with malnutrition, starvation, and dehydration in nursing home residents (Kayser-Jones, 1996, 1997; Kayser-Jones and Schell, 1997; Kayser-Jones et al., 1999). Licensed nursing hours (but not unlicensed hours) have been found to be significantly related to improved functional ability, increased probability of discharge to home, and reduced mortality in the first year after admission (Bliesmer et al., 1998). And higher total nurse staffing hours, particularly higher RN hours, were shown to be associated with fewer facility deficiencies in a study of all U.S. nursing homes (Harrington et al., 2000b). Other studies have found that gerontological nurse specialists and geriatric nurse practitioners also contribute to improved quality outcomes in nursing homes (Buchanan et al., 1990; Kane et al., 1988; Mezey and Lynaugh, 1989).

These and other studies are reviewed in two Institute of Medicine (IOM) reports (IOM, 1996, 2001b) that confirm the important relationship between staffing and quality. The 1996 IOM report Nursing Staff in Hospitals and Nursing Homes: Is It Adequate, found that “the preponderance of evidence from a number of studies using different types of quality measures has shown a positive relationship between nursing staff levels and quality of nursing home care.” Based on this evidence, “a relationship between RN-to-resident staffing and quality of care in nursing facilities has been established” (IOM, 1996:153).

Subsequent, additional strong evidence of the effect of nurse staffing on nursing home resident outcomes is provided by a congressionally mandated study on the Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes carried out under the auspices of the U.S. Department of Health and Humans Services’ (DHHS) Centers for Medicare and Medicaid Services (CMS) between 1998 and 2002. This study was conducted in two phases, with a Phase I report being provided in July 2000 (CMS, 2000) and a Phase II report in December 2001 (CMS, 2001). The Phase I study involved the development of methodologies and a preliminary assessment of relationships between patient (resident) outcomes and staffing levels using 1996 and 1997 data from three states and over 3,000 facilities. The Phase I report provides a discussion of relevant policy issues, including trends in payment and staffing levels in nursing homes; a discussion of how current federal regulatory staffing requirements are implemented; stakeholder perspectives; a literature review; and an analysis of different staffing data sources. The report also includes two other approaches to determining staffing needs: a time-motion study and use of operations research models.

The Phase II report provides further analysis of staffing–outcome associations using 1999 data from almost 9,000 facilities in 10 states. This report includes a refinement of the previous operations research estimates, studies of nursing staff turnover and retention, case studies of the relationship between care outcomes and nurse staffing issues beyond staffing levels,

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