Case Study 3
Start-Up of Blissful Gardens
Adapted from Singh (2023). Additions by Dr. Brandi Sillerud (2023).
Instructions- please read information below and answer the case study questions as listed below.
References/citations must be in APA format- provide a reference page that is in APA format. You will
use several chapters in your textbook, IHI, and LinkedIn modules to help you answer these questions as
indicated in the questions to help you in forming your answers. Please submit answers to the Case Study
to the Assignment Folder per the course due date.
Blissful Gardens is a new long-term care (LTC) and independent living facility set to open its doors to the
first residents in approximately a year. The facility is located in the outskirts of St. Louis, Missouri, a
major metropolitan area. In the state of Missouri, an LTC facility could not be licensed without certificate
of need (CON) approval. Necessary permissions have been obtained, and construction has begun.
Building and Facility Plans
Blissful Gardens will have two separate buildings that will be joined by a central atrium and a section that
will house administrative offices, a dining room, a piano lounge adjoining the dining room, and an arts
and crafts room. One of the buildings will have three stories with 12 one-bedroom apartments for
independent living. Each apartment will have its own private bathroom and a kitchenette. The building
will be constructed as a “green facility,” making use of many recycled materials for construction and also
many energy conservation and efficiency devices. At least some of the trash will be recycled. Each
apartment will have security features, including pull cords to summon help when needed.
The Base Package Fees will cover: monthly rent, emergency pull cord with 24/7 access to on-site staff,
daily “I am OK” checks, once-a-week housekeeping services, lounge area with a big-screen TV with full
cable access and comfortable seating for group TV viewings. A separate common room will have four
computers with printers provided by the facility for the residents’ use. Residents will have the option to
do their own washing and drying in a household laundry. This base package fee will be $3600/month.
Level One Package Fees will cover: All services of the Base package, in addition: laundry service and
two-three meals daily in the main dining room. Meal times are: 8am, 12pm, and 6pm. Snacks are offered
at 2pm and 8pm. The Level One package fee will be $4100/month.
Level Two Package Fees will cover: All of the services in Base and Level One packages, in addition:
nursing services (medication set-up, wound care, basic activities of daily living – like showers/help with
dressing). The Level Two package fee will be $5000/month.
Residents will need to furnish the apartments with their own furniture, linens, and other furnishings.
High-speed internet connections and TV cable in individual apartments will need to be secured by
individual residents (staff can assist with getting that established). There is 24/7 emergency/security care
that is available for no fee with pull cords in all apartments.
Blissful Gardens will have a 20-seat bus to provide a complimentary shuttle service once a week to the
grocery store, department stores, the movie theatre, and some local restaurants. Other local entertainment
outings at various local attractions will also be scheduled. Residents will reserve their seats for these
outings in advance.
The second building will be single-story with the capability to house 24 residents who require substantial
assistance with activities of daily living and clinical interventions. The facility has a nested single-room
design with four “neighborhoods.” Two of these neighborhoods will be used for dementia care. In the
dementia unit, the decorations will be brightly colored and cheery. The rooms will all be painted a light
tan with white ceilings and baseboards. The curtains will be either bright blue or green, and the tiled floor
will be tan and blue. The residents and their families will be encouraged to hang pictures on the walls and
bring other artwork of their choice. Each room will be furnished with a bed, a lift chair, a small table, and
two straight-back chairs. The hallways will be decorated with black and white pictures of many historical
places and events in the St. Louis area. These
Current Operations and Plans
You have been recently hired as the executive director (ED) of the entire facility. The board of directors
had established a strict set of minimum requirements when they began their search for an ED:
•
A master’s degree in gerontology, healthcare administration, and/or related discipline Current
nursing home administrator’s license
•
A minimum of 10 years’ experience in the LTC field, with a progression of management
responsibilities
•
Criminal background clearance
Construction of the facility is about one-third complete. You and your administrative assistant currently
occupy a temporary office space in a strip mall approximately one mile from the construction site.
