Shaping the Future: Melissa Purvis on Long-Term Care Leadership

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Melissa Purvis, a registered nurse, certified gerontological nurse, and nursing home administrator, who currently serves as VP of Program and Policy Development for Saber Healthcare Group.

Melissa reflects on her career in long-term care and argues that strong leadership and investing in staff are central to better resident care and improved retention. She discusses how COVID-19, expanding regulations, and emerging tools like AI are shaping nursing homes, and shares advice for new nurses while calling for a less punitive, more improvement-focused survey approach.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-090426-GK

Transcript

Copy Transcript Copied

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hi, everyone. Welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director at Quality Insights. Today, I'm joined by a leader who has spent her career helping shape the future of long-term care. Melissa Purvis is a registered nurse, certified gerontological nurse, nursing home administrator, and she currently serves as vice president of program and policy development for Sabre Healthcare, which is one of the nation's largest long-term care providers. Throughout her career, Melissa has worked at the intersection of clinical care, operations, quality improvement, and policy development, helping organizations navigate some of the most challenging and transformative periods in long-term care history. I will say, as someone who has been in it myself, this has been such a challenging 10-year period. I've never seen anything like it in my life, and I'm sure Melissa feels the same, as we're gonna be talking about during our conversation. From workforce shortages and regulatory pressures to the lasting effects of the COVID-19 pandemic, Melissa has had a front-row seat to the evolving landscape of nursing homes and post-acute care. Her experience provides a unique perspective on what it takes to support residents, families, caregivers, and healthcare leaders in an increasingly complex environment. And, and I will say, I feel like long-term care is... has a unique place in our healthcare system, and it it's only as strong as the weakest link, so we really have to focus on long-term care if we want to strengthen healthcare overall in this country. Today, we're gonna be talking about the current state of long-term care, the realities of staffing and regulation, the role of emergence tech- emerging technologies like AI, what they may play in the future, and where she believes the industry is headed over the next five years. We're also gonna be hearing her advice for the next generation of nurses I am very excited about that part of this conversation, and we're gonna be hearing what changes she would make if she had the opportunity to reshape healthcare. Melissa, I am really excited for this conversation. Thanks so much for joining me today. Thanks for having me, Jean. I'm pretty excited myself. So as I mentioned, you're a registered nurse, you're a certified gerontological nurse, you're an administrator, and now you're vice president of program and policy for SABR. Just a tremendous amount of training and background and experience. What first drew you to caring for older adults and what were the key moments that shaped your career into the leadership role you hold today? I think just this one question, Jean, could take the entire podcast, but I'll try to be as brief as I can. I've been doing this a really long time. But if I start at the beginning, I was working as a new nurse in a hospital in Boston in the mid-1980s, don't do the math, and getting admissions from the local nursing home. and they came in with pressure injuries, most people think of those as bedsores. They were disheveled, sometimes malnourished, and thinking how awful that nursing home must be, like it had this reputation for being terrible. Um, it was very close by to the hospital where I worked. So interestingly enough, within a year or two of that, I had the opportunity to actually work in that very nursing home. My friend started a nursing agency and convinced me to go in there and being super- be a supervisor for her. And what I discovered was a staff that really no one had invested any time in. They were very thirsty for knowledge really weren't getting much respect, weren't really getting any attention, and just any little bit of acknowledgement of their hard work. And I also saw an administrative team that was disengaged and unapproachable, and that's always a recipe for disaster, so in other words, a broken and unjust culture. So if you fast-forward a few years, I was then married with a young child and had moved to a different state and was looking for some flexibility in my work life that I just couldn't get from the local hospital, so I went back to nursing homes again. I went to the local nursing home where their scheduling was more creative, for my needs at the time. I started, like most people, as a supervisor and a floor nurse, and within a couple of years I was actually hired as a director of nursing, and I never left the field from that point on. So almost my entire career, other than the first four or five years spent in a hospital, I've been in skilled nursing. And I loved then, as I do now, the camaraderie and the opportunity to help employees grow, particularly within the nursing field. I was lucky enough to open two new facilities from construction onward, which is a rare opportunity, and talk about work, but you do have the opportunity to lead the culture, shape the