Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care Conference Package. Nursing Home Workforce and Quality

05/01/2004

John Schnelle, Ph.D.
University of California, Los Angeles

MAJOR POINTS

  • Staffing numbers are related to quality.
  • Staffing low in most homes.
  • Training and management interventions will have limited effectiveness.
    • National reports on the workforce crisis.
    • Counter-productive if they imply unrealistic work expectations.
  • What should staffing levels be?

STAFFING REQUIREMENTS

  • Kramer: 4.1 nurse + aide hours.
  • Expert consensus: 4.5 total hours.
  • IOM recommendation: 4.1 total hours.
  • Simulation: 2.8-3.1 aide hours (CMS study).

IF PROJECTIONS CORRECT

  • THEN, Staffing above 4.1.
  • Better process implementation related to outcomes.

FIELD TEST EVALUATION

  • Directly measured care process implementation in:
    • Homes in upper decile staffing vs. all others.

STUDY SAMPLE

  • N=34 homes.
  • Lower 90th vs. upper 10th percentile.
  • Total staff hours = 3.1 vs. 4.5.
  • Aide hours = 2.3 vs. 2.9.
  • Aide report = 9.8 vs. 7.6 ratio.

QUALITY ASSESSMENT

Seven Standardized Measurement Protocols

STAFFING CONCLUSIONS

Different on 13 out of 16 care processes implemented by aides (Schnelle et al, Health Serv Res J 2004).

NO OR MARGINAL DIFFERENCE

  • Social interaction during meals.
  • Repositioning at night.
  • Reported walking assists [low across all homes].
  • Licensed nurse/physician driven indicators.

WHAT ARE THE SOLUTIONS?

  • Objective analysis of staff requirements to meet regulations.
  • Staffing projections (unit level).
  • Staff at required levels or reduce care expectations.
  • Will increasing staff to required levels be enough?

SECOND STEP

  • Accurate and timely information about care delivery.
  • Training and management.
  • Job design.
  • Environmental design.

ACCURATE AND USABLE INFORMATION

  • Point of service documentation technology.
  • Auditing controls.
  • Electronic medical record.

TRAINING AND MANAGEMENT MODEL

  • Brief.
  • Ongoing.
  • Focused on realistic work conditions (see accurate information and staffing requirement slides).
  • Quality monitoring between sessions.
  • Meaningful incentives.

JEWISH HOME NUTRITION PROGRAM

Training and Management Model

  • 5-minute weekly sessions.
  • Focused on specific objectives (talk to resident before assistance).
  • Illustrated with video (real residents and aides).
  • Quality monitoring between sessions.
  • Feedback/Discussion.
  • Incentive (employee involvement).

CONCLUSIONS

  • Workforce related to quality.
  • We should know more about staffing issues than we do.
  • First step: Realistic evaluation of staffing requirements.
Out of Bed/Engagement
  Low Staffing
N = 432 Residents
High Staffing
N = 125 Residents
% observations out of bed 54 74
% observations engaged 45 52
SOURCE: Bates-Jensen et al., JAGS (in press).

 

Feeding Assistance
  Low
N = 217
High
N = 72
Chart
% residents require assistance and receive >5 minutes 57% 80% 100%
SOURCE: Simmons et al., JAGS 2003.

 

Incontinence
  Low
N = 102
High
N = 31
Number of toileting assists reported (MDS recall 2+) 1.8 2.8
SOURCE: Schnelle et al., Medical Care 2003.

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