Change is a constant that skilled nursing facility (SNF) leaders must navigate, but in the transition to value-based care, SNFs must accelerate their evolution to meet customer quality expectations. SNFs pursuing the AHCA/NCAL National Quality Award learn the importance of delighting customers, because those who aren’t engaged with the SNF will not continue the relationship. While residents have always been the customer that inspires the pursuit of excellence, the Centers for Medicare & Medicaid Services (CMS), also a customer, sets expectations for excellence. To meet the expectations of both residents and CMS and succeed in the value-based care market, SNFs must also treat staff as customers and delight them.

CMS Sets Quality Expectations

“Quality” is a nebulous term; the customers’ expectations define the degree of excellence sought. As the largest payor of healthcare services, CMS is the biggest customer in terms of financial support. CMS therefore defines quality for all SNFs.

CMS emphasizes staffing’s importance by including workforce stability in the quality equation. Staffing measures already affect facilities’ Five-Star ratings. Moreover, the Fiscal Year (FY) 2024 Skilled Nursing Facility Prospective Payment System (PPS) proposed rule adds the same Nursing Staff Turnover measure from the Five-Star Quality Rating System to the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, thus financially incentivizing or penalizing facilities’ staff retention performance.

 In the future, CMS plans rulemaking regarding a minimum staffing mandate. While SNFs oppose this mandate, citing evidence it could cause serious problems including lack of access to care, the message is clear that CMS equates staffing levels and workforce stability with quality of care. SNFs cannot meet CMS’s expectations without prioritizing staffing.

Creating Value Depends on an Engaged Workforce

The traditional fee-for-service structure separated quality care outcomes from reimbursement, but CMS’s shift to value-based care has made quality synonymous with financial stability. Value for customers, including CMS and residents, requires sustained quality outcomes that are generated in an effective and efficient manner. An engaged workforce is essential to create that value. SNF success in a value-based market therefore depends upon staff.

Impact of Government Funding and Policies

With a staggering staffing crisis, attracting a workforce is a daunting challenge, yet one that is vital for SNFs. Not only does the future require a pipeline of developing leaders, but current operations are in dire need of staff now to provide care. With that in mind, SNFs must remain united in urging federal and state governments to fund quality care that allows SNFs to pay competitive wages and attract top talent. Continuing to lobby for policies that incentivize work in SNFs and increase the pool of who can enter healthcare is vital for the profession.

Engage Staff for Excellence

Leaders who value the workforce can more successfully attract and retain staff. The Baldridge Excellence Framework states “an organization’s success depends on an engaged workforce that benefits from meaningful work, clear organizational direction, the opportunity to learn, and accountability for performance.” Although it may require changes to operations or their own behaviors, leaders can act immediately to enhance these factors in their facilities.

Meaningful work is deeply personal; individuals must believe their actions make a difference or serve something they view as important. SNFs present a unique opportunity to bond with residents while providing care to those who need it. Leaders should acknowledge these relationships and celebrate staff contributions to quality-of-care outcomes. By reinforcing the impact staff have, leaders can cultivate meaning in the work environment.

Make Time to Inspire the SNF’s Vision and Mission in Staff

Leaders may find themselves focusing on problems and addressing staff only when tasks are incomplete. While resolving issues with staff performance is an essential management responsibility, this is not the only time staff should interact with leadership. Staff want to know what direction the SNF aspires to go—the vision—and the SNF’s mission—the purpose of the SNF. Leaders should diligently and intentionally communicate with staff in a way that reinforces realizing those aspirations and purpose. Staff need to know their responsibilities are more profound than simply completing tasks; they need to be inspired by how their role contributes to achieving the vision and mission.

Invest in Staff Education

While regulatory compliance is important, if the goal of educating staff is avoiding citations, leaders are missing the opportunity to show they value staff and prioritize individuals’ development. To demonstrate this perspective, invest in the staff’s professional development. Provide education staff need to advance their knowledge and cultivate skills they can use to fulfill their roles’ responsibilities. Not only does this send the message that staff are valued, but it can also improve the quality of care and services for residents.

Align Staff Education with Processes and Policies

Ensure that staff competence equals compliance. When staff become competent performing a skill, but bad processes mean that even outstanding performance does not lead to compliance, they often feel defeated and perceive that leaders don’t care about the quality of their performance. Leaders are responsible for designing processes that allow staff to consistently apply the skills they are competent in, but leaders must ensure that staff doing so are compliant; following the SNF’s policies should lead to compliance with the regulations. Staff feel confident when they are empowered to do their best, providing quality care and services to residents.

Involve Staff in Quality Improvement

To keep staff engaged through accountability, encourage them to take ownership of results, including those that show achievement or progress. Keep staff informed of progress made and reinforce their contributions by sharing goals and correlating performance data. For example, discussing resident satisfaction scores for nursing care with nurses and certified nursing assistants encourages them to take credit for a job well done and allows leaders to give kudos for excellent care. When the data indicates a decline, seek insight from staff to understand what is not working well; they may be best positioned to identify barriers to quality.

Furthermore, employ their solutions to overcome the barriers. When leaders solicit and apply staff feedback, it reinforces that all staff are expected to produce solutions and that leadership values them for doing so.


Alexis RoamSNFs that value staff as customers can not only attract and retain a workforce but also thrive in a value-based market. During an unprecedented staffing crisis, it is even more critical to embrace staff as customers; seize every opportunity to delight them and strengthen the relationship.

Alexis Roam, MSN, RN-BC, CPHQ, DNS-MT, QCP-MT, Curriculum Development Specialist for the American Association of Post-Acute Care Nursing (AAPACN).