child as it is, into your shared vision with your staff. And I'm happy to say that both of those nursing homes still have outstanding reputations decades later, and I like to think I played some small part in laying a sort of an unbreakable foundation in both of them. And from there it was what you would kind of expect. I worked as administrator some, but my heart really has always been in nursing, so over time I rose to become a chief nursing officer and have had related roles ever since. And from the beginning until now, it's the same driver. I just wanna help other people, and I think a lot of nurses say that. I want to assist them to be the best caregivers and the best leaders that they can be, and they in turn then become stronger caregivers and mentors, and on the cycle goes, I hope. Yes. And it definitely sounds like you are where you are supposed to be. You found your purpose in life. It certainly feels that way to me. I mean, I've spent really almost my entire career doing this, and I really do love it. It has been, a, a tremendous amount of work and, like you said, many, many challenges over the decades, but it has improved so much. I believe nursing home care has improved tremendously over those decades, and I, and I look forward to seeing further improvement as we move ahead. Yes. I mentioned staffing i- in the introduction, and it continues to be the most discussed challenges in long-term care. I've read a statistic that, like, 99% of nursing homes in the United States are facing challenges with staffing. From your perspective, what does the staffing environment look like today compared to five years ago, and what strategies are actually working to recruit and retain great caregivers? I mean, probably right now our staffing challenges look about the same as they did five years ago, but there was a big, huge bump in the middle, right? That COVID bump. But the owner of our company said something in a leadership meeting when I very first joined the company that I really agreed with, and he said, "If you're having staffing problems, look in the mirror." And what he meant was you aren't being the leader or the employer that people want or need, so they're just gonna move on. And I really could not agree with that sentiment more. Of course, it was much tougher during COVID, especially with all the negative media coverage, you know, that tried to lay COVID at the doorstep of nursing homes. But even then, strong leaders with strong cultures were able to keep away from using contract labor in their homes. They were right there side by side with their caregivers working through it all. I have a very dear nurse friend who I met 30-plus years ago working in a nursing home in Connecticut who was herself a director of nursing during those first few years of COVID and in a memory care facility, so lots of challenges involved with that. And she is very proud, and should be, of the fact that they never had one COVID-positive resident in several years. So that is amazing and a testament to the power of personal commitment, steadfastly following processes, and modeling the excellence that you expect from others. And I think that is the recipe for success always where staffing comes in. Invest in your staff, and I think we do that really strongly in the company that I work for now. We have countless avenues for staff to grow professionally. And they're as informal as on-demand web content, for instance, to learn new skills like a software program or some basic management techniques, all the way to fully funding BSN and MSN degrees for our directors of nursing, and programs every room in between. We have scholarships, partnerships with states, partnerships with schools and colleges let's see, internships. The... We have a very broad list of offerings. And we see the commitment that is returned to us as an organization when we invest in that way in our staff. Happy and engaged staff mean happy and engaged residents. I've always believed it. I've always found it to be true. Residents will not ever get good care without a caring and engaged staff, and that comes from leadership. Yes. Yes I wholeheartedly agree and have talked to many individuals, uh, who feel the same way. M- we met because we were talking about survey and the survey environment in long-term care facilities now. Many nursing home leaders like yourself feel that the survey environment has become increasingly complex and punitive. Do you believe that the survey process is fair? And that's the first part of the question. And the second part of the question is what are changes, what changes, if any, would help surveyors better support quality improvement while still protecting residents? Wow. Okay. So that's a lot. Let's unwrap all that. So I do believe certainly that the survey process has become more complicated. If you look at the number of tags you know, that were in, in ef- in effect when I first became a director of nursing in the very late '80s, I don't know, it was maybe 50. And now it's several hundred. but the actual survey process itself from my perspective really hasn't changed that much over the decades of my career t- in my view. They slice and dice it a lot of different ways, but it's really a lot the same as when I started. There's certainly tremendous variation across states, tremendous variation across regions, and sometimes even field offices, and I think that's just the human element and a lot of state sort of culture that's, that gets baked into it. There are, you know, survey field offices that are considered tough. There are certainly unrealistic surveyors sometimes I feel, but there are also effective