twelve or more female nurses in blue scrubs standing side by side with arms folding

Better Nurse Staffing Shown to Reduce Readmission Penalties

Hospitals with higher nurse staffing are less likely to be penalized by the Centers for Medicare & Medicaid Services (CMS) for excessive readmission rates than similar hospitals with lower nurse staffing ratios, researchers have found. In fact, each additional nurse hour per patient day was associated with 10 percent lower odds of receiving penalties under the Hospital Readmissions Reduction Program.

The new study out of the University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research in Philadelphia, was published in the October issue of Health Affairs.

Matthew McHugh: Higher nurse staffing levels lower penalties for hospital readmissions.
Matthew D. McHugh, PhD, JD, MPH, RN, FAAN, makes a financial case for improving nurse staffing.

“Investments in nursing make a difference for a broad set of outcomes,” said Matthew D. McHugh, PhD, JD, MPH, RN, FAAN, the Rosemarie Greco associate professor in nursing at the University of Pennsylvania School of Nursing, Center for Health Outcomes and Policy Research, and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar.

“Nurse staffing is something hospitals can do while the patient was there to reduce readmission rates and these penalties,” McHugh added.

The readmission reduction program is intended to reduce preventable readmissions, and CMS estimates that they will reduce payments to hospitals by roughly $280 million in fiscal year 2013 due to excessive readmission rates. Medicare spends about $15 billion annually on preventable readmissions.

“Readmissions are bad for patients,” said Elizabeth A. Madigan, PhD, RN, FAAN, associate dean for academic affairs and professor of nursing at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. “Medicare and Medicaid have gotten serious about this and say we can do better. That’s why they did this, and hospitals have paid attention.”

Readmission penalties begin at 1 percent and will ramp up over time.

“As the penalty increases, there is more of a case of savings through nurse staffing,” McHugh said.

Hospitals with higher nurse staffing levels had 41 percent lower odds of receiving the maximum penalty for readmissions, compared with hospitals with lower staffing, the researchers reported.

“More nurse staffing has an impact on patient outcomes in many ways,” said Madigan, explaining that this study continued Linda Aiken and other nursing researchers’ work about the importance of staffing in achieving better patient outcomes.

Knowing from prior studies that nursing care--including care coordination, discharge planning and education--affects readmission and other quality indicators, McHugh and colleagues decided to examine nurse staffing levels and readmissions penalties for 2,826 U.S. hospitals. Madigan said the large number of hospitals adds confidence in the findings.

Much of the effort to reduce readmissions and now avoid penalties has focused on specific programs, such as transitional care and discharge coordination, and in many ways, those are add-ons, McHugh explained. The team considered a solution within the current hospital experience and found nurses a leverage point in improving readmission rates.

“Nurse staffing is associated with a lot of other patient outcomes, and there is evidence nurses are less able to do the kinds of things evidence suggests are associated with readmissions when they are overburdened,” McHugh said.

The University of Pennsylvania researchers used penalty data from CMS and hospital characteristics and nurse staffing information from the 2009 American Hospital Association Annual Survey. They used a pairing approach to match hospitals with similar characteristics. For instance, hospitals were randomly cross-matched to control for minority populations, socioeconomic mix, being a teaching facility, location, size and other such demographic variables. The matching algorithm paired hospitals with different staffing levels.

“We were able to isolate in this way the effect of having different staffing levels,” McHugh said.  

The staffing measure used was based on the number of hours of nursing per patient day, not a ratio of nurses to patients, because that is what data was available nationwide. The average or mean nurse staffing level in the high nurse-staffing group was 8.0 registered nurse hours per adjusted patient day compared with 5.1 registered nurse hours per adjusted patient day in the low-staffing group.

“Three hours per day is a pretty wide gap between the two groups,” McHugh said.

Madigan agreed that was a big difference, but said the profession does not know the ideal number of nurse hours per patient day, since it varies with patient acuity.

The team completed a supplemental analysis of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from the Hospital Compare database to assess whether patients in hospitals with high nurse staffing vs. lower nurse staffing differed in satisfaction with the hospital experience and if they felt prepared to go home.

“In those hospitals where staffing is not good, patients are telling us they are not getting discharge instructions to the same level of quality at other hospitals,” McHugh said. “That was a confirmation for us.”

The study helps to build a business case for improving nurse staffing, McHugh proclaimed.

“With readmissions there is a clear financial link,” McHugh said. “If [hospitals] don’t meet the thresholds, they will be penalized under the Hospital Readmissions Reduction Program.”

However, McHugh acknowledges that savings from only one single patient population outcome associated with staffing, such as reducing readmission penalties, would not likely pay for all of the nurse staffing increases that would need to go on across all hospitals.

“But the good thing about nurse staffing is it is not limited to a single patient population [outcome],” McHugh added. “Not only do you accrue the benefits of reduced penalization under the Hospital Readmissions Reduction Program, but you also gain the benefits of fewer infections and a loss in payment reductions associated with the Hospital-acquired Conditions program. You get better processes of care and better patient satisfaction, which are associated with Medicare’s Value Based Purchasing Program.”

Taken together, McHugh makes a case for building value with improved nurse staffing.

Madigan added that many hospitals are contemplating changes in staffing levels.

“The timeliness of this Health Affairs article is perfect,” Madigan added. “What it says is, if hospitals are making staffing changes in anticipation of the Affordable Care Act, you probably don’t want to be cutting frontline nursing staff. It shows more nursing hours reduces readmissions and readmission penalties.”

Ultimately, nurses save hospitals money.

“The message is that this provides evidence for hospitals to look within,” McHugh concluded. “The primary reason patients are in the hospital is so they can get direct one-on-one nursing care, and if that’s neglected, none of the other things [to reduce readmissions] are going to be as effective. Having good staffing levels with nurses with manageable workloads is in itself an intervention that shouldn’t be forgotten.”

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