The board has been meeting twice a month. Board members have been mainly focused on timely progress
of the facility’s construction. You visit the construction site once or twice a week, meet with the
contractor, and discuss progress with the board. The board has asked you to begin marketing and staff
recruitment efforts. The goal is to recruit an experienced director of nursing within the next 5-6 months so
the facility can begin planning for Medicare and Medicaid certification. In addition, all department
head/coordinator positions should be filled two months before the facility opens. The department
heads/coordinators will be heavily involved in recruiting and training qualified associates. The goal is to
have adequate staffing in all areas to serve the facility’s residents at 25% capacity (9 total residents) when
it opens its doors.
Proposed Core Staffing
The core staffing for 25% capacity (or nine patients between building one/two). Nursing shifts will be:
7am-7pm (days) and 7pm-7am (nights) will include:
•
One RN from 8-4:30pm (7 days a week) for Building Two and can consult for Building One for
nursing care/services. The DON can assume the role of the RN for two of the seven days and
sick/vacation days upon initial start-up. Once resident capacity rises, additional staffing for RN’s
would need to be considered.
•
One LPN for Day and Night shifts (7 days a week) for Building Two and can consult for Building
One for nursing care/services.
•
One CNA for Day shift and Night shifts for Buildings One and Two (7 days a week). It is
assumed that only one resident in Building One will be requiring Activity of Daily Living
assistance with initial opening.
•
One Housekeeper for Building One and Two – Day shift is from 8:4:30 pm (7 days a week)
•
One Cook for shared dining room – Day shift: 6-2:30pm and Partial Evening Shift: 3-9pm (7 days
a week)
•
One Dietary Assistant for shared dining room- Day Shift: 6:30-3:00pm; Partial Evening Shift: 39pm (7 days a week)
•
One Activities Staff: 8-4:30pm (7 days a week). Note- the activity staff does not need to work MF. Combination of staffing can occur to cover weekend outings, etc.
Funding
An entrepreneur is the primary contributor for the start-up of the facility, which will be operated as a forprofit venture. The entrepreneur chose the name Blissful Gardens in honor of her late mother, Mrs.
Hatbliss, who was an avid gardener and left behind a fairly substantial estate. Part of the proceeds from
the estate was designated to fill some need in the local community. Before she passed away, Mrs. Hatbliss
was in a local nursing home, and the family did not have good experiences with the care she had received.
Hence, the daughter decided to dedicate the funds to develop a resident-friendly, yet sophisticated and
top-notch facility where people would not only feel comfortable and valued, but they would also receive
the best services and care available in the community. According to the philosophy expressed by the
board of directors, “resident-friendly” means that the facility will provide the comforts of one’s own
home and the associates will help nurture the residents so that each individual could continue to enjoy his
or her golden years and realize self-fulfillment. To maintain high standards, the independent living section
will be 100% private pay, and the goal is to have 75% private-pay residents in the nursing center.
Board Composition and Funding
The eight-member board has the following composition:
•
Chairman of the board: a local board-certified internist with experience in geriatrics. Mrs.
Hatbliss was his patient for many years.
•
Financial adviser: the president of a local bank.
•
The chief executive officer of a local manufacturing business.
•
The chief operating officer of a managed care organization.
•
Legal counsel: an attorney with a prestigious local law firm.
•
Two local well-known small-business owners.
•
A retired school superintendent.
The estate of Mrs. Hatbliss provided $2 million. Total start-up costs have been estimated to be between
$3.2 and $3.5 million. The board has secured a loan of $1 million from a local bank, with a line of credit
approved for another $500,000. Local businesses will be solicited for donations for some of the
equipment. Plaques will be displayed on the walls to recognize such donations.
Market and Competition
There are four medical systems located within 15 miles of Blissful Gardens. Two of the hospitals have
their own LTC facilities. These hospital-operated facilities, with a total of 22 beds, present the only
competition in the immediate area. One of these facilities, located 5 miles away, recently came under
scrutiny for alleged health and safety violations. The media aired some unfavorable stories. The other
hospital facility is 12 miles away and is running at full capacity with a waiting list.
