Association between staff turnover and nursing home quality – evidence from payroll‐based journal data

Background Staff turnover is considered an important indicator of nursing home quality. We used auditable staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll‐Based Journal (PBJ) system to calculate turnover measures for nurse staff and administrators and examined the relationship between turnover and nursing home quality. Methods Our analyses included data from 13,631 nursing homes that submitted complete staffing data through PBJ for 2018Q3 – 2019Q4. We identified turnover based on gaps in days worked by eligible employees, allowing us to calculate turnover measures that do not depend on termination dates reported by nursing homes, which are not captured in PBJ. We linked staff turnover measures to nursing home quality measures and star ratings published on CMS' Care Compare website in January 2020 and examined the relationship between turnover and quality of care. We used ordinary least squared models for continuous outcomes and ordered logit models for categorical outcomes, controlling for facility, and county characteristics. Results Mean annual turnover rates were about 44% for RNs and 46% for total nurse staff. On average, there was one administrator leaving each nursing home during this period although about half of nursing homes had no administrator turnover. Turnover rates varied greatly across nursing homes. For‐profit and larger nursing homes had higher turnover rates. Higher turnover was consistently associated with lower quality of care. Conclusions Our study highlights the importance of staff turnover due to its relationship to nursing home quality. In January 2022, CMS started posting turnover measures on Care Compare to allow consumers to use this information in their assessment of nursing home quality and to motivate nursing homes to implement innovative strategies to retain staff. While these actions are challenging, they are nonetheless warranted for improving the quality of care for nursing home residents. See related Editorial by Carnahan & Unroe