Daily Variation in Nursing Home Staffing and Its Association With Quality Measures

Mukamel, Dana B.; Saliba, Debra; Ladd, Heather; Konetzka, R. Tamara

doi:10.1001/jamanetworkopen.2022.2051

Cited by 15 publications

(15 citation statements)

References 37 publications

(64 reference statements)

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“…Our findings support the hypothesis proposed by Mukamel et al 12 with respect to most outcomes we studied for CNAs and LPNs but not for RNs. We found that, for CNAs and LPNs, the traditional staffing measures, based on average HPRD, and the new measure based on percentage of days of below-average staffing, were independently associated with outcomes in regression models, where each measure serves as a control for the other.…”

Section: Discussionsupporting

confidence: 93%

“…The below-average staffing days measure reflects the daily ability of the facility to meet the care needs of its residents. In proposing this measure, Mukamel et al 12 hypothesized that both the average staffing level and the daily deviations from the average would be independently associated with the quality of care and with resident outcomes. The objectives of this study were to examine this hypothesis and to assess it with respect to several important outcomes reported in NHCC.…”

Section: Discussionmentioning

confidence: 99%

“…The study demonstrated the importance and relevance of this concept in producing high-quality care in nursing homes. 12 In the present study we add to this foundational work that established a working definition of staffing instability by rigorously testing the hypothesis that staffing instability adds information about quality of care above and beyond the traditional average staffing measure. We estimate 12 regression models, 1 for each of 12 standard QMs, with all models including both the instability and the average staffing measures for RNs, LPNs, and CNAs.…”

Section: Introductionmentioning

confidence: 99%

“…A recent study has shown that when staffing variations are examined on a daily basis, different patterns emerge, revealing additional information about the association between nurse staffing levels and quality of care. Mukamel et al 12 defined new measures of below-average staffing days as the number of days during a period (eg, 1 year) in which the number of RN (or CNA or LPN) staffing hours per resident-day (HPRD) is less than 20% of the facility's average for the period. They have shown, for a national sample of nursing homes, that these measures are associated with other QMs such as the Five-Star QMs and survey ratings published by the CMS, as well as facility ownership.…”

Section: Introductionmentioning

confidence: 99%

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Association of Staffing Instability With Quality of Nursing Home Care

et al. 2023

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ImportanceRecent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown.ObjectiveTo examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels.Design, Setting, and ParticipantsThis quality improvement study of 14 717 nursing homes used the merged Centers for Medicare &amp; Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022.Main Outcomes and MeasuresLinear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations.ResultsFor the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P &lt; .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01).Conclusions and RelevanceThis study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Association of Staffing Instability With Quality of Nursing Home Care

et al. 2023

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“…Often, the number of nurses per resident is low, with 75% of nursing homes failing to meet Centers for Medicare & Medicaid Services' (CMS’) expected registered nurse staffing levels based on residents' acuity (Geng et al, 2019). Staffing is also highly variable from day to day (Geng et al, 2019; Mukamel et al, 2022), and the average annual staff turnover rate exceeds 120% (Gandhi et al, 2021). Residents may develop new health problems after nursing home admission due to unsafe care practices.…”

mentioning

confidence: 99%

Paying for Nursing Home Quality: An Elusive But Important Goal

Grabowski

Chen

Saliba

2023

J American Geriatrics Society

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Health Care Staff Turnover and Quality of Care at Nursing Homes

Shen,

McGarry,

Gandhi

2023

JAMA Intern Med

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ImportanceTurnover in health care staff may disrupt patient care and create operational and organizational challenges, and nursing home staff turnover rates are particularly high. Empirical evidence on the association between turnover and quality of care is limited and has typically relied on low-quality measures of turnover, small and selected samples of facilities, and comparisons across facilities that are highly susceptible to residual confounding.ObjectiveTo quantify the association between nursing home staff turnover and quality of care using within-facility variation over time in reliable turnover measures available for virtually all US nursing homes.Design, Setting, and ParticipantsIn this cross-sectional study, data from the Centers for Medicare &amp; Medicaid Services on health inspection citations and quality measures at US nursing homes were combined with turnover measures constructed from daily staffing payroll data for quarter 2 of 2017 (April 1 to June 30) to quarter 4 of 2019 (October 1 to December 31), covering 1.06 billion shifts for 7.48 million employment relationships at 15 869 facilities. A 2-way fixed-effects design was used to estimate the association between staff turnover (direct care nursing staff and administrators) and quality-of-care outcomes based on how the same facility performed differently in times of low and high turnover. Data analysis was performed from September 2022 to August 2023.ExposuresFacility turnover, defined as the share of hours worked in a period by staff hired within the last 90 days.Main Outcomes and MeasuresNumber, type, scope, and severity of health inspection citations, overall health inspection scores, and Nursing Home Compare quality measures.ResultsThe study sample included 1.45 million facility-weeks between April 1, 2017, and December 31, 2019, corresponding to 13 826 unique facilities. During an average facility-week, 15.0% of nursing staff and 11.6% of administrators were new hires due to recent turnover. After both administrator turnover and the overall staffing level were controlled for, an additional 10 percentage points in nursing staff turnover in the 2 weeks before a health inspection was associated with an additional 0.241 (95% CI, 0.084-0.399) citations in that inspection, compared with a mean of 5.98 citations. An additional 10 percentage points in nursing staff turnover was associated with a mean decrease of 0.035 (95% CI, 0.023-0.047) SDs in assessment-based quality measures and 0.020 (95% CI, 0.001-0.038) SDs in claims-based quality measures, with the strongest associations found for measures related to patient functioning.Conclusions and RelevanceWithin-facility variation in staff turnover was associated with decreased quality of care. These findings suggest that efforts to monitor and reduce staff turnover may be able to improve patient outcomes.

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Daily Variation in Nursing Home Staffing and Its Association With Quality Measures

Cited by 15 publications

References 37 publications

Association of Staffing Instability With Quality of Nursing Home Care

Association of Staffing Instability With Quality of Nursing Home Care

Paying for Nursing Home Quality: An Elusive But Important Goal

Health Care Staff Turnover and Quality of Care at Nursing Homes

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