The local community is ethnically diverse and has a stable economy because of its proximity to St. Louis.
Most of the people settled in this area are either retired or are middle-aged, the median age of the
population being 52. The average household income in the area is $100,000. New businesses have been
steadily opening up in the area. A new shopping mall is being built approximately eight miles from
Blissful Gardens. A new condominium community, about seven miles away, opened six months ago.
Main Goals
The facility’s utilization is projected to be at 50% capacity six months after opening, and at 75% by the
end of its first year of operation. To achieve this goal, a relationship must be established with the two
hospitals that do not have their own LTC facilities. The board anticipates that the facility will start turning
a profit by the end of its second year of operation. One of the board members is a good friend of the
owner of a local talk radio station, who could be tapped to help promote the facility.
The board assigned you with several tasks to complete and report back.
1. This is a new facility, creating and leading a positive culture and climate is important for
employee engagement and morale. Compare and contrast culture vs. climate in an organization.
When hiring staff, what considerations should you take for the following groups: baby boomers,
Gen x, Gen Y/Millennial, and Gen Z? What factors impact morale and how will you prepare/lead
to create high moral and productivity within the organization? Refer to chapters 22 and 23 in your
textbook.
2. One of the first tasks you must undertake is to prepare a recruitment plan to hire management
personnel. Outline your plan. See Operations Budget Table for a suggestion of personnel. You
can add to this listing. Justify each position, and provide the main qualifications these individuals
must possess. Use at least one scholarly source in developing that recruitment plan.
3. How do you plan to staff each of the buildings based on 50% capacity, 75% capacity, and 100%
capacity? The core staffing plan for 25% capacity is presented in the Case Study; do you think
this core staffing is adequate and safe? The organization desires a case-mix adjusted licensed
nurse hours (RN and LPN hours) per resident day of 1.20 and case-mix adjusted total nurse staff
(RN + LPN + CNA’s) of 3.25 nurse hours per resident day. This will be slightly above the
national average and aligns with the mission of quality/resident centered care (KFF.org, 2022).
See Productivity FTE Analysis supplemental notes/PPT under week 6.
a. Calculate the FTE’s needed for each classification of staff based on those
recommendations and nursing hours per resident day to provide safe care for 25%
capacity (do you recommend any changes from presented core staffing plan, also,
calculate nursing hours/resident day), 50% capacity, 75% capacity, and 100% capacity.
It is assumed that staffing for smaller resident numbers assumes higher nursing hours per
resident day, but as you admit more residents, you should be able to achieve the desired
nursing hours per resident day per your recommended staffing plan. Remember that this
is a for profit facility, but the mission/goal is to provide exceptional care/services.
b. Please create a staffing grid to outline staffing expectations/plan for 25%, 50%, 75%, and
100%. Ensure that you are clear on each classification (number RNs, LPNs, CNAs) of
nursing staff, as well as show your calculations for nursing hours per resident day for
each level of capacity. See/complete productivity calculations document.
c. In addition, will you recommend any changes to housekeeping, dietary, and/or activities
as resident admissions increase? Clearly discuss how those staffing guidelines might
change as capacity increases.
4. Assuming that the facility will open on January 1, prepare a budget for the first year of operation.
See/complete Operational Budget Table document. At what capacity level will the facility start
making money? What is the breakeven point? After developing your budget, do you wish to
change any of your recommended scheduling/plan from question 4? Why or why not? See
Breakeven Analysis Supplemental Notes in week 9.
5. How can you go about developing relationships with the two hospitals? What steps should the
leadership team take? These relationships will be critical in attracting potential residents. You
must support your answer with at least one scholarly source.
•
What data should the organization measure after start-up of the organization (think in terms of a
balanced scorecard – what data would be needed in the major categories?). Provide/find an
example of a scorecard that leaders might use to evaluate the following elements: Finances,
Operations, Quality, and Satisfaction. You must support your answer with at least one scholarly
source. Refer to Chapter 15 in your textbook. You can also check out a couple of examples of
organizational scorecards/data monitoring via these two links:
o
https://sunnybrook.ca/content/?page=strategic-plan-2021-25-performance
o
https://southlake.ca/about-southlake/our-performance-and-accountability/balancedscorecard/
6. What methods could be used to involve the resident/families in identifying key elements of the
balanced scorecard? You must support your answer with at least one scholarly source. Refer to
Chapter 15 in your textbook.