survey offices and effective surveyors. And we're all supposed to want the same thing, safe care and home-like environment for th- for the people that we care for, mostly elders, but also other people, other types of patients and residents. And I really do believe that every nursing home should be survey ready every day. I don't-- They don't expect anything of me or my staff that I don't expect of myself or my staff. I will say I sometimes feel that the expectation is perfection, which has always kind of grated on me which is not achievable. Nothing is perfect. In their own playbook, the state operations manual really defines the standard as substantial compliance. That's their phrase, and that is very different than perfection. I do see what I consider to be some pretty silly survey citation, and I sometimes think when I read them, "Well, they were substantial in compliance," so I'm not sure why, why that got cited. But not, you know, not all nursing home leaders have been around as long as I have, and they aren't as comfortable debating a point like that with a surveyor as I might be. But there's no question that the playbook has gotten deeper and wider, and it is more difficult, I think, to manage and and be survey perfect, or survey ready on a daily basis than it was 20 or 30 years ago. Well, that's good to hear. That should make people feel you know, happy. Maybe it will continue to improve. I hope so. I think, you know, it's, it's really hard. I mean, I sometimes think back to when I very first became a director of nursing and had the opportunity to open those two communities, which were very different from one another, in two different states, and I think, you know, could I succeed at that now? I mean, it's so much harder, right, than it was. There's so many more rules. But I still think it comes down to doing the right thing. And oftentimes when I would be in orientation with new staff, you know, they would say, "How do you know all those rules? You know, there's so many rules." And I would say, "I d- I don't know all of the rules, you know, word by word, just like a minister probably doesn't know the entire Bible word for word, chapter and verse, but I do know that it says do the right thing," right? At the end of the day, if you are efforting to do the right thing, we're probably gonna be in a better place than we will be if you are not efforting to do the right thing. Yes, and I, I think that's fundamentally where we have to stand in healthcare, where we need to draw the line. We're doing the right thing no matter what, and hope that it all, it all works out for the best beyond that. You know, it's a lot easier to, to defend, I guess, an action or something that happened when, when you know your staff's heart is in the right place and they were just trying to do the right thing. And if it turns out to be regulatorily a problem, but it's not a problem because they did the right thing, that's okay. I can argue that point, and I'll take my lumps. Yes. I know no one wants to talk about this, including me, but I think there are some important lessons that we can learn from the pandemic. It fundamentally changed long-term care. Looking at the industry today, do you feel that nursing homes have truly bounced back, or do you think there are still lingering effects that the public and policymakers may not fully appreciate? You know, this might sound strange, Jean, but in some ways I think the pandemic was beneficial to our sector. People are probably saying, "What on earth is she talking about?" You know, and of course at the beginning it was never-ending work, emotional exhaustion, patient deaths, resident deaths staff dying sometimes. I mean, you know, that was emotionally heart-wrenching, obviously. , And constant adaptation to ever-evolving rules, sometimes on a daily basis, sometimes on an hourly basis from CDC and, you know, all the other, bodies that we answer to. But I think once we got past that part, it really forced employers to start focusing on their employees if they weren't already doing it. Because of the devastating impacts of the pandemic on staffing, they had to do it, right, if they wanted to address staffing. So if you wanna keep them, as we just talked about, you need to invest in them. Not... And I don't just mean financially, though that is important, but you have to care about them. You need to make their lives easier outside of work if you can. Maybe, maybe that's... And that looks very different for different organizations. Maybe that's offering childcare, offering gas cards, offering babysitting, grocery exchanges where they can shop for necessities before they go home after an exhausting shift. Offer on-site healthcare clinics for minor ailments. I mean, all kinds of creative things. Employers have gotten very creative, and it's great to see it. Nursing homes really are family, and you have to love your family, right? If you have to... You have to love your family for your family to flourish. So love your staff. Only by loving them are they going to flourish. It really is that simple and really is that hard. So making headway with the public, oh, boy. I'm not sure we can ever shift or it's certainly an uphill battle, the image of nursing homes, but we are trying. And I think you have to spend some time in a nursing home to really see it. Go visit one, is what I would tell people, and see. Offer to volunteer. Go spend some time in a nursing home. They are part of the fabric of your community, and they really need to be embraced as such. And I think a, a valuable part of the community. In terms of policymakers, ooh, it's nice to see... I