Staffing Ratios and Quality: An Analysis of Minimum Direct Care Staffing Requirements in Nursing Homes

Department of Economics, Farmer School of Business, Miami University, 800 E. High Street, Oxford, OH 45056, USA.
Health Services Research (Impact Factor: 2.78). 05/2011; 46(5):1495-516. DOI: 10.1111/j.1475-6773.2011.01274.x
Source: PubMed


To study the impact of minimum direct care staffing (MDCS) requirements on nurse staffing levels, nurse skill mix, and quality.
U.S. nursing home facility data from the Online Survey Certification and Reporting (OSCAR) System merged with MDCS requirements. STUDY DESIGN; Facility-level outcomes of nurse staffing levels, nurse skill mix, and quality measures are regressed on the level of nurse staffing required by MDCS requirements in the prior year and other controls using fixed effect panel regression. Quality measures are care practices, resident outcomes, and regulatory deficiencies. DATA EXTRACTION METHOD: Analysis used all OSCAR surveys from 1999 to 2004, resulting in 17,552 unique facilities with a total of 94,371 survey observations.
The effect of MDCS requirements varied with reliance of the nursing home on Medicaid. Higher MDCS requirements increase nurse staffing levels, while their effect on nurse skill mix depends on the reliance of the nursing home on Medicaid. MDCS have mixed effects on care practices but are generally associated with improved resident outcomes and meeting regulatory standards.
MDCS requirements change staffing levels and skill mix, improve certain aspects of quality, but can also lead to use of care practices associated with lower quality.

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    • "The study findings are consistent with previous studies, in which stronger RN and total staffing standards are related to higher RN and total staffing levels (Bowblis, 2011; Harrington et al., 2007; Mueller et al., 2006). And, the facility-level measurement used in this study could provide additional understanding of the policy impact. "
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    ABSTRACT: This study investigated the impact of state nursing home staffing standards on nurse staffing levels for the year 2011. Specifically, the study attempted to measure state staffing standards at facility level (i.e., nurse staffing levels that each individual nursing home must retain by its state staffing standards) and analyzed the policy impact. The study findings indicated that state staffing standards for the categories of registered nurse, licensed nurse, or total nurse are positively related to registered nurse, licensed nurse, or total nurse staffing levels, respectively. Nursing homes more actively responded to licensed staffing requirements than total staffing requirements. However, nursing homes did not increase their staffing levels as much as those required by state staffing standards. It is possibly because the quality-oriented inspection allows flexibility in nursing homes' control of nurse staffing levels. © The Author(s) 2015.
    Medical Care Research and Review 07/2015; DOI:10.1177/1077558715594733 · 2.62 Impact Factor
    • "The authors assume that if the RN is not situated at the elderly setting, there is a higher risk of adverse events. Among the few studies in elderly care reporting levels of competence and adverse events, Bowblis (2011) found an association between increased RN staffing and decreased rates of pressure ulcers. Lerner (2013) pointed out that the RN staffing in elderly care settings was not associated with numbers of deficiencies but with the deficiency severity. "
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    ABSTRACT: Patient safety is an important global issue. While it is well known that patients can suffer from adverse events in nursing care, there is a lack of knowledge as to how they experience them. To examine adverse events in nursing care as they are experienced by patients and relatives. This was a retrospective study taking both a qualitative and a quantitative approach. It was based on data regarding 242 adverse events in nursing care, as reported by patients and relatives to Sweden's Medical Responsibility Board, content analysis was used to analyse the reports. Patients' and relatives' experiences were analysed into four categories of adverse events, as concerning participation, clinical judgement, nursing intervention and the essentials of care. The reports were classified by the Medical Responsibility Board, without a standardized system. The adverse events reported were few in number and were reported by patients and relatives only. Lack of participation has negative consequences and contributes to adverse events. Adverse events occur through missed care as well as through carer errors. Nurses need to improve their skills that support patient participation. Patient participation needs to be incorporated into nurses' duties. Resources for patients to participate in their own care needs to be a priority underpinning policy-making in health systems. Nursing education systems need to teach students about the value and benefits of involving patients in their care. © 2015 International Council of Nurses.
    International Nursing Review 06/2015; 62(3). DOI:10.1111/inr.12192 · 0.95 Impact Factor
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    • "These regulations increase costs by forcing many NHs to hire additional nurses, and may lower quality in other dimensions, such as quality of life. For example, NHs substitute higher skilled nurses, such as RNs and LPNs, for lower skilled and less costly CNAs (Park and Stearns 2009; Bowblis 2011a), or NHs reduce staffing in areas not specifically related to nurse staffing, such as support staff (Thomas et al. 2010; Bowblis and Hyer 2013). "
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    ABSTRACT: The implementation of regulation in the health care sector is often motivated by assuring a minimum level of quality, but there is little understanding of the cost of this regulation. This paper explores the cost of regulation in the nursing home industry. Using panel data on the same nursing homes from 1999 to 2004, this paper examines how financial performance is impacted by regulations that increased the minimum number of nurses that provide direct care to residents. While nursing homes attempt to increase revenues and mitigate the cost of responding to more stringent regulation, various measures of profitability show nursing homes are worse off financially. In fact, more stringent staffing regulations cause some nursing homes to lose money providing services.
    Journal of Regulatory Economics 06/2015; 47(3). DOI:10.1007/s11149-015-9269-z · 0.84 Impact Factor
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