7. Develop a recommended plan for communication with the Board. What documents/policies will
you need to develop to ensure you are communicating and promoting board governance during
the start-up and after the doors open? You must support your answer with at least one scholarly
source. See articles/readings below to help you with this answer.
8. Discuss your plan to involve physicians/providers in referring to the facility? How will you
recruit a medical director (shared provider governance) and ensure that you have active
relationships with providers for resident care? What is your plan to deal with any provider
conflict that might arise? You must support your answer with at least one scholarly source. See
articles/readings below to help you with this answer.
9. Work is supported by outside evidence – at least 5 scholarly sources are utilized.
Please review these articles/readings to assist with answering question 8 and 9:
1. MacLeod, L. (2019). Trust: The key to building stronger physician relationships. American
Association for Physician Leadership. https://www.physicianleaders.org/news/trust-key-buildingstronger-physician-relationships
2. Rural Health System Analysis and Technical Assistance. University of Iowa. (2013). How
hospital leaders can build good working relationships with physicians.
https://ruralhealthvalue.public-health.uiowa.edu/files/Physician%20Relationships.pdf
3. Symplr. (2021). Healthcare governance & why it matters.
https://www.symplr.com/blog/healthcare-governance-why-it-matters
4. ACHE. (n.d.). Basic responsibilities of a board and its members.
https://account.ache.org/iweb/upload/BiggsCh1-7dcfe3cb.pdf
Course Learning Outcomes (CLO) that apply to this assignment:
•
•
•
•
•
•
•
•
•
CLO 1: Explore the challenges and opportunities for improving healthcare operations
CLO 2: Explore the methods/tools for problem solving and decision making in healthcare
operations
CLO 3: Assess potential errors and methods to design safe systems
CLO 4: Collaborate to analyze operational issues and present a cogent strategy to address
those issues
CLO 5: Evaluate patient flow and satisfaction and how these impact healthcare
operations
CLO 6: Assess the supply chain and inventory management process
CLO 7: Analyze and apply data to impact operational decisions
CLO 8: Apply principles of project management to implement performance improvement
and other activities
CLO 9: Synthesize operations management techniques in support of an organization’s
strategy
Program Domains and Competencies Guiding this Assignment:
Domain #1: Leadership – the ability to inspire individual and organizational excellent, create and attain
a shared vision and successfully manage change to attain the organization’s strategic ends and successful
performance.
Competencies:
• Leadership Skills & Behaviors (4)
• Organizational Climate & Culture (3)
•
•
Communicating Vision (3)
Managing change (3)
Domain #3: Communication and Relationship Building – the ability to communicate clearly and
concisely with internal and external customers, establish and maintain relationships, and facilitate
constructive interactions with individuals and groups.
Competencies:
• Relationship Management (3)
• Communication Skills (3)
Domain #4: Knowledge of the Healthcare Environment – the understanding of the health care system
and the environment in which health care managers and providers function.
Competencies:
• Healthcare Personnel (3)
• The Patient’s Perspective (3)
Domain #5: Business Skills- the ability to apply business principles, including systems thinking, to the
healthcare environment.
Competencies:
• Operations management (4)
• Organizational Dynamics and Governance (3)
• Quality Improvement (3)
• Human Resource Management (3)
• Financial Management (3)
• Patient Safety (3)
Case Study 3 Rubric – MHA 651
Description of
5 – Proficient
4-3 – Competent
Rubric Element
2-1 – Advanced
0 – Missing
Beginner/Novice
Q1: Culture, Climate,
Clearly compares
Unclear comparison
Very unclear
Generational Needs,
culture/climate,
culture/climate, and/or
comparison
Morale
discusses generational
discusses generational
culture/climate,
Competencies
Assessed:
• Organizational
Climate &
Culture
• Communicating
Vision
needs, analyzes
needs, and/or analyzes
and/or discusses
morale and
morale and
generational needs,
productivity.
productivity.
and/or analyzes
Supported with
Missing/unclear
morale and
scholarly resource.
scholarly support.
productivity.