happen to like to see that so many nurses are becoming legislators. I think that adds a very healthy perspective, that's refreshing sort of to, the stage. But in the end, I think, you know, there's only so much money to spend, and we're going to have to make some hard choices as a society, and hopefully our legislators will follow our lead. You know, are we going to fund healthcare but spend less on defense or less on education or less on infrastructure, or are we going to pay more in taxes, or are we going to do all of that? And I think, you know, that's well beyond my expertise, but certainly as a taxpayer and a citizen and a healthcare professional, I think, you know, there's, there's, uh, with an aging population, there's a lot of tough choices that lay ahead for all of us. And so I would encourage folks to be active and,, engaged with their legislators. Whether they like it or not, that's how the system works. Make your voice heard so that long-term care is funded and we can afford to take good care of the people that deserve it the most. You know, we at Sabre are fortunate to have a CEO and a chief of government affairs that are advocating for our sector nonstop, and of course, that's an investment not every organization can afford. But we can, and it does end up benefiting many, many organizations beyond our own, so I'm very proud of that. Yeah, Sabre, uh, Sabre is really doing tremendous efforts in this area, and I, I commend them. I mean, it's it is, and, and it really benefits the entire industry, so I appreciate that. I'm very excited about this next question. I was raised by a nurse, a- an RN who's now retired- But I thought a lot about nursing when I was in college, and I have a tremendous amount of respect for nurses. If a newly licensed nurse told you they were considering a career in long-term care, what would you say to them? And what opportunities and rewards do you think are often overlooked in this setting? Well, first I'd jump up and give them a hug, assuming they're comfortable with it, of course. but seriously here's how I, here, here's how I would explain it. I'd say long-term care is relationship-based nursing. It's not like the emergency room where your re- relationship lasts 15 minutes or maybe a couple of hours, or even a med-surg unit where, you know, your relationship m- lasts a couple of days. You're gonna be caring for the same people for several weeks if they're rehab patients, or sometimes for the remainder of their lives if they're residents coming for long-term care. So, so I always ask this question of new nurses, really think about the type of nursing you want to engage in. If you enjoy older people, if you like hearing about their life experiences and perspectives, and you really enjoy relationships and relationship-based nursing, then there is no better setting, in my opinion, to make a career. It's a wonderful setting to invest in others and to watch others grow, particularly staff. So, whether it's a fellow caregiver at the outset of your career or later on developing future leaders, I think that it, long-term care prevent, presents a real opportunity for people who love leading. I think there's a lot of long-term care companies now that help folks further their formal education, so that that can be a huge advantage when you're recruiting folks and entering skilled nursing. I think there's a lot of avenues to take to keep going if you want to, whether that's from a CNA to an LPN, an LPN to an RN, an RN to a BSN, a BSN to an MSN, or everywhere in between, or a nurse practitioner. , I think there's just a lot of opportunity that certainly did not exist, at the time that I went on and got my my degrees. But whatever you do is what I would say, make sure that you commit at least 12 years, 12 years, 12 months to it, because it really does take that long to adapt, to settle in, to learn systems, to learn a culture. And I think, long-term care if they haven't spent any time in a nursing home in their, in their nursing education, can be a real eye-opening experience in a lot of ways, both positively and negatively. And I think that it takes time to settle in. And I would also encourage them to find an organization to partner with if they're interested in a career in skilled nursing that's really gonna invest some time in them at the outset. You know, you just can't give somebody a day or two in a cl- in a classroom watching videos and then, y- you know, put them on a, on the unit and expect them to succeed. You have to give them a lot more time and investment than that, and we do as a, as an organization as well. Another thing I'm very proud of. I love all those tips, and I think, again, I'm gonna say it again, Sabre is doing a wonderful job in supporting, um, new nurses. That's what we need. We need a strong nursing care force in long-term care. So yes. I wanna shift a little bit to AI because I always talk about AI in all my podcasts. It's becoming part of every healthcare conversation. Where do you see the greatest opportunity for AI in long-term care, and are there areas where you think we should be cautious about relying too heavily on technology? You know, we see this really almost on a daily basis at this point, and we're intersecting with a lot of this technology. But like most people, I think I'm both excited and anxious about what AI means, for me, for us as a society, for us in healthcare. What I don't think that a lot of people realize is AI and machine learning h- has been shaping our lives for quite a while. So, you know, we've been searching on Google for how long? I don't know, a couple of decades, right? And getting pointed to