The Impact of Chain Standardization on Nursing Home Staffing

Abstract

Background: Standardization in production is common in multi-entity chain organizations. Although chains are prominent in the nursing home sector, standardization in care has not been studied. One way nursing home chains may standardize is by controlling the level and mix of staffing in member homes. Objectives: To examine the extent to which standardization occurred in staffing, its relative presence across different types of chains, and whether facilities became more standardized following acquisition by a chain. Research Design: We estimated predictors of the difference between facility and chain staffing using Generalized Estimating Equations with 2000-2010 data. Subjects: This study included nursing homes nationally, excluding hospital-based homes and homes in Alaska, Hawaii, and District of Columbia. Measures: Chain ownership was coded from text identifying chain names. Two nurse staffing measures were used: staff hours per resident day and staff mix. Results: Very large for-profit chain nursing homes and large nonprofits had less variation in staff hours per resident day (p<.001) but greater variation in staffing mix (p<.001) compared to the chain average nationally. Large for-profit chains and medium nonprofit chains had greater dispersion on staff hours per resident day (p<.001), while large nonprofit chains had greater dispersion in staffing mix (p<.001). The difference between facility and chain staffing decreased over time. Conclusions: The largest chains (for profit and nonprofit) had less staffing variation compared to national standards, suggesting they were best at implementing corporate practices. Following ownership changes, staffing converged towards chain averages over time, suggesting standardization takes time to implement.

Are firms with ‘deep pockets’ more responsive to tort liability? Evidence from nursing homes

“…This in turn, means that large chain inputs may still respond very elastically to changes in the tort environment, even if their marginal inputs have little effect on quality. As noted previously, there is evidence that chains, and particularly large chains, use rules or algorithms to staff their homes (Banaszak‐Holl et al., 2018).…”

“…Second, we contribute to the literature on the role of large corporate chains in health care services. Within the nursing home industry there is a strand of research that concludes that chains, and particularly large chains, provide standardized care measured in terms of nursing inputs and that these staffing practices are implemented following an acquisition (Banaszak-Holl et al, 2018). Kamimura et al (2007) find mixed effects of self-reported chain standardization on quality while several other papers find that nursing home chains provide worse quality, overall (Harrington et al, 2001, GAO, 2009, You et al, 2016 Our research shows how staffing practices of large chains can be materially affected by litigation risk.…”

“…Second, we contribute to the literature on the role of large corporate chains in health care services. Within the nursing home industry there is a strand of research that concludes that chains, and particularly large chains, provide standardized care measured in terms of nursing inputs and that these staffing practices are implemented following an acquisition (Banaszak‐Holl et al., 2018). Kamimura et al.…”