The impact of managed care penetration and hospital quality on efficiency in hospital staffing

The state of California has recently mandated minimum nurse-staffing ratios, raising concerns about possible affects on hospital efficiency. In this study, we examine how market factors and quality were related to staffing levels in California hospitals in 1995 (prior to implementation of the new law). We are particularly interested in the affect of managed care penetration on this aspect of hospital efficiency because the call to legislative action was predicated on fears that hospitals were reducing staffing below optimal levels in response to managed care pressures. We derive a unique measure of excess staffing in hospitals based on a data envelopment analysis (DEA) production function model, which explicitly includes ancillary care among the inputs and outputs. This careful specification of production is important because ancillary care use has risen relative to daily hospital services, with the spread of managed care and advances in medical technology. We find that market share (adjusted for size) and market concentration are the major determinants of excess staffing while managed care penetration is insignificant. We also find that poor quality (outcomes worse than expected) is associated with less efficient staffing. These findings suggest that the larger, more efficient urban hospitals will be penalized more heavily under binding staffing ratios than smaller, less-urban hospitals.     

A longitudinal examination of hospital registered nurse staffing and quality of care

OBJECTIVE: To evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in registered nurse staffing on change in quality of care. DATA SOURCES/STUDY SETTING: Secondary data from the American Hospital Association (AHA)(nurse staffing, hospital characteristics), InterStudy and Area Resource Files (ARF) (market characteristics), Centers for Medicare and Medicaid Services (CMS) (financial performance), and Healthcare Cost and Utilization Project (HCUP) (quality measures-in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection, which were risk-adjusted using the Medstat disease staging algorithm). STUDY DESIGN: Data from a longitudinal cohort of 422 hospitals were analyzed from 1990-1995 to examine the relationships between nurse staffing and quality of care. DATA COLLECTION/EXTRACTION METHODS: A generalized method of moments estimator for dynamic panel data was used to analyze the data. Principal Findings. Increasing registered nurse staffing had a diminishing marginal effect on reducing mortality ratio, but had no consistent effect on any of the complications. Selected hospital characteristics, market characteristics, and financial performance had other independent effects on quality measures. CONCLUSIONS: The findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care.     

Effects of state minimum staffing standards on nursing home staffing and quality of care

Objective. To investigate the impact of state minimum staffing standards on the level of staffing and quality of nursing home care.
Data Sources. Online Survey and Certification Reporting System (OSCAR) merged with the Area Resource File from 1998 through 2001.
Study Design. Between 1998 and 2001, 16 states implemented or expanded staffing standards in excess of federal requirements, creating a natural experiment in comparison with facilities in states without new standards. Difference-in-differences models using facility fixed effects were estimated to determine the effect of state standards.
Data Collection/Extraction Methods. OSCAR data were linked to the data on market conditions and state policies. A total of 55,248 facility-year observations from 15,217 freestanding facilities were analyzed.
Principal Findings. Increased standards resulted in small staffing increases for facilities with staffing initially below or close to new standards. Yet the standards were associated with reductions in restraint use and the number of total deficiencies at all types of facilities.
Conclusions. Mandated staffing standards affect only low-staff facilities facing potential for penalties, and effects are small. Selected facility-level outcomes may show improvement at all facilities due to a general response to increased standards or to other quality initiatives implemented at the same time as staffing standards.     

The influence of staffing characteristics on quality of care in nursing homes

OBJECTIVE: The influence staffing levels, turnover, worker stability, and agency staff had on quality of care in nursing homes was examined. DATA SOURCES/STUDY SETTING: Staffing characteristics came from a survey of nursing homes (N=1,071) conducted in 2003. The staffing characteristics were collected for Nurse Aides, Licensed Practical Nurses, and Registered Nurses. Fourteen quality indicators came from the Nursing Home Compare website report card and nursing home organizational characteristics came from the Online Survey, Certification, and Recording system. STUDY DESIGN: One index of quality (the outcome) was created by combining the 14 quality indicators using exploratory factor analysis. We used regression analyses to assess the effect of the four staffing characteristics for each of the three types of nursing staff on this quality index in addition to individual analyses for each of the 14 quality indicators. The effect of organizational characteristics as well as the markets in which they operated on outcomes was examined. We examined a number of different model specifications. PRINCIPAL FINDINGS: Quality of care was influenced, to some degree, by all of these staffing characteristics. However, the estimated interaction effects indicated that achieving higher quality was dependent on having more than one favorable staffing characteristic--the effect of quality was larger than the sum of the independent effects of each favorable staffing characteristic. CONCLUSIONS: Our results indicate that staff characteristics such as turnover, staffing levels, worker stability, and agency staff should be addressed simultaneously to improve the quality of nursing homes.     