Missing
Missing/unclear
scholarly support.
Q2: Recruitment Plan
Clearly develops
Unclear recruitment
Very unclear
Competencies
Assessed:
• Healthcare
Personnel
• Human Resource
Management
• Operations
Management
recruitment plan;
plan and/or justification
recruitment plan
justifies positions, and
of positions, and/or
and/or justification of
provides main
qualifications for each
positions, and/or
qualifications for each
individual.
qualifications for
individual. Supported
Missing/unclear
each individual.
with scholarly
scholarly support.
Missing/unclear
resource.
Missing
scholarly support.
Q3: Staffing plan
Clearly presents
Unclear presentation
Unclear and/or
Competencies
Assessed:
staffing plan/grid for
for staffing plan/grid
missing presentation
each capacity level.
for each capacity level.
for staffing plan/grid
Missing
Pts Earned/Comment
Description of
5 – Proficient
4-3 – Competent
Rubric Element
•
•
•
Operations
Management
Financial
Management
Human
Resources
Management
2-1 – Advanced
0 – Missing
Beginner/Novice
Calculates nursing
Unclear calculations for
for each capacity
hours per resident day
nursing hours per
level. Unclear and/or
for each capacity
resident day for each
missing calculations
level. Discusses
capacity level. Unclear
for nursing hours per
recommendations for
recommendations for
resident day for each
changes to other
changes to other
capacity level.
support staff with
support staff with
Unclear and/or
different capacity
different capacity level.
missing
level.
recommendations for
changes to other
support staff with
different capacity
level.
Q4: Budget
Clearly presents
Unclear operational
Unclear operational
Competencies
Assessed:
• Operations
Management
• Financial
Management
operational budget.
budget. Operational
budget. Operational
Operational budget
budget table document
budget table
table document
has some errors and/or
document has
completed. Calculates
incomplete. Incorrect
multiple errors and/or
breakeven point and
breakeven point/when
incomplete. Incorrect
when facility will start
facility will start
breakeven point/when
making money (what
making money (what
facility will start
capacity). States if any
capacity). Unclear
making money (what
Missing
Pts Earned/Comment
Description of
5 – Proficient
4-3 – Competent
Rubric Element
2-1 – Advanced
0 – Missing
Beginner/Novice
recommended changes
discussion on any
capacity). Unclear
to staffing plan after
recommended changes
and/or missing
calculating operational
to staffing plan after
discussion on any
budget.
calculating operational
recommended
budget.
changes to staffing
plan after calculating
operational budget.
Q5: Relationships
Clearly discusses
Unclear discussion on
Unclear and/or
Competencies
Assessed:
• Leadership Skills
& Behaviors
• Relationship
Management
• Communication
Skills
methods to build
methods to build
missing discussion on
relationships with
relationships with
methods to build
hospitals. Discusses
hospitals. Unclear
relationships with
steps leadership team
discussion on steps
hospitals. Unclear
should take. Supports
leadership team should
and/or missing
with scholarly
take. Unclear scholarly
discussion on steps
evidence.
evidence support.
leadership team
Missing
should take. Unclear
and/or missing
scholarly evidence
support.
Q6: Data
Clearly discusses data
Unclear discussion on
Unclear and/or
Competencies
Assessed:
to be measured after
data to be measured
missing discussion on
start-up. Example of
after start-up and/or
data to be measured
Missing
Pts Earned/Comment
Description of
5 – Proficient
4-3 – Competent
Rubric Element
•
•
•
Managing
Change
Quality
Improvement
Patient Safety
2-1 – Advanced
0 – Missing
Beginner/Novice
balanced scorecard
balanced scorecard
after start-up and/or
provided. Supports
example missing.
balanced scorecard
with scholarly
Unclear scholarly
example missing.
evidence.
evidence support.
