A recent analysis by The New York Times and Kaiser Health News demonstrated alarmingly low staffing levels in nursing homes across the United States, including large day-to-day fluctuations.1 This finding builds on previous reports that nursing homes were able to add staff just prior to annual inspections when staff ratios were determined, thereby inflating the number of staff hours available and helping to increase their status in the Nursing Home Compare star rating system.2 This new analysis was made possible by the CMS mandate, set in place by the Affordable Care Act, that certain nursing homes report staffing levels and patient census on an almost real-time basis.3
The efforts by nursing home to skirt around staff-patient ratios raises important questions about staffing levels in other types of facilities and for other types of health professionals, both of which have been woefully understudied. Dialysis services, like nursing homes, are primarily paid for by CMS.4 Also like nursing homes, dialysis facilities are part of a star-rating system based on quality and process measures, which are publicly available at www.dialysisfacilitycompare.gov and are meant to encourage both improvement by facilities and provide informed consumer choices.5
However, unlike Nursing Home Compare, Dialysis Facility Compare does not include staffing in the reported data or as part of the five-star rating.5 While stakeholders who initially developed the measures for Dialysis Facility Compare believed staffing was an important measure, it was struck from the list at the last minute due to concerns from facility administrators and dialysis companies that these data might be confusing and potentially inaccurate.6
Currently, dialysis facilities report staffing data for nurses, patient care technicians, social workers and registered dietitians to CMS once a year,7 but initially the information was not made easily accessible to the public.8 The data are now available for download by researchers directly from CMS but are not easily searchable for the consumer. Like nursing homes prior to the ACA Section 6106 mandate to report payroll-based (almost) real-time staffing, these figures are self-reported by the dialysis facilities at a specific time each year.7
My own research has shown that the staffing data reported to CMS for registered dietitians in dialysis facilities is lower (ie, better) for patient: staff ratios than those reported by dialysis dietitians in surveys.9 There is no evidence to suggest that dialysis facilities “staff up” prior to the reporting period, so this discrepancy is due at least in part to the relatively vague way of reporting staffing levels to CMS: Full-