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

IMPORTANCE: Average staffing measures are a focus of nursing homes’ quality assessments and reporting. They may, however, mask daily variation in staffing, additional information that could be important for understanding nursing home quality and relative ranking. OBJECTIVE: To examine daily variation in staffing, its association with quality, and whether daily variation provides information regarding quality ranking of nursing homes over and above the information provided by average staffing levels. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study included registered nurses (RNs) and certified nurse aide (CNAs) at 13 339 certified nursing homes throughout the United States during 2017 to 2018. Retrospective analyses of the Payroll-Based Journal, Medicare Cost Reports, and Nursing Home Care Compare were conducted. Data were analyzed from January 2017 to December 2018. MAIN OUTCOMES AND MEASURES: Three measures of daily variation, ie, coefficient of variation (COV), total outlier days (TOD), and low outlier days (LOD), were calculated for RNs and CNAs. The association between these measures and quality rankings and other facility characteristics were evaluated. RESULTS: A total of 13 339 nursing homes were included in this study, with 9476 (71%) for-profit facilities. The mean (SD) hours-per–resident-day were 0.41 (0.29) for RNs and 2.16 (0.49) for CNAs, and a mean (SD) 55% (26%) of residents were Medicaid beneficiaries. Outcome measures were as follows: mean (SD) COV, 0.5 (0.6) for RNs and 0.1 (0.1) for CNAs; mean (SD) TOD, 220 (69) for RNs and 44 (45) for CNAs; and mean (SD) LOD, 116 (45) for RNs and 22 (24) for CNAs. All 3 variation measures, for both RNs and CNAs, were significantly associated with both the 5-Star Quality Measures (COV among RNs, −0.014 [95% CI, −0.021 to −0.007]; P < .001; COV among CNAs: −0.004 [95% CI, −0.006 to −0.003]; P < .001; TOD among RNs, −3.79 [95% CI, −4.59 to −2.99]; P < .001; TOD among CNAs, −2.52 [95% CI, −3.08 to −1.96]; P < .001; LOD among RNs, −2.46 [95% CI, −3.03 to −1.88]; P < .001; LOD among CNAs, −1.29 [95% CI, −1.58 to −0.99]; P < .001) and the 5-Star Survey rankings (COV among RNs,−0.026 [95% CI, −0.033 to −0.019]; P < .001; COV among CNAs: −0.006 [95% CI, −0.007 to −0.004]; P < .001; TOD among RNs, −5.10 [95% CI, −5.97 to −4.23]; P < .001; TOD among CNAs, −4.16 [95% CI, −4.77 to −3.55]; P < .001; LOD among RNs, −3.04 [95% CI, −3.65 to −2.44]; P < .001; LOD among CNAs, −1.97 [95% CI, −2.29 to −1.65]; P < .001) published in Nursing Home Care Compare. Low κ values, ranging from 0.23 to 0.63, indicated that the variation measures add information about ranking to the information provided by average staffing measure. CONCLUSIONS AND RELEVANCE: These findings highlight the importance of reporting daily variation in staffing to improve understanding of the relationship between staffing and quality. They suggest that 2 facilities with the same average staffing achieve different quality of resident care and survey ratings in association with on the day-to-day variation in staffing. Measures of daily staffing may enhance the value of Nursing Home Care Compare for nursing homes and others engaged in quality improvement and consumers searching for high quality nursing homes.