer,

Therefore Jane had poor care.

Again, this is a perfectly valid argument that is logically sound, but again, due to the initial premise, is totally incorrect for Jane Doe. Jane had very good care as we mentioned. If one read Part I of the series, you will remember how important it is to have a well defined problem and look at many alternatives in formulating a sound problem statement. A well thought out and structured problem is the driving force behind sound implementation of finding cause.

I hope part two was able to convey the importance of failing to fall into the trap of semantics that often leads to illusory assumptions. Facts and validity do not necessarily guarantee truth. Yet, the power behind these words often makes individuals assume truth and reality without checking further and determining whether truth and cause is actually being captured. Long-term care practitioners often hear these terms and take them for granted. However, as has been demonstrated, taking them for granted can lead to a path of erroneous root cause analysis. Please share any thoughts you may have.

Root Cause Analysis—Starting Out With A Problem, Part I

Brian Garavaglia — Tue, 11 Dec 2007 21:26:00 GMT

Nursing care facilities are faced with a myriad of problems daily. In addition, solving problems in nursing care facilities is often far from simple solutions. However, those that work in long-term care administration have often heard of the phrase-looking for the root cause. Its use in long-term care has often become cliché. This in turn has led to root cause analysis often viewed as an easy approach that can be used in a cursory manner to find solutions to problems that arise in the nursing care center. However, finding a cause is often predicated on identifying the problem. It is at this very early stage of problem identification, in which the problem is poorly defined, that root cause analysis goes awry, leading to failure in finding a cause or solution to a problem.

Often individuals are so enamored toward finding a cause that the cause becomes their ultimate goal. Although this is not a problem in itself, the problem exists when one puts the cart before the horse. Many will fail to miss the most important starting point-identifying and defining the problem clearly. This sounds quite simple, yet problem definition and clarification is often quite difficult and entered into often too cursory. In working with students and workers alike I have found that it is often very difficult for them to define the problem, and when the contextual nature of the problem becomes more complex, the difficulty in clearly delineating the problem becomes compounded. In looking for cause one of the biggest mistakes people make is taking problem formulation and development too lightly.

The reason that identifying the problem clearly and accurately is so important is that it drives everything else that follows. Without a clearly stated problem you become a ship sailing without a particular destination; a ship that may touch many ports and areas of land without ever knowing if the port that you have entered or the land that you touched is the correct point of destination. As Chaffee (2004) stated, "The first step in solving problems is to determine exactly what the central issues of the problem are. If you do not clearly understand what the problem really is, then your chances of solving it are considerably reduced"(p. 87).

As health care professionals we face a panoply of issues with graded complexity as well as different levels of urgency. However one has to always be sure that the problems that we are struggling to solve are actually the problems that are the issues. Problem identification is the first step toward finding the cause of any issue, yet we have often been taught to define problems is a hasty, ambiguous, and often very generalized fashion. Furthermore, we have come to accept ill-structured problem statements without challenge, whether it is from political candidates, bosses, or experts in other areas giving their opinions on topics they know very little about. Moreover, a well-defined problem is more than just an opinion, but a structured, analytical premise that has examined alternatives, and with it leads to a well-grounded starting point for continued investigation and analysis.

One does not have to be a seasoned scientist to determine root cause, but one does have to be a seasoned practitioner who exercises their skills regularly in this area. Root cause analysis is a skill that needs to be learned and practiced. It is more than just asking questions, but asking the correct questions, look at pertinent alternatives, and developing a clear problem that will hopefully lead toward finding the ultimate cause to a particular issue. In upcoming postings I will look at this issue further in parts II and III. Feel free to offer any feedback that you have on this topic.

Reference

Chaffee, J. (2004). Thinking critically-A concise guide. Houghton Mifflin Company, Boston.