Parkview Community Hospital Medical Center in Riverside, Calif. and South Haven, Mich.-based South Haven Community hospital selected the Keane InSight healthcare information system by Keane Inc. of Boston.

HFMA President and CEO Richard L. Clarke, DHA, FHFMA, discussed the increase in the number of consumers who are using credit cards to pay for their medical expenses during a segment on “NBC Nightly News.” The segment aired Feb. 7, 2007, and also was published on the MSNBC web site.

A recent study by Demos and the Access Project linked high credit-card debt to medical expenses. In a survey of low- and middle-income households, 29 percent of those who cited medical expenses as a factor in their credit card debt had higher balance–46 percent higher, on average–than those who did not use credit cards to pay for health care. Low- and middle-income households who used credit cards to pay for medical expenses averaged credit card debt of $11,623, according to the study, while households that did not charge medical expenses averaged credit card debt of $7,964.

Clark told “NBC Nightly News” that hospitals, too, are in a tight spot, given the number of patients who are uninsured (47 million) or who have high-deductible plans and cannot afford their deductibles.
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“The high-deductible health plans are causing hospitals to have to collect more up front,” Clarke told NBC. “[Hospitals] are worried about the fact that patients will need treatment, yet they won’t have the money to pay up front.”

Clarke also discussed rising costs in two other recent television appearances. He recorded two interviews with “First Business Morning News” to discuss HFMA’s recent report Healthcare Finance Outlook 2007. To watch the videos, visit www.hfma.org/about/pressroom and click on “press releases.”

WITH HEADLINES proclaiming another medical malpractice crisis, it’s a good idea to take stock of how physicians conduct business with patients.

Let’s face it, in malpractice cases the trouble doesn’t begin with lawyers, it begins with doctors’ interactions with patients. Patients who feel well cared for and have an amicable relationship with their physicians rarely sue, even when there may be a poor outcome to some element of a care plan.

In medical practice for 38 years, I’ve seen the malpractice concerns of physicians rise from minimal to, sometimes, almost hysterical. The scope of our problems accelerated in the early 1970s.

I believe our risks for litigation grew as individuals dispersed away from their core family groups after World War II. The close, long-term contacts with which many of us grew up in our well-defined communities were disrupted. Trust became a victim of that dispersion. People did not have the family ties and, due to frequent moves, did not develop new ones.

That mobile pattern continues to increase today. In addition, the highly publicized scientific developments in medicine began to make the public believe that medicine could cure almost anything and expectations became unrealistic in many cases.
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This combination of lost trust in physicians and publicity surrounding miracle cures played a large part in the development of the litigious society in which we live. Of course, this litigious attitude is not limited to physicians, but it hits us hard when we see our insurance premiums rise each year and our coverages reduced.

Cost of doing business

Involved in medical malpractice crisis since the early 1970s with the Nebraska Medical Association committee on malpractice, I later served as a co-author in a group that helped write the Nebraska medical malpractice statute that still exists today.

In the mid-1980s while a professor of family medicine at the University of Cincinnati, I took a sabbatical at the University of Cincinnati College of Law as a scholar in residence to study the basic elements of tort law and how they affect the medical profession. That sojourn led to continued activity in the area of malpractice for the past 16 years.

After leaving law school, I continued to practice medicine, but also worked as a consultant with a number of law firms to review potential malpractice cases. I reviewed cases for plaintiffs attorneys, defense lawyers and medical malpractice insurance companies. I occasionally served as a witness for both defense and plaintiffs.

It is my observation that most doctors practice quite good medicine, but some just don’t do their jobs with care. There truly is medical malpractice out there, but in some cases malpractice suits are filed due to factual misunderstandings or poor communication.

Unfortunately, even good physicians are sometimes inadvertently negligent in the care of a patient. Most negligence is an unintended lapse or accident and not a sign of incompetence. Good doctors do get sued and this does not necessarily reflect on their abilities. Nonetheless, litigation is an unhappy cost of doing business in our society.

On the other hand, there are some doctors that I am ashamed to call colleagues. Their behavior toward patients would turn the stomach of even the most adamant defenders of the medical profession.

It is our duty to police ourselves and protect patients. We have a sworn duty to do no harm and that duty extends to preventing harm done by others.

Avoiding lawsuits

Based on my experience in the review of over 200 medical malpractice cases, I created a list 10 ways to help practitioners to avoid litigation. The list is not all-inclusive, but it does provide a number of preventive measures that, if followed, can reduce litigation risks significantly.

