Stakeholders were universally concerned about staff turnover and the related issues of maintaining adequate staffing in facilities. All complained of staffing shortages, high turnover, lack of mid-level staff with management skills, and pervasive use of contract staff. One state's consumer representative said that while she was not opposed to new quality improvement programs, the main issues at hand concerned inadequate staffing of the programs currently operating. Some stakeholders, particularly consumers, believe that the best thing the Federal Government can do to improve nursing home quality is to do "whatever it takes to improve staffing." On the other hand, some providers expressed concern that requiring minimum staffing ratios would not be appropriate, particularly if there were not significant reimbursement increases to pay for the higher staffing levels. There is concern about the ability to staff at the required level, given the nursing shortages that exist in many parts of the country, and also concern about how to account for differences in facility case mix in determining the required minimum staffing level for each facility.