Nursing Home Nursing Homes P4P Quality

Is nursing home staff turnover a good quality metric?

There are a few sub-questions we need to break down to answer before answering this one larger question. These sub-questions include:

  1. Is nursing staff turnover at nursing homes a big problem?
  2. Is nursing staff turnover correlated with quality of care?
  3. Does using nursing staff turnover as a quality metric provide the right incentives?

A paper by Ghandi, Yu and Grabowski (2021) provide some answers to these questions. To do so, they look at employee-level data between October 1,2016, and March 31, 2019 from the Payroll Based Journal; while CMS’s has aggregated daily counts of staffing hours, the Ghandi paper’s use of individual employee data allows for a weighted measure of employee turnover based on hours worked. Thus, their turnover metrics weights turnover by a full-time worker more heavily than a part-time worker.

Using these data, they answer question (1) finding that ‘yes’ turnover is a major issue.

RNs had the highest mean turnover rate (140.7 per-cent). Although lower, the mean turnover rates for LPNs (114.1 percent) and CNAs (129.1 per-cent) were also substantial.

More than 100% turnover across the board! That is pretty unbelievable.

The authors also answer question (2) in the affirmative by showing that in fact turnover is correlated with quality. The authors use Nursing Home Compare Five-Star Quality Rating System.

Low-rated (one-star) facilities had the highest median turnover rate (135.3 per-cent), whereas the highest-rated (five-star) facilities had the lowest median turnover rate (76.7 percent).

Some could argue whether this relationship is causal. Perhaps nurses don’t like working at poor quality nursing homes with poor management and this leads to high turnover; or alternatively, it could be the case that more staff turnover leads to poor quality as less experienced individuals arrive. Likely both are the case.

For the purposes of answering question (3) however, just a correlation is sufficient. It would not matter if staff turnover and quality were causal, if they are correlated with quality, that could be useful information. Thus, it should not be surprising that the authors propose that:

Policy makers may wish to consider reporting facilities’ staffing turnover rates on the Nursing Home Compare website, as well as incorporating turnover rates into the five-star staffing rating system used by Nursing Home Compare.

While this may seem to be an obvious conclusion, measuring quality based on staff turnover is highly problematic. To understand why this is the case, consider a nursing home with a low quality employee. To improve quality, a nursing home should look to replace that individual with a high-quality employee. In fact, assume that doing so would improve quality of care for patients. However, if staff turnover is a quality metric, then even though firing the individual would improve quality, the nursing home would be penalized in their Nursing Home Compare star rating for doing so. Further, if one believes that the star rating already captures quality, it would not be necessary to include an additional metric which only indirectly affects patient quality of care. In short, including this process measure as a quality metric provides the wrong incentives in many cases.

If you’ve made it this far in this post, the answers to the three questions posed above are (1) yes, (2) yes and (3) no.


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