(1) Maintain open communication.

One of the leading causes of litigation is poor communication between doctors and patients.

Patients view their physicians as arrogant or distant when they do not make an effort to speak with them and their families.

I recently dealt with a case that centered solely on a surgeon’s failure to explain to the family the complications that arose during an elderly patient’s operation. The need to communicate with patients and families pertains to us all.

Remember the great French barber surgeon Ambrose Pare’s admonition to all physicians; “We are sometimes to cure, often to treat, but always to console.”

(2) Keep accurate medical records.

Keep clear and concise records. If handwritten, be certain the records are legible.

I went to a trial where a physician could not read his own medical records. It cost his insurance company a bundle. Use only standard abbreviations. Do not use personal codes that others cannot decipher.

The records are for the benefit of patients and the information they contain belongs to them. Keep pertinent positives and negatives in the notes.

A record needs to reflect the logical pursuit of a diagnosis and treatment plan. Remember, the records must be kept confidential.

The Senate bill, similar to one the House passed in March, would have limited awards for pain and suffering to $250,000. By a largely party-line vote of 49-48, the bill fell 11 votes short of the 60 required to break a Democratic filibuster. Republicans cast all 49 votes in favor of the measure. Two Republicans–Senators Lindsey Graham (S.C.) and Richard Shelby (Ala.)–joined 45 Democrats and one independent in voting against the measure.

Majority Leader Bill Frist, who has made malpractice-reform his signature issue, brought the bill up for a vote in the Senate without committee hearings or public testimony–a move reminiscent of Lyndon Johnson in his Senate days. By bringing the bill up for a vote, even if it would not pass, Frist forced Democrats to take a stand, exposing them to more pressure from lobbyists and the public.

The issue is not dead for this Congress, with a second vote corning perhaps as early as this fall. Even if that vote fails, the issue will have been framed for Campaign 2004. To paraphrase the Wall Street Journal’s July 9, 2003, editorial, voters know the difference between a lawyer and a physician.
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Democrats have gone on the offensive with their own plans for medical malpractice change, focusing on insurance-industry reforms and tax benefits for providers. Alternative medical liability legislation sponsored by Florida Democratic Senator (and presidential candidate) Bob Graham would not cap noneconomic damages in malpractice lawsuits; instead, Graham would provide tax credits for physicians and hospitals to help cover the cost of malpractice insurance.

The Graham-sponsored bill also would repeal malpractice antitrust exemptions for the insurance industry, provide $10 million in grants to help local governments attract physicians in areas with high malpractice insurance premium rates, and establish a system to penalize attorneys who rile frivolous malpractice lawsuits. In addition, the bill would establish a commission to study increased malpractice insurance costs.

Legislative Impasse

How did we get to this impasse? With a Republican in the White House and Republicans controlling both houses of Congress, proponents of malpractice-law changes should have had their case already made for them.

But in February, just as the House was planning to take up its bill, Jessica Santillan, a 17-year-old transplant patient, died after physicians at Duke University in North Carolina gave her a heart and lung of the wrong blood type. Opponents of the bill cited the death in arguing that a $250,000 cap for pain and suffering was too low. Critics, including some Senate Republicans, began to argue that any malpractice legislation would need an exemption for catastrophic cases.

For a time, it seemed that Republicans and Democrats might be able to broker a deal. But the lead Democrat in the negotiations, Senator Dianne Feinstein of California, dropped out when physician groups refused to support a proposal that would limit jury awards for pain and suffering to $500,000.

What Is Causing the Crisis?

Solving the problem requires that we look beyond the politics of passing legislation to the cause. Since 1999, medical malpractice premium rates have increased dramatically for physicians in some specialties in a number of states. Much outcry has targeted trial lawyers, accompanied by anecdotal allegations of frivolous lawsuits and run-away juries awarding outlandish judgments.

But in a General Accounting Office (GAO) report this past July (GAO-03-702), the blame was spread much more widely. Multiple factors, including falling insurer investment income, depressed stock-market values, and the insurance industry’s rising reinsurance costs, have contributed to recent increases in premium rates.

The GAO did find that losses from medical-malpractice litigation, both in judgments and settlements, made up the largest part of insurers’ costs. These costs have been, the GAO said, the primary driver of rate increases over the long run. But while losses for the entire industry have shown a persistent upward trend, insurers’ loss experiences have varied dramatically across the several states, resulting in wide variations in premium rates.

