High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information

Abstract

Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities' nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

Appendix Exhibit A:. Total nursing staff departure by days to last day of the quarter

Source: Authors’ analysis of data from the Payroll-Based Journal (PBJ). Notes: Total nursing staff includes registered nurses, licensed practical nurses and certified nurse aides.

Appendix Exhibit B:. Median total nursing staff turnover by overall Nursing Home Compare five-star rating, 2017-2018

Source: Authors’ analysis of data from the Payroll-Based Journal (PBJ) and Nursing Home Compare. Notes: The Nursing Home Compare website features a quality rating system for each nursing home, measured on a scale of one to five stars. This rating reflects a facility’s performance on health inspections, staffing levels, and quality measures. Nursing homes that receive five stars are considered to have the highest level of quality. Turnover is computed based on total nurse staffing, including registered nurses, licensed practical nurses, and certified nurse aides. We compare the medians of total nursing staff turnover rate using the Mood’s test. The p-values for tests are all less than 0.001, indicating significant difference of medians at different star rating level.

Exhibit 1:. Mean and median of annual nursing staff turnover rates at Nursing Homes by staff type, 2017-2018

Notes: The annual turnover rates are measured as a percentage of the hours of nursing care that a facility provides. We calculate the turnover rate by summing the percentages of care hours provided by departing employees in the 90 days prior to their last workday.

Exhibit 2:. Distribution of annual nursing staff turnover rates at Nursing Homes by staff type, 2017-2018

Notes: We exclude observations with turnover rates greater than 400%, as these are likely to reflect data reporting issues rather than true turnover rates. For registered nurses (RN), licensed practical nurses (LPN), and certified nurse aides (CNA) turnover, we respectively exclude 2,438, 1,325, and 1,367 facility-year observations.

Exhibit 3:. Median annual total nursing staff turnover rates at Nursing Homes, by state, 2017-2018

Notes: Turnover is computed based on total nurse staffing, including registered nurses, licensed practical nurses, and certified nurse aides.

Exhibit 4:. Median annual total nursing staff turnover rates by overall Nursing Home Compare five-star rating, 2017-2018

Notes: The Nursing Home Compare website features an overall rating for each nursing home, measured on a scale of one to five stars. This rating reflects a composite score of the facility’s performance on health inspections, staffing levels, and quality measures. Nursing homes that receive five stars are considered to have the highest level of overall quality. Turnover is computed based on total nurse staffing, including registered nurses, licensed practical nurses, and certified nurse aides. We compare the medians of total nursing staff turnover rate using the Mood’s test. The p-value is less than 0.001, indicating significant difference of medians at different star rating levels.