Almost all states had some type of formal training as part of their quality improvement programs. In general, these training sessions have been well attended and feedback has been positive. It is not possible to determine whether these training programs have led to quality improvements, although there is some anecdotal evidence of practice changes that were made following training sessions. The experiences of states that have conducted joint surveyor-provider training programs is mixed. Having both surveyors and providers at the same training session often inhibits discussion, and there is often resistance from both sides. Such sessions do, however, ensure that both providers and surveyors receive the same information and may ultimately help to improve the surveyor-provider relationship, leading to better communication during the survey process. With respect to training programs, some participants noted the need to educate the public about realistic expectations regarding nursing home care outcomes and the need for facility training to help them to manage better the expectations of patients and families.