The effects of scheduled intern rotation on the cost and quality of teaching hospital care

We studied the effect of scheduled intern rotations on the cost and quality of inpatient care at one teaching hospital. For all discharges from the internal medicine service between 1980 and 1986, we identified 1,705 rotation patients and 3,141 no-rotation patients. Using linear or logistic regression analysis to control for baseline differences, we evaluated for the effect of rotation. We found that rotation was significantly related to longer length of hospital stay, b = 0.341 days, p = 0.001, and higher hospital charges (for log charges, b = 0.053, p = 0.016. Hospital deaths, nursing home placements, and 30-day readmissions were not significantly related to rotation, p > 0.1. These results suggest that the systematic discontinuity induced by scheduled intern rotations may be another source of increased health care costs experienced at teaching hospitals.     

Nurse staffing found to impact quality of care

The size and mix of nurses in a hospitals throughout the country make a difference in the quality of care provided to patients, according to a Department of Health and Human Services study released last month. The study, Nurse Staffing and Patient Outcomes in Hospitals, found a consistent relationship between nurse staffing and outcomes for four medical conditions--urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding--and length-of-stay.     

Nurse staffing patterns and quality of care in nursing homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.     

Relationship of nursing home staffing to quality of care

OBJECTIVE: To compare nursing homes (NHs) that report different staffing statistics on quality of care. DATA SOURCES: Staffing information generated by California NHs on state cost reports and during onsite interviews. Data independently collected by research staff describing quality of care related to 27 care processes. STUDY DESIGN: Two groups of NHs (n=21) that reported significantly different and stable staffing data from all data sources were compared on quality of care measures. DATA COLLECTION: Direct observation, resident and staff interview, and chart abstraction methods. PRINCIPAL FINDINGS: Staff in the highest staffed homes (n=6), according to state cost reports, reported significantly lower resident care loads during onsite interviews across day and evening shifts (7.6 residents per nurse aide [NA]) compared to the remaining homes that reported between 9 to 10 residents per NA (n=15). The highest-staffed homes performed significantly better on 13 of 16 care processes implemented by NAs compared to lower-staffed homes. CONCLUSION: The highest-staffed NHs reported significantly lower resident care loads on all staffing reports and provided better care than all other homes.     

The cyclical behavior of hospital utilization and staffing.

Aggregate monthly data on hospital utilization and staffing are examined to assess the hospital industry's ability to adjust staffing levels to regular monthly cycles in demand. Graphical analysis and linear regression are used to assess the relationship between monthly trends in utilization and full-time-equivalent hospital personnel. We show that although regular seasonal patterns exist in both utilization and staffing levels, these series are largely independent of each other. The staffing level response to cycles in admissions and patient-days is, in fact, small relative to those observed for other industries that face predictable and regular fluctuations in product demand. Staffing levels appear to be more closely related to bed levels than to actual utilization levels. For a typical hospital which does not face effective incentives to control costs, smoother patterns of seasonal utilization probably will not result in lower staffing levels and reduced costs unless accompanied by a slowdown in the rate of increase in hospital bed size.     

Association between perceived inadequate staffing and musculoskeletal pain among hospital patient care workers

Objective

To examine association between perceived inadequate staffing and musculoskeletal pain and to evaluate the role of work-related psychosocial and physical work factors in the association among hospital patient care workers.