specific answers or sites. All of that sort of activity, at least in my understanding, relies pretty heavily on both AI and machine learning. You know, so for example, on a personal level, I use... You know, I look up recipes, right? So I say, "Give me a recipe for chicken piccata." but AI takes that a step further. I can say, "I have chicken, I have broccoli, I have rice. What can I make with that?" Right? So instead of looking specifically for a recipe, I can say, "Here's some ingredients, help me make something of that." Which is, you know, two different things. They're related, but they're not the same. But for healthcare, I think we need added safeguards, obviously, to ensure the security of health information and the validity of the advice or direction we may be getting from I'll call it, from these assisted technologies, I'll call it. You know, we have clinical decision support as a physician. I'm sure you're very familiar with that term. That means that technology is being increasingly used to help guide clinicians, whether they're doctors, nurses, pharmacists, in their own decision-making around either a known or potential problem, issue, or diagnosis. So for example, several clinicians might have documented over the course of several shifts some symptoms and vital sign changes in a record that might indicate that a patient has an infection brewing or is having a reaction to a medication or some other issue. And alone, each of those encounters and their documentation might not rise to a level of concern. But the record, the technology can aggregate this data and sort of look at it and search through it and analyze it over time and consider that this may be a concerning trend that might be developing with this person. So it can start to ask us questions as professionals, as clinicians. Did you consider there might be an infection? It can suggest actions. Should you listen to the patient's lungs? Ask them about pain? Ask about urination? Ask if there's a new medication or dosage? So the record can identify changes in a resident sometimes well before we can, and that's the power of it. But the downside to me is twofold first, will the clinician re- rely solely on the judgment of the AI rather than thinking of its feedback as supplemental information? Pr- and I worry about this particularly for nursing. And secondly, when AI begins suggesting treatment, are providers using technology like this... You know, y- you as a provider, you use technology like this all the time. Algorithms are built into electronic health records, software suggests possible diagnosis and then treatments. And in and of itself, that is not a bad thing, but I believe it requires the provider still to question and validate where the diagnoses or the suggestions are coming from. So asking, you know, what is the source or the evidence base for this advice or direction you're leading me in? And to use their own clinical judgment in deciding whether that's valuable supplemental information or not. So I don't think it should replace the human element, but I think we should use it as an assisted device or tool. And there's no doubt in my mind that this tech saves time that can be better spent with our patients and residents instead of with documentation, which everyone hates. We just need to be cautiously optimistic and somewhat skeptical, I think, as it evolves and when we use it. And then of course, as we talked about, before we, started the podcast, there's the ethical side of things, the ethical consideration. Is it safe to use this technology? Is it safe not to use this technology? Is it a bad decision not to use technology that can really help us? So I've always had a really intense interest in ethics, and I actually serve on the Post-Acute Long-Term Care Medicine Ethics Committee. And this topic fascinates me on a very personal and professional level. So I'm pretty excited to see what develops, but also, as I said at the outset excited but anxious. Yes, and we could talk a lot about that, but I wanna We could. I wanna move on. I really, I am very excited to think about where the future is in long-term, long-term care. So if we look ahead to the next five years, what changes do you expect to have the biggest impact on nursing homes, whether it's related to workforce, regulations, technology, reimbursement, resident expectations in care? And after all, I guess, I guess this is another, a side question, w- after all your years in long-term care leadership, what is one misconception about nursing homes that you wish every American understood? And maybe that happens in the next five years. Well your add-on question is kind of y- like the big one in my mind, so I'm, I think I'm gonna start with that one. So I'm gonna start, with the second part of your question, which is what about the misconceptions about nursing homes? Everybody's seen the ads on TV and billboards when you're driving down the road Has your loved one been abused?" , Had a, a pressure injury, whatever, a fall. And so the default position, I think, and perception is bad things happen in nursing homes. I've never seen a billboard that says, "Hey, you know, great things are happening at, happening, you know, at, at your local nursing home. Stop in for a visit." Actually, I think I did see one billboard one time that suggested that. So we kind of start at a disadvantage before a person ever sets foot in a, a nursing home. Everybody's like, "I don't wanna go in there," right? Bad things happen. So are there bad nursing homes? Of course, there are bad nursing homes. When there are tens of thousands of anything, there will be some things that