The economic boom of the late 1990s, and the high return insurers received on their investments, allowed many malpractice insurers to price their insurance below the expected cost of paying claims. In a competitive marketplace, this strategy created a lag between collecting premiums and paying claims.

Now the economic boom is over, and the market is mandating large premium rate hikes to cover the losses masked in earlier years. In some areas particularly hard hit by malpractice rate changes, providers are just now catching up with other market areas, and the premium adjustments are severe.

New research published in the latest issue of Journal of Empirical Legal Studies examines Texas medical malpractice claims and finds no tort crisis. Instead, the study’s authors find that, over a 15 year period, the system was largely stable and generated few significant changes in claim frequencies, payments, or jury verdicts. “Average payments on medical malpractice claims rose because small claims were squeezed out of the system over time, not because payments on larger claims increased,” the authors explain. The authors used a comprehensive database of insured closed claims maintained by the Texas Department of Insurance since 1988. The data presented a picture of stability in most respects and only moderate change in others. Their research also revealed a weak connection between claims-related costs and short-to-medium fluctuations in insurance premiums. “Our hope is that better understanding of the claims process will lead to reforms that address real shortcomings in the malpractice litigation and claims payment systems, rather than respond to anecdotes or the rhetoric of crisis” the authors Bernard Black, Charles Silver, David A. Hyman and William M. Sage conclude. From 2000 to 2004, the increase in premiums collected by the leading 15 medical malpractice insurance companies was 21 times the increase in the claims they paid, according to the study.

Few people would disagree that the current state-specific medical liability systems throughout the United States are slated for significant changes to address what many have termed the “medical malpractice crisis.” (1) Although there seems to be consensus regarding the breadth of the so-called crisis and the need for successful reform, there is little agreement regarding which methods of change will result in the most effective strategy for medical malpractice reform. The fact that more than 400 legislative bills on this topic were filed in 48 states in 2005 is indicative of the diverse, and oftentimes contentious, solutions to reform. (2)

The numerous solutions suggested by state legislators illustrate that medical malpractice reform is a multidimensional issue that cannot be resolved with one distinct strategy. Legislators must take a number of factors into consideration when proposing medical malpractice reform strategies, making the task both complex and controversial. Among the many elements that factor into the reform strategies are economics (eg, rising health care costs, increased medical malpractice insurance premiums, jury awards in malpractice lawsuits); patient rights (eg, access to quality health care, compensation for negligent medical acts); regulatory aspects (eg, of physicians, the insurance industry, attorneys); and the affect of the proposed law on existing laws both at the state and federal levels.

CURRENT MEDICAL MALPRACTICE LAWS
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This article explores some of the reform strategies that state governments have adopted, including the elements of the medical malpractice system the state legislatures intended to change. It also provides a brief discussion regarding the states in which medical malpractice reform initiatives are anticipated to continue during the 2006 state legislative session. Overall, this article explores the extreme complexity and political polarization that state legislators face in attempting to successfully achieve medical malpractice liability reform.

Damage caps. One of the common approaches to medical malpractice reform adopted by states is to implement damage caps. Damage caps limit the amount of money a patient can receive as compensation for injury(ies) suffered as a result of an alleged negligent medical act. Approximately 32 states have laws that cap specific types of compensatory damage awards in medical malpractice cases. (3) Many of these laws restrict the amount of money that a patient can receive for noneconomic damages or what is often referred to as “pain and suffering.” (4)

For example, Alaska, California, Idaho, Kansas, Montana, Ohio, Texas, and West Virginia laws prohibit a patient from receiving more than $250,000 for noneconomic damages. (3) One rationale behind noneconomic damage caps is that because such damages are extremely difficult to quantify, a jury often will inflate the award to the injured patient. In turn, such awards are believed to increase the costs associated with medical malpractice insurance (eg, increased medical insurance premiums that then create increased health care costs). (4)

Other states, including Colorado, Indiana, Louisiana, Nebraska, New Mexico, and Virginia, have laws that apply in all injury-related cases, medical liability Included, that cap the monetary amount that an injured patient can receive for all damages, both economic (eg, lost wages) and noneconomic. (4) Further, a number of states have adopted laws that restrict the amount of and the conditions under which monetary damages are awarded to punish the health care provider for a “wanton disregard of [patient] safety” (ie, punitive damages). (3,5)

Although they are popular in the medical malpractice reform arena, damage caps are not without their critics. Opponents of damage caps, including attorneys and patient rights and safety organizations, contend that damage caps penalize the most seriously Injured patients while reducing health care providers’ accountability for negligent acts. (4)

