Daily Variation in Nursing Home Staffing Led to Poorer Clinical Quality

Daily variation in nursing home staffing was associated with poorer clinical quality in Medicare and Medicaid-certified nursing homes, suggesting that reporting staffing variation could help provide new quality improvement information,  according to a study published in JAMA Network Open.

Typically, nursing home quality regulations include minimum staffing standards to ensure that facilities provide residents with quality care. Meeting the average staffing level has been associated with better performance on process quality measures, on-site survey scores, and resident outcome measures.

CMS does not require nursing homes to report daily variation in staffing levels, even though facilities frequently experience different staffing levels during the week compared to the weekend or even day-to-day throughout the week.

To understand how daily variation in staffing impacts nursing home quality and to assess whether CMS should add it to the Nursing Home Care Compare (NHCC) report card, researchers gathered Payroll Based Journal data from 2017 to 2018 for Medicare and Medicaid-certified nursing homes. The data reported how many hours each staff member worked each day.

Researchers measured nursing home quality using the 5-Star Survey and the 5-Star Quality Measures included in the NHCC.

The final results included data from 13,339 nursing homes.

Researchers measured the coefficient of variation (COV)—the ratio of the annual SD of staffing hours per resident-day divided by its annual mean, total outlier days  (TOD)—the number of days during the year in which staffing hours per resident-day deviated from the annual facility mean in either direction by at least 20 percent, and low outlier days (LOD)—the number of days during the year in which staffing hours per resident-day were less than the annual facility mean by more than 20 percent.

The measures varied across nursing homes and differed for registered nurses (RNs) and certified nurse aides (CNAs). The mean COV was 0.50 for RNs and 0.13 for CNAs. The mean TOD was 220 for RNs and 44 for CNAs. The mean LOD for RNs was 116, while the measure for CNAs was 22.

Daily variation in nursing homes was negatively associated with 5-Star Survey and 5-Star Quality Measures rankings, the study found. The association for RNs and Survey rankings was higher than for CNAs and Quality Measure rankings.

Certain characteristics were associated with daily variation in nursing home staffing.

For example, for-profit nursing homes had more daily staffing variation than nonprofit and government-owned facilities, indicating that for-profit facilities tend to have less stable staffing. Being part of a chain was also negatively associated with measures of variation for RNs and CNAs.

Smaller nursing homes were also generally less stable, while larger facilities scored lower on the variability measures.

Nursing homes fall into quality deciles based on the measures from the NHCC, which includes average level of staffing. Researchers found that only one-third of nursing homes would fall into the same quality decile for their average staffing and daily variation measures, indicating little agreement between the classifications. The disagreement was more significant for CNAs compared to RNs.

The remaining two-thirds of nursing homes fell into vastly different quality deciles when considering the two staffing measures. These findings suggest that variation measures can offer additional information beyond the traditional average staffing measure.

Reporting daily variation of staffing in the NHCC may help consumers choose a quality nursing home more accurately, as high variation was associated with poor quality measures.

“From an organizational perspective, the absence of stable staffing inputs impedes management’s ability to create a high-reliability organization with consistent, safe workflows,” the study stated. “Everyday tasks, such as medication administration and monitoring, can be adversely affected by both inadequate staffing and a lack of stability in staffing availability.”

Considering staffing variation and not only staffing levels in nursing homes may offer new perspectives and improve quality, researchers said. However, variation in staffing may be common and even unavoidable as nursing home facilities face heightened staffing shortages during the COVID-19 pandemic.

Provider burnout, COVID-19 vaccine mandates, and COVID-19 surges have been driving factors behind the national nursing home staff shortages.