are very bad, some that are exceptionally wonderful and many that are just doing the best that they can each and every day. And honestly, from my perspective as a society, I don't think Americans really value our elders as much as other cultures can and do. I think We sometimes think that when people are not useful anymore, we're mostly done with them, which is sad and then we need to put them someplace to be cared for. And because so many people work now, often almost everybody that's, you know, of an adult age, there's sometimes no extended family to provide the physical and emotional care, you know, for the many hours of every day that an older person may need. Of course, these are generalizations, but it's my observation over decades that it's often true. Families hate having to put a loved one in anyone else's care, period. And so when they need to do it, they are emotionally tied to the care that is delivered by other people that they cannot provide themselves. So it's a really emotionally charged decision when you have to put a loved one in a nursing home. And nobody wants to go to a nursing home. I suspect if you polled 100 people and asked if they'd like to live any part of their life in a nursing home, 100% would say no. So right out of the gate, we're fighting the stigmas of both aging and of nursing home care. But I can tell you that staff in nursing homes, and I promise you this are working tirelessly to give care every minute of every day, and it's physically and emotionally exhausting work, and it's truly a devotion. And yet we don't get reimbursed, right, anywhere near what it costs to actually deliver the care. The operating margins are so thin in, in our sector of healthcare. That's why so many nursing homes had to close, at the beginning of the pandemic. They just couldn't afford to pay the rising wages that were escalating so quickly at the beginning of the pandemic, the rising cost of supplies like food, , PPE facility maintenance. So they either had to close or sell to a larger company where there are at least some economies of scale, to help with, I guess, the survival of the sector. So when you combine all of that with trying to attract staff to a setting with such a stigma it really is a calling. And I believe that employees want to feel connected and valuable to what they're doing. It comes down to culture and leadership. If you create a culture where you care for your employees and where you listen to them and you care for them, they will care for your residents in the same way. I truly believe it's it's like a garden that you're growing, right? If you're in, if you're planting really healthy, nourishing seeds with your staff, it's going to result in excellent patient care. I was a director of nursing and a chief nursing officer for a very long time, and I think I was a really good one, but I worked really hard and I put serious effort into modeling work ethic, professional caring conduct, and empathy so that I could grow others within our environment. I loved and still love mentoring employees and watching them blossom and grow and sometimes furthering their own educations and careers. And there's nothing like mentoring someone into your own job, which I've done countless times. I mean, I've, I've I've grown so many directors of nursing, I can't even count them on my hands and my fing- my toes. Now, for the first part of your question, I, I went on a little bit about the second part, you know, what about workforce pressures, regulations, tech, expectations? And I think those have always been and will likely always be our challenges in skilled nursing. We live in a very politically charged society, particularly right now, but regulations just keep growing regardless of which party has the most influence in, in a moment. I haven't seen those regulations get smaller or thinner over the course of my career. They just keep growing regardless of who's in charge. And when I was very first a director of nursing, which was a very long time ago, the OBRA, or the Om- Omnibus Reconciliation Act of '88, was a brand-new initiative, nursing homes being regulated and inspected by the federal government in addition to their states. That was like a new concept, and I do believe that reform was badly needed in the 1980s. But a nursing home today doesn't look anything like a nursing home did in the mid-'80s, or at least I hope it doesn't. No one's tied up. Most nursing facilities today are vibrant, warm, nurturing, and engaging homes. They're, they're basically microcosms of our larger society, or at least I like to think they are. And we can't prevent every bad thing that might happen when you put 100 or so inhabitants of all different ages and backgrounds together in a communal living environment, and then you add 100 or so staff with the same variables. Obviously, bad things are gonna happen, but having high expectations and nurturing, engaging and a transparent, and I'll talk about that in a little bit, culture for both staff and residents, I think that's the huge difference-maker. Be transparent. Be honest about your mistakes, and constantly seek and focus on improvement. Yes. I love that I could go on forever about this. I told you. Yeah, I- and I, I totally agree and I, I just love that you're, you are just very matter-of-fact and just you It is such a long-term... It... The long-term care environment is so complex and complicated and fraught with difficulties, and you just break it down into very simple, manageable things that leadership can focus on, and I just love that Thanks. I mean, you know, I think I, I think everybody gets really tied up in the