Unclear and/or
missing scholarly
evidence support.
Q7: Resident
Clearly discusses how
Unclear discussion on
Unclear and/or
Involvement
resident/families can
how resident/families
missing discussion on
Competencies
Assessed:
• Managing
Change
• Quality
Improvement
• Communication
Skills
• Relationship
Management
• The Patient’s
Perspective
• Patient Safety
Q8: Board
be involved in
can be involved in
how resident/families
identifying key
identifying key
can be involved in
elements of the
elements of the
identifying key
balanced scorecard.
balanced scorecard.
elements of the
Supported with
Unclear scholarly
balanced scorecard.
scholarly source.
evidence support.
Unclear and/or
Clearly discusses plan
Unclear plan for Board
Unclear and/or
Communication
for Board
communication.
missing plan for
Competencies
Assessed:
• Communication
Skills
communication.
Unclear discussion on
Board
Discusses
policies/documents
communication.
policies/documents
needed for
Unclear and/or
Missing
missing scholarly
evidence support.
Missing
Pts Earned/Comment
Description of
5 – Proficient
4-3 – Competent
Rubric Element
•
•
Relationship
Management
Operation’s
Management
Organizational
dynamics &
Governance
2-1 – Advanced
0 – Missing
Beginner/Novice
needed for
communicating and
missing discussion on
communicating and
promoting board
policies/documents
promoting board
governance. Unclear
needed for
governance. Supported
scholarly evidence
communicating and
with scholarly source.
support.
promoting board
governance. Unclear
and/or missing
scholarly evidence
support.
Q9: Provider
Clearly discusses plan
Unclear plan for
Unclear and/or
Relations
for provider/physician
provider/physician
missing plan for
Competencies
Assessed:
• Leadership Skills
& Behaviors
• Communicating
vision
• Managing
Change
• Relationship
Management
• Human
Resources
Management
• Organizational
Dynamics &
Governance
referrals. Discusses
referrals. Unclear
provider/physician
recruitment plan for
recruitment plan for
referrals. Unclear
medical director and
medical director and
and/or missing
active provider
active provider
recruitment plan for
relationships. Discuses
relationships. Unclear
medical director and
plan to deal with
plan to deal with
active provider
provider conflict.
provider conflict.
relationships. Unclear
Supported with
Unclear scholarly
and/or missing plan
scholarly source.
evidence support.
to deal with provider
conflict. Unclear
and/or missing
Missing
Pts Earned/Comment
Description of
5 – Proficient
4-3 – Competent
Rubric Element
2-1 – Advanced
0 – Missing
Beginner/Novice
scholarly evidence
support.
Q10:
Utilizes at least 5
Utilized 4 scholarly
Utilized 3 or less
No scholarly
Evidence/Scholarly
scholarly references,
references, and/or
scholarly references,
evidence and/or
Support/Grammar
integrated into
unclear integration into
unclear integration
multiple
answers. Minimal
answers. Multiple
into answers.
grammar/spelling
grammar and/or
grammar and/or
Multiple grammar
errors.
spelling errors.
spelling errors.
and/or spelling errors.
Total Points:
50
Pts Earned/Comment
References
Caring.Com. (2022). Nursing homes in Missouri. https://www.caring.com/senior-living/nursing-homes/missouri
KFF.org. (2022). Average nurse hours per resident day in all certified nursing facilities. https://www.kff.org/other/state-indicator/average-nursehours-per-resident-day-in-all-certified-nursing-facilities-20032014/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Singh, D.A. (2023). Effective management of long-term care facilities. (4th ed). Jones & Bartlett Learning.
Southlake Regional Healthcare. (2022-2023). Balanced scorecard. https://southlake.ca/about-southlake/our-performance-andaccountability/balanced-scorecard/
Sunnybrook Health Sciences Centre. (2021-2025). Strategic plan 2021-2025: Q1-Q4 fiscal year 2022-2023 results.
https://sunnybrook.ca/content/?page=strategic-plan-2021-25-performance
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