Guest Columns

From volume to value: The conversation now applies to staffing

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Steven Littlehale
Steven Littlehale

It's all you hear about in healthcare today: from Volume to Value. With the July 30 release of the PPS proposed rule, we see how this discussion now applies to staffing.

The Centers for Medicare & Medicaid Services is clearly indicating that adequate staffing is not based solely on how many are staffed, but also on the clinical competencies of the staff, which determines the adequacy of your staffing levels.

This year, staffing has been a frequently discussed issue. The mid-winter changes to the CMS Five-Star Rating System included a small change to Staffing Domain. You can no longer get a 4-star rating in Staffing if you have RN levels at 3 stars and total staffing at 3 stars. That combination now can get you only a Staffing star rating as high as 3.

Then in April, the draft release by CMS of the electronic Staffing Data Submission Payroll-Based Journal outlined new requirements for providing staffing and census information to CMS on a quarterly basis.

The Proposed Rule for Skilled Nursing Facilities was published July 30 and, no surprise, staffing figured prominently.

Specifically, CMS did not dictate a specific direct-care-to-resident ratio. Based on their findings, regulators did not have a high degree of confidence in the data supplied that would lead them to establish one.

Rather, they directed facilities to conduct their own internal assessments to evaluate whether or not they had adequate staffing. The individual facility assessment should take into account elements such as: number of residents, resident acuity, the range of diagnoses; and the content of resident care plans. After the assessment is completed, staff competencies to meet those factors, as well as the number of staff involved, would determine whether or not enough caregivers were on hand. In other words: not just volume but value.

Various studies of ours concur: It's less about total number of staff but rather the staff type and consistency that aligns with quality. We've long found that “staffing to need” — not a “one-size fits all” — yields more meaningful outcomes. In last month's blog, I noted that higher RN hours per resident day (HPRD) was correlated with lower rehospitalization. While this was a positive correlation (and not causation), it only becomes meaningful when caring for medically complex post-acute patients. If your resident population is more traditional long-term care, other staffing goals are appropriate.  

After digesting the proposed rule, skilled nursing providers should work to clearly articulate their own policies and procedures for staffing, including clinical competencies that are identified as important from your facility assessment. Please note: Focused Surveys will ask for your staffing policies and procedures for staffing to acuity. Your comprehensive review must be thoughtful and documented.

Identifying the clinical competencies needed is the easy part of the review, but do you have the tools required to objectively measure resident acuity that drives your facility assessment? Are you able to use your staffing and MDS data to give you a clear understanding of your staffing to acuity numbers? How do you compare to industry benchmarks and acuity adjusted Five-Star staffing ratings?

Once again, data and analytics are vital as your staff and your overall staffing plan transition from volume to value.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.