Methods

A cross-sectional study was conducted among 1,572 patient care workers in two academic hospitals. Perceived inadequate staffing was measured using the “staffing adequacy subscale” of Nursing Work Index, which is a continuous scale that averages estimates of staffing adequacy by workers in the same units. Musculoskeletal pain (i.e., neck/shoulder, arm, low back, lower extremity, any musculoskeletal pain, and the number of area in pain) in the past 3 months was assessed using a self-reported Nordic questionnaire. Multilevel logistic regression was applied to examine associations between perceived inadequate staffing and musculoskeletal pain, considering clustering among the workers in the same units.

Results

We found significant associations of perceived inadequate staffing with back pain (OR 1.50, 95 % CI 1.06, 2.14) and the number of body area in pain (OR 1.42, 95 % CI 1.01, 2.00) after adjusting for confounders including work characteristics (job title, having a second job or not, day shift or not, and worked hours per week). When we additionally adjusted for physical work factors (i.e., use of a lifting device, and the amount of the time for each of five physical activities on the job), only the association between perceived inadequate staffing and back pain remained significant (OR 1.50, 95 % CI 1.03, 2.19), whereas none of the associations was significant for all of musculoskeletal pains including back pain (OR 0.96, 95 % CI 0.66, 1.41) when we additionally adjusted for work-related psychosocial factors (i.e., job demands, job control, supervisor support, and co-worker support) instead of physical work factors.

Conclusions

Perceived inadequate staffing may be associated with higher prevalence of back pain, and work-related psychosocial factor may play an important role in the potential pathway linking staffing level to back pain among hospital workers.     

Optimal staffing in community health centers to improve quality of care

ObjectiveTo explore optimal workforce configurations in the production of care quality in community health centers (CHCs), accounting for interactions among occupational categories, as well as contributions to the volume of services.Data SourcesWe linked the Uniform Data System from 2014 to 2016 with Internal Revenue Service nonprofit tax return data. The final database contained 3139 center‐year observations from 1178 CHCs.Study DesignWe estimated a system of two generalized linear production functions, with quality of care and volume of services as outputs, using the average percent of diabetic patients with controlled A1C level and hypertensive patients with controlled blood pressure as quality measures. To explore the substitutability and complementarity between staffing categories, we estimated a revenue function.FindingsPrimary care physicians and advanced practice clinicians achieve similar quality outcomes (3.2 percent and 3.0 percent improvement in chronic condition management per full‐time equivalent (FTE), respectively). Advanced practice clinicians generate less revenue per FTE but are generally less costly to employ.ConclusionAs quality incentives are further integrated into payment systems, CHCs will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost‐effective investment for CHCs.     

The effect of investor-owned chain acquisitions on hospital expenses and staffing.

Much concern has been raised about the effect of "corporatization" of health through the expansion of investor-owned hospital chains. One method of expansion is through hospital acquisition. At issue is the question of the effect of acquisitions on expenses and on such patient care inputs as staffing levels. In this article, we examine the effect of acquisition by one investor-owned chain on hospital costs and staffing. Subsequent to acquisition, hospital costs increase and staffing decreases, relative to competitor hospitals. However, since investor-owned hospitals not recently acquired do not have higher cost levels than their competitors, the increase in costs appears to be due to factors associated with the acquisition itself rather than factors associated with being an investor-owned hospital. Under the retrospective payment system in effect at the time, revenues also were higher for acquired hospitals. Under prospective payment, increasing revenues has been more difficult, decreasing acquisition incentives.     

Perceived quality of hospital care.

Physicians, nurses, and consumers in the New York City area were asked to indicate which of 76 acute-care hospitals they would be willing to be patients in if they became seriously ill. Percentages of favorable judgments ranged from a high of 95% for one university hospital to a low of less than 10% for a community hospital. Over half of all responding physicians, nurses, and consumers indicated that they would not wish to be a patient in the majority of the 76 hospitals sampled. Although a high degree of consistency (r = .93) was observed among all three types of respondents, physicians were on the average significantly more pessimistic (X percentage of favorable judgments = 34) than nurses and consumers. All three groups indicated a statistically significant (p less than .001) preference for larger hospitals as well as institutions that were affiliated with a medical school in some way.     

The effect of soft budget constraints on access and quality in hospital care

Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals’ overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3–30, 1986) as an alternative financial measure of a hospital’s overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.