Dr. El
Dr. El

The Five-Star Quality Rating System reports the results of health inspections, staffing and quality measures. I suggest we replace the current staffing measure with one tracking staff retention.

Here’s my logic:

The existing staffing score is the ratio of nursing staff to residents, taking care needs into account. In allowing for self-reporting of the data, some nursing homes overstated their resident/staff ratio. It therefore hasn’t been a particularly accurate measure of staffing.

It also misses the fact that while some residents have low-acuity physical health needs, they — or their family members — may have high-acuity emotional or mental health needs that require a great deal of staff time and attention. In such situations there are enough workers for the facility to be compliant technically but understaffed in reality.

If we shift to a system that measures staff retention rather than staff ratio, however the whole picture changes.

Staff turnover is a strong signal that something is wrong with a nursing home.

As I noted in an earlier post here, “Reducing Turnover in LTC,” employees tend to leave facilities not just because the pay and benefits are low, but also because of a high workload, poor staffing, unsatisfactory work conditions and a lack of appreciation. Unless they’re older, invested in the facility and perhaps looking forward to retirement benefits, employees depart when a facility isn’t a good place to work.

If a nursing home isn’t a good place to work, it’s an even worse place to live.

Residents and their families want clean, safe environments with quality care and reasonable food — and they especially want workers who know and respect them. High turnover makes meeting these expectations virtually impossible.

Impact of turnover

A constant influx of new staff can lead to a host of survey citations. For example, the top five F-tags as of early July 2018 were:

  1. F880 Infection Prevention & Control
  2. F689 Free of Accident Hazards/Supervision/Devices
  3. F656 Develop/Implement Comprehensive Care Plan
  4. F812 Food Procurement, Store/Prepare/Serve Sanitary
  5. F684 Quality of Care

The tasks that fall under these F-tags rely on being completed by a full complement of well-trained staff members.

Workers who are stretched beyond their limits covering shifts aren’t able to implement care plans properly. New employees don’t have the experience and training needed to comply with infection control procedures or to understand the proper use of devices. Quality of care suffers greatly when staff members don’t know the residents and therefore don’t notice changes in presentation or behavior that signal health problems.

A star for staff retention

If facilities focused on staff retention rather than on resident/staff ratio, it’s likely that the ratio would rise anyway as a side effect. According to a 2007 Donoghue and Castle study, increasing the number of aides per resident — from 33 per 100 to 41 per 100 — reduced CNA turnover from 65% to 41% and also lowered LPN and RN turnover.

A push to retain workers would direct more effort into onboarding so that new team members would get the support and guidance they need to be successful in their positions.

More thought would be put into the type of amenities that encourage longevity – flexible schedules, competitive salaries and benefits, permanent assignments, opportunities for professional growth, etc.

In-service training — time and money otherwise wasted when workers leave after being trained — could go beyond mandatory basics towards staff development, leadership skills and team building.

In addition, as a profession we’d be encouraging managing for long-term stability and discouraging managing for short-term profit.

There are great costs of turnover, including increased hospital readmission rates, high employee replacement costs, loss of productivity, poorer quality of care, a decrease in staff and resident morale, greater work stress, higher job dissatisfaction, increased accident and absenteeism rates, escalating overtime costs and reduced resident and family satisfaction. The very visible loss of a star on the rating system could be added to this list.

Changing the star rating from assessing resident/staff ratio to measuring staff retention would create an incentive to deal directly with the seemingly intractable problem of turnover. It would open the door for the many intelligent, innovative and caring people in this field to devise creative, cost-neutral solutions to confront our astronomical turnover rate. In the process, it would better the lives of all those who depend on the industry for their health and for their livelihood.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.