Modifying the collateral source rule. A second approach to medical liability reform that a number of states adopt is modifying the collateral source rule. Intact, the collateral source rule prohibits defendants from introducing information at trial or during negotiation for the purpose of off setting the damages awarded by asserting that the plaintiff may have received compensation from another source (eg, worker’s compensation, another Insurer). (5)

Connecticut, Hawaii, Maryland, Missouri, North Carolina, Oklahoma, Oregon, Tennessee, and Vermont permit consideration of collateral source payments received by the patient when damages are awarded in medical malpractice cases. (6) Proponents of this type of reform argue that “[w]hen a plaintiff receives compensation from their insurance company and again at trial, the Insurance proceeds do not represent actual compensation for an Individual’s injuries, but rather a source of windfall.” (7)

A recent randomized, controlled trial conducted in Italy sheds new light on the use of spinal manipulation in the treatment of acute back pain and sciatica with disc protrusion. Results of the study, published in a recent issue of The Spine Journal, indicate that active spinal manipulation relieves pain more effectively than a sham simulation, leading to fewer days of localized pain and fewer days of radiating pain, and with no side-effects.

The study population consisted of 102 adults seen in two medical rehabilitation centers in Rome. All of the patients demonstrated the following characteristics: moderate to severe low back pain, moderate to severe radiating pain in one leg, and MRI evidence of disc protrusion in the spinal segments believed to be associated with the pain. Obese patients with acute LBP were excluded, as were patients with chronic LBP, disc protrusion with a ruptured annulus, and those who had already received spinal manipulation.

Upon admission to the study, each patient was interviewed and given a complete physical examination. During the interview, researchers collected detailed information on low back pain and leg pain (using a pair of visual analog scores), including the location of pain and the patient’s overall quality of life with the pain.
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Participants were randomized into two types of manipulation groups active and simulated. Individuals in the active manipulation group received a maximum of 20 sessions over a 30-day period, with each session lasting five minutes. Active manipulation consisted of examining the range of motion in the patient’s back, followed by soft-tissue manipulation and “brisk rotational thrusting away from the greatest restriction.” The purpose of manipulation was to restore movement to the “physiological motor unit” (with each motor unit consisting of two vertebrae, disc and surrounding structures). Subjects in the simulated manipulation group received soft muscle pressing that was similar to manipulation, but did not follow any specific patterns or involve rapid thrusts. All manipulations were performed by two experienced chiropractors with similar formal training from a U.S. chiropractic college.

During the treatment period, patients in both groups were asked to track the number of days they were in pain, the number and type of nonsteroidal antiinflammatory drugs (NSAIDs) they took, and the number of drug prescriptions. In addition, patients were assessed at 15, 30, 45, 90 and 180 days to document changes in pain.

Among the variables the researchers measured were the number of patients who were free of pain at the end of the study period, along with treatment failure (the number of patients who stopped receiving care because it failed to relieve the pain). Changes in visual analog scores at both anatomical locations and in the number of patients experiencing a reduction in disc protrusion (at 45 days) also were recorded.

Results

At the end of the follow-up period, the authors noted “a significant difference” in the percentage of patients between manipulation groups who were pain-free. Fifty-five percent of patients in the active treatment group were free of radiating pain, compared to only 20 percent of patients who received simulated manipulations. Moreover, 28 percent of the active manipulation patients were free of local pain, versus 6 percent of simulated manipulation patients.

In addition, there were significant differences between groups in terms of the number of days patients suffered pain. Active manipulation patients experienced an average of 23.6 days with pain (including 13.9 days experiencing moderate or severe pain). Among patients who received simulated manipulations, the average number of days with pain was higher (27.4), as was the number of days they experienced moderate or severe pain (17.9). Patients who received active manipulations also reported taking fewer NSAIDs and for fewer days than simulated-manipulation patients, although these results were considered nonsignificant. No adverse events were reported by patients.

Two limitations were noted by the study authors: the lack of an exit interview (which precluded the researchers from ascertaining whether the patients were truly “blinded” with regard to treatment) and the specificity of the condition being treated (pain with disc protrusion). Because of these limits, the authors stated that their study “needs to be replicated in other settings to verify its findings.”

