Guest Columns

Why 'Staffing to the Stars' isn't enough: How to make the right staffing decisions

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Steven Littlehale
Steven Littlehale
Providers often ask us to recommend staffing ratios for their residents: “How many RNs/LPNs and CNAs should I have?”

You would think this straightforward question warrants a simple answer. Regulatory agencies in most, if not all, states require staffing differently from federal requirements. But why not just use those guidelines? Alternatively, why not lean on the Centers for Medicare & Medicaid Services' Five-Star methodology to guide staffing decisions? It's easy to calculate what staffing levels will give you a desired number of “stars,” right? 

Wrong. Neither strategy will guarantee you a satisfactory outcome.

Meaningful staffing choices for skilled nursing facilities are predicated upon a fundamental principle that all people receiving care in a SNF are not the same, and many have unique care requirements. There are traditional nursing homes with residents and post-acute nursing homes with patients. LPNs may be an appropriate and cost-effective solution for the majority of residential care, but the outcomes data suggests this isn't true for patient care.

In addition, meaningful staffing ratios should be constructed with careful identification of the desired outcome. In other words, what are you trying to accomplish? Are you trying to improve survey performance? Clinical outcomes? Do you wish to improve patient/resident experience? Or do you simply want to reduce professional liability, or reduce hospitalizations? Without a clear outcome, you might satisfy one objective while wreaking havoc on another.

States define sufficient staffing in such non-specific ways ranging from “to meet the needs of residents as determined by their levels of care” to “attaining or maintaining the highest practicable level of physical, mental and psychosocial well-being.” However, there are some general principles to consider when considering appropriate staffing ratios:

Hire Registered Nurses: A higher RN-to-total-licensed ratio is associated with better clinical outcomes, lower workers' compensation costs, better survey outcomes, more stars on the Five-Star Rating System, fewer significant professional liability (PL) claims and a higher proportion of Medicare and private pay as opposed to Medicaid residents.

These offsets strongly suggest that operators should try to hire RNs whenever they have a vacant position for a licensed nurse — the increased hourly wage will be more than offset by the increased revenue and decreased costs. Nonetheless, there are facilities with very high RN staffing (or all RN staffing) that have problems with PL claims, quality measures and workers' compensation claims. These facilities tend to be ones with very high medical acuity.

Our analysis suggests that the high acuity rather than the high RN staffing is the cause of the problem. Why? Because high-acuity facilities with mainly licensed practical nurse (LPN) staffing have even worse problems. Do not rely on Five-Star's RN ratings for your comparative benchmark. This category includes all types of nurses (RN/LPN/LVN) if they are involved in “administrative duties.”

Avoid contractors: The use of supplemental (contract) staffing to fill vacant positions in a nursing home (i.e., CNA, licensed personnel) is associated with a greater risk of non-compliance with facility processes, poor care outcomes and significantly higher risk of a large professional liability loss. The more contract CNAs, the greater the risk. Using contractors to for nursing leadership positions is associated with increased risk as well. However, using temporarily contract-licensed staff to deal with increased acuity is better than not adding licensed staff at all.

Minimize worker's comp claims: Workers' comp claims are higher when licensed positions are filled with LPNs as opposed to RNs. Even though RNs are paid higher wages, their workers' comp claims are lower.

And what about Five-Star? Facilities that staffed to the Five-Star level were most likely a Four-Star for quality (27.3%), more than any other group. That makes sense. However, when you examine facilities that staffed at the One-Star level, 31% were Four-Stars in quality, which doesn't make sense at all.

The takeaway? There is no correlation between Five-Star's quality domain and staffing. Period.

Steven Littlehale is a gerontological clinical nurse specialist, and EVP 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.