regulations, right? You present a new director of nursing, you know, with a state operations manual that's, I don't know, three inches thick at this point, and i- is that not gonna scare them beyond belief thinking, "I have to digest that and make all this happen," right? As opposed to, I think, uh, y- I really do think it's as simple as boiling like down to take care of your staff, love on your staff, and do the right thing. Just do the right thing. And at the end of the day, you'll be meeting most of the, most of the intent of most of those regulations. And then over time, you know you can absorb more of the technical sides of, of all of that, I think. But really focus on doing the right thing and taking care of your staff, and they will in turn take care of your residents. Yeah, definitely. My last question, I ask this of almost every guest, and I eventually maybe will compile a l- a list of all the responses. If you were given the opportunity to make one major change to the US healthcare system tomorrow, what would be the first thing you would do, and why do you believe it would make the biggest difference for patients, providers, and long-term care residents? If I had to pick just one, 'cause I got a couple , I would love to see us gain deemed status. So, you know, The Joint Commission or another accrediting organization, probably The Joint Commission, you know, and what that means to the average, I think, layperson is that they would... A, a third party would survey and inspect our nursing homes against a set of standards and determine whether that nursing home is safe and a, a, and a good quality-driven provider. They have their own comprehensive set of standards that they use to determine safety and quality, and many of those standards are a basis for CMS standards that get later developed and added to our state operations manual anyhow. CMS and the states could then accept that instead of sending in their own survey teams. I mean, hospitals have had this arrangement forever. I, I mean, I worked in a hospital when I very first got out of nursing school in the early '80s, and they had deemed status back then through The Joint Commission. And what I really like about The Joint Commission or other accrediting bodies is they're not typically punitive in nature. You know, their approach is built on transparency, constantly questioning and challenging our own systems, and the pursuit of improving quality at every opportunity. And despite an enormous increase in the number of surveys, I think this is like a many-headed monster, this, this question, but let me tackle a couple of aspects of it. So even though there's so many more surveys now than there were, let's say, five years ago, CMS has not had increased funding for their own surveyors to conduct that many more surveys. So, you know, we hear that state survey agencies can't attract staff themselves. They're facing the same challenges that we face with attracting our own workforce. So it would also help to re- relieve some of the burden for them. So maybe make it so higher-performing nursing homes can opt into a deemed status system, and that would allow CMS to then focus their efforts maybe on the more historically poor performers. I know they're working on something like that, that's a risk-based survey, approach now that's in pilot, I think, in a very, fairly small number of areas. And maybe that will help, but I don't know if they have the bandwidth to make that work over time, and it's just such a small pilot subset. And, and then what happens if administrations change again, right, with the next election? You know, does all that go out the window? And, you know, that's what I worry about, I guess, with I feel like politics is influencing our world to some degree, and I just don't feel there's a place for that in healthcare. I just think that regulations just never seem to stop. So if the Joint Commission can ensure safe and sound care in our hospitals, why can't, why wouldn't they be able to do the same thing in our nursing homes? And many nursing homes are also Joint Commission accredited, but it's an extra step that they take, so they're dealing with kind of two sets of standards, that are sometimes related and sometimes not. So it, you know, the organization's been in existence a long time. It's very well-respected. It's not so influenced, I think, by changing political administrations. So it would relieve some of the backlog for the survey agencies and it would shift the cost of the actual survey process away from the government and onto us as providers. You know, basically a win-win, right? I- in effect, privatizing the survey process. I love this. I hope you get your wish, and I hope you- Ugh ... write it. Come true. If people wanna learn more about Sabre Health Care, you know what the initiatives and the exciting things that you're doing there, how can they do that? Oh, gosh. We have lots of presence in blogs and things like that. We have, o- obviously a website, sabrehealthcare.com. Um, We have a very strong presence on LinkedIn and other, social media platforms. So I think if you just Google Sabre Health Care, you'll probably get lots of information to learn about our organization. Yeah, so if you are looking, you have a loved one who would need the facility, or you're a nurse in training and looking for a career, there's lots of opportunities and things to check out on, Sabre Health Care website. Melissa Purvis, I really enjoyed this conversation. Thank you so very much for joining me today. Thanks for having me, Jean. I really had fun chatting with you.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.