Limitations aside, active chiropractic manipulation appeared to have a greater effect on overall pain relief than simulated chiropractic manipulation, with secondary benefits such as reduced use of pain medication, and without causing any adverse effects. As the researchers noted in the study’s conclusion:

“Patients receiving active manipulations enjoyed significantly greater relief of local and radiating acute LBP, spent fewer days with moderate-to-severe pain, and consumed fewer drugs for the control of pain. … Thus, manipulations may relieve acute back pain and sciatica with disc protrusion, although the results of subgroup analyses must be interpreted with caution.”

* Don’t be afraid of needles–especially if you suffer from arthritis pain. A study published in the British Medical Journal shows that acupuncture may be an effective treatment for osteoarthritis of the knee. Researchers gave 97 patients older than age 45, who had never received acupuncture, the anti-inflammatory medication diclofenac and either authentic or placebo acupuncture treatments. The same certified professional performed all acupuncture procedures, using needles with adhesive ends that didn’t penetrate the skin during the placebo procedures. Those who received the true acupuncture took less medication and reported better knee function at the end of 12 weeks.

Staying abreast of technological advancements in manufacturing is a daunting task. Over the past years while machine tool capacity has become an issue, management’s first response has likely been to reduce cycle times and/or purchase new machines. For years, the misconception that automation is only for production has persisted. However, for one Indianola, Pennsylvania shop, challenging this notion and taking a look “outside the box” has enabled the company to standardize its fixturing procedures while reducing errors.

Founded in 1964, Medrad Inc. operates according to the slogan “Performance for Life.” The company says its mission is to become a worldwide leader of medical devices and services, to either enable or enhance diagnostic and therapeutic imaging procedures. Daniel Kazousky, Manager of the Rapid Prototyping Center for Medrad, recently faced a serious manufacturing problem–his department needed to increase throughput and improve the overall turnaround time for mold production.

Even though the company employs hundreds of individuals around the world, the Rapid Prototyping Department is no bigger than the average job shop, with a staff of approximately seven to ten individuals. During a typical year, the department produces about 50 injection molds. On the machining side every year, nearly 3,000 new parts are completed for product development. To support the steel inserts and mold plates necessary for manufacturing these parts, the company uses just two machining centers.
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“Although we were producing quality molds in-house faster than could be done if outsourced, we felt internal pressure to operate more effectively by increasing our overall flow of output,” explains Mr. Kazousky. “The urgency we faced involved a bottleneck at the primary point of burning (EDMing) the steel. This was partially the result of our not being able to produce electrodes quickly enough.”

After discussing its options, the company contacted its current EDM supplier to discuss the problem. At first, Medrad contemplated adding another sinker EDM to improve the volume of mold throughput. To the company’s surprise, however, the supplier proposed taking a different route. Suggesting that automation could resolve many of the issues, the supplier referred Medrad to a local representative for Erowa Technology (Arlington Heights, Illinois).

Mr. Kazousky says he was shocked to learn that purchasing an additional sinker EDM and/or milling center was, albeit an obvious solution, not the best option in terms of the overall production problem “My first thought was that automation would be far too costly for an organization our size,” he says. “We were just a small job shop tackling one and two jobs at a time.”

Putting his skepticism aside, Mr. Kazousky called Erowa Technology to investigate the process. By his own admission, Mr. Kazousky had previously been “in the dark” about what automation actually entailed. His rationale was that there was no harm in exploring the viability of the automation packages available. It wasn’t until he spoke with Bob Meyers, Senior Applications Engineer for Erowa Technology that Mr. Kazousky says he realized that automation was attainable for his company and that the entire process could be implemented on the machining centers operating within the prototyping department.

“Some are afraid that automation will eliminate jobs in the plant,” states Mr. Meyers. “By adding automation to your machining centers, however, you can use your machines, work space and employees more efficiently. In addition, companies can improve production output and quality.

“It should never be the reason employees lose their jobs,” he adds.

In addition to working with Mr. Meyers, the company consulted Tom Watkins, Erowa’s Vice President of Engineering. Together, the two examined the applications being performed by Medrad, and then they collaborated to pinpoint the appropriate package.

Mr. Meyers had to take into account the characteristics of the part being produced; more specifically, size, weight and average cycle time to make the part before selecting a package. The team also needed to understand exactly how much time the machine would run unattended. Thereafter, Erowa made some specific calculations regarding the storage capacity in various robots to decide which would be the best fit for Medrad.

“We didn’t want to short-change the customer by suggesting only the purchase of electrode tooling to reduce setup time,” says Mr. Watkins. “At the same time, we only wanted to present an automation solution that was absolutely essential for improved efficiency and output.”

