Staffing Measure

Statement of Alice H. Hedt, Executive Director

For the CMS Staffing Quality Measures Project

March 2, 2004

Since its founding in 1975, the National Citizens’ Coalition for Nursing Home Reform has consistently identified an adequate, well-trained workforce as the primary key to good nursing home care. As a member of the National Quality Forum steering committee that developed recommendations for the nursing home Quality Measures (QMs), NCCNHR strongly advocated for a measure on nurse staffing. Although the other measures that the NQF recommended to CMS are indicators of quality, if we could select only one identifier of a good nursing home, nurse staffing is the one we would choose.

Most of the neglect and abuse that plague so much of the nursing home industry could be eliminated if nursing homes were required to meet the minimum standards identified by Andrew Kramer and John Schnelle in HHS’s study of the appropriateness of requiring minimum nurse staffing ratios. NCCNHR is extremely pleased that Dr. Kramer is now engaged in this project to develop Quality Measures on nurse staffing so that consumers at least can judge for themselves whether or not facilities are adequately staffed.

Following are NCCNHR’s recommendations:

• Quality Measures for nurse staffing cannot be developed without accurate data on the total number of residents and total number of direct care nursing staff (RNs, LPNs/ LVNs, and CNAs) in every certified facility. While we understand that CMS is considering ways to improve the current, self-reported data on OSCAR, we urge it to move forward immediately to implement a new, audited data collection system. Research begun during Phase II of the staffing ratio study and completed last year should enable CMS to design a data collection system based on payroll records and invoices. This new system should be developed as quickly as possible and be put in place no later than the completion of this project to develop Quality Measures for staffing.

• NCCNHR recommends reporting the QMs in both case-mix adjusted and unadjusted formats. Although staffing measures may be case mix-adjusted, the minimum staffing level identified in the Phase II report -- 4.1 hours of direct care per resident day – should be the baseline for the standard. This level of staffing is essential to perform the minimum tasks of nursing home care and to prevent adverse events, such as loss of functioning, pressure sores, and avoidable hospitalizations. This was the conclusion of a distinguished panel of experts convened by the John A. Hartford Institute for Geriatric Nursing that evaluated the staffing standards adopted by NCCNHR members in 1998; it was confirmed by the research of Dr. Kramer and Dr. Schnelle in the HHS study. Some nursing homes may require more hours of nurse staffing, but few if any could provide good care with fewer hours of care.

• NCCNHR supports implementation of Quality Measures based on ratios expressed as hours of direct care per resident day. (1) One set of measures would be disaggregated by type of direct care provider (RN, LPN/LVN, or nurse aide).  (2) A separate Quality Measure would show these direct care staff as total nurse staffing hours per resident day. Feeding assistants, medication aides, and other non-nursing personnel should not be included.

• The collection of staffing data from payroll records and invoices will enable CMS to develop Quality Measures that reflect two other powerful indicators of quality: (1) nursing staff turnover/retention, and (2) use of temporary agency personnel. NCCNHR strongly supports the development of Quality Measures that incorporate turnover/retention and use of agency staff.  

• In addition to the Quality Measures, NCCNHR recommends that Nursing Home Compare make additional information available. Currently, other consumer Web sites, both public and private, publish information such as CNA wages, “productive” hours of non-nursing staff per resident day, change in nursing staff, expenditures for direct care staff per resident day, and numerical ratios of nursing staff to residents. Consumers continue to tell us that this other staffing information is essential.

Finally, we urge that the contractors develop clear, concise, understandable explanations of the Quality Measures.

NCCNHR welcomes the opportunity to work with and make recommendations to CMS and the researchers for this important project.