compared it with the 6 months after the nursing home opening, the department had lost cases and found that, on average, each case kept by the hospital required 30% more services than the average rehabilitation case in the past. This demonstrated the need to measure the units of service that are used for calculating a department's volume to accurately determine workload. The post-acute care unit team leader also compared the average number of staff needed prior to the nursing home rehabilitation unit opening with the average number of staff needed after the nursing home unit opening. This staff number increased from an average of 4.0 staff per room to 4.5 staff per room. This information was instrumental in helping the unit justify its additional staffing needs. With its new rehabilitation unit open on the other side of town, the nursing home owners began actively recruiting the best staff from the post-acute care unit at Sunnyside with offers of better shifts, an enhanced benefits package, and onsite childcare. Three key therapists in Sunnyside's unit started to call in sick and take their vacation days earlier than in the past. The unit's team leader asked Human Resources for assistance but was told that Sunnyside had already negotiated union contracts for the next 2 years and that HR had no flexibility in the pay and benefits that could be offered to the therapists. 1) Key issue(s): identify at least one key issue 2) Causes/Impacts: identify the cause(s) \& impact(s) of the issue(s) 3) Stakeholders: identify the stakeholders and any conflicts between them 4) Alternatives: present/explain recommendations on practical actions (alternatives) to correct (mitigate) the issue(s) central to the case 5) Select Action: identify which alternative action you, as a leader in the scenario, would recommend implementing and why you selected this action The question many healthcare leaders grapple with is: "How many staff members (measured as full-time equivalents, or FTEs) do I need to cover my daily census?" This introduces us to a discussion of units of service and what are the determinants of adequate staffing. Consequently, we have developed a case study of a nursing home taking residents for rehabilitation and therapy wherein accurate calculation of FTEs made an enormous difference. A community hospital, Sunnyside Health Center, provided surgical services on an inpatient and outpatient basis, and was the only surgical center in the city of Sunnyside. The nurse manager of the surgical services department traditionally measured its volume by counting the total number of surgical cases. About 80% of all its rehabilitation cases were transferred to its post-acute care unit, where the manager counted their volume of work in a similar fashion. In February, a new retirement community opened, and its administrator hired a marketing manager who actively recruited rehabilitation cases from Sunnyside, claiming that they could provide the same quality of therapy services at a significantly lower cost. It was estimated that half of all the rehabilitation cases would transfer to the new therapy unit at the nursing home. The staff in the post-acute care unit at Sunnyside was reduced to account for this reduction in outpatient volume. When the nursing home opened, the hospital could not retain sufficient staff to handle the number of cases that remained in the hospital therapy unit, as they did lose rehabilitation cases. However, a different problem arose: the remaining hospital post-acute care staff were working overtime, there was never enough staff for the daytime shift, and existing rehabilitation cases experienced long delays for therapy services. Where had Sunnyside gone wrong? The majority of the rehabilitation cases that had been transferred to the nursing home were short-stay cases that required minimal therapy services. The cases that remained at Sunnyside were therapy cases that were clinically complex and longer in duration, requiring more rehabilitation services and ongoing nursing care. It became clear that, when it came to measuring the work involved in servicing patients needing rehabilitation care, a case is not a case. A new approach to measuring the workload of the unit had to be devised. The care team in Sunnyside's post-acute care unit decided to look at each patient's functional assessment and need for rehabilitation care, as these assessments would more accurately reflect the measurement of work. When the team leader did a retrospective review of the 6 months prior to the opening of the nursing home and rnmnared it with the 6 months after the nurcind hnme nnening the denartment had