What followed was the purchase of Erowa’s Robot Multi and the EasyChange Robot and ITS palletizing system. The ITS Zero Point palletizing system uses a chuck operating on a principle that allows the company to standardize its fixturing procedures. It holds both electrodes and workpieces with equal precision and with a high degree of repeatability, says the manufacturer. Appropriate for numerous applications, it is the basis for a modular tooling system. Able to be integrated on milling, grinding and drilling machines, on EDM sinking and WEDM centers or on measuring and presetting stations, ITS assists the company in achieving a more profitable use of production time.

This study used a sample of 209 repeat-respondent medical technologists over a 4-year period to investigate correlates of intent to leave one’s job. Correlates measured included two job search behaviors (i.e., preparatory and active) and three job search motives (i.e., gain leverage, leave employer, and family related). Results showed that active job search and the leave employer job search motives were each positively related to final intent to leave one’s job. The gain leverage job search motive was negatively related to final intent to leave one’s job. In addition, job satisfaction was negatively related, while only initial job loss insecurity was positively related, to final intent to leave one’s job. J Allied Health 2006; 35:94-100.

JOB SEARCH remains an important applied topic and research area for study across different samples, for example, graduating students entering the job market,1,2 the unemployed,3-5 and the employed.6-8 Job search is also a topic of international interest.4,9-11 Recent research on further understanding job search has focused on personality-motivation and cognitive ability variables,7 including a meta-analysis by Kanfer et al.12 The dominant research samples captured in the meta-analysis by Kanfer et al. were individuals entering the job market following a period of full-time education or those who were unemployed. Boudreau et al.7 argued for focusing more job search research on those currently employed because they compose a larger domain. There is a current general shortage of health care employees in the United States, including nursing, radiologic technology, and medical technology employees.13-15 Any type of labor shortage in a particular occupation can make it easier for those currently employed to change jobs across organizations.16 The purpose of this study was to further investigate the impact of correlates on medical technologists’ intent to leave their jobs.
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Why Do the Employed Job Search? Different Motives

Using a sample of higher-level managers, Boswell et al.6 distinguished between specific leverage-seeking versus separation-seeking job search motives or objectives. They found that leverage-seeking but not separation-seeking search was positively associated with actual use of leverage one year later, while separation-seeking but not leverage-seeking search was positively associated with voluntary turnover one year later.

Bretz et al.17 observed that because job search activity may not always be associated with separation, there can be greater observed variance in search behavior than turnover. Using a sample of 1,388 employed managers, Bretz et al.17 found that a considerable amount of managers’ job search activity did not lead to subsequent voluntary turnover. Whether it leads to voluntary turnover or not, job search by itself can be a costly behavior because it can distract an employee from his or her current job duties18 or reduce the employee’s commitment to his or her current employer.19

Beyond its relevance to voluntary turnover, research has suggested that job search can serve several other distinct purposes for the employed.17 A second “motive” suggested for job search is to increase one’s leverage or advantage in a current job,20 such as gaining higher pay or other improved employment conditions. Clearly this motive is related to at least some degree of employee unhappiness with the current job situation. However, this motive suggests that employees do not necessarily want to leave their employer but to improve their situation (e.g., pay, promotion) while remaining with their current employer.21 Deshpande and Schoderbek22 found that getting a job offer elsewhere was used by subordinates to get a pay raise from their current boss. There can be “other” motives for job search, such as family related. For example, if one’s working spouse is transferred, the affected individual must now find a new job in the working spouse’s new location. Another family-related reason for job search is if an employee moves to be closer to an elderly parent to help care for that parent.16

Job Search Activity

For an individual who voluntarily changes jobs, most prior turnover research suggests that the closest proximal determinant to such change is the intent to leave that job.”16,23 Prior theory on job search activity suggests distinct preparatory and active search phases (Rees24 and Soelberg,25 as noted by Power and Aldag26). During the preparatory phase, individuals gather their resources (e.g., prepare/revise their resume, research getting/changing jobs) and collect potential job leads through various sources (e.g., Internet, newspaper, friends, previous employers); in the active phase, individuals apply to specific job positions/employers they have identified (e.g., sending a resume to or interviewing with an employer, filling out a job application). Generally, it is assumed that preparatory job search precedes active job search, because often individuals will want to first determine the perceived availability of “greener pastures” (preparatory job search) before determining their accessibility,27 which involves active job search.