Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality

John R. Bowblis
Amy Restorick Roberts
Peer-Reviewed Article
June 2020
Cover of "Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality"


Higher staffing levels for specific types of staff improve quality of care in nursing homes.


Staffing levels impact the quality of care provided in nursing homes, and nursing home providers often adjust staffing levels to fit within fixed reimbursement rates from Medicare and Medicaid. Policy changes can also impact nursing home staffing levels when staffing regulations target one specific type of staff role. This can divert resources and subsequently reduce staffing levels for other types of staff who also contribute to improving the quality of the nursing home. In this study, the authors use data from the Certification and Survey Provider Enhanced Reports (1999-2015) to examine how staffing levels influence two key quality measures in the nursing home industry: the number of deficiency citations and the deficiency score.


The most significant improvements in quality of care were associated with increased staffing for administrative registered nurses and social service staff, followed by registered nurses and activities staff, and lastly by certified nursing assistants. Notably, increasing social services staffing is the most cost-effective investment for improving overall deficiency outcomes. Deficiencies related to quality of care are improved by increasing administrative nursing and social service staff, while quality of life deficiencies benefit from an increase in social service and activities staff.


Overall, study findings demonstrate that higher staffing levels are associated with higher quality care in nursing homes. However, the authors underscore the need for building a more comprehensive understanding of how different types of staff contribute to improving quality, as regulations often focus primarily on nurse staffing ratios even though social support staff and the other ancillary services make valuable contributions to nursing home quality. The authors recommend that providers consider making small increases in social services, activities, and administrative registered nurse staff to have the largest effect in improving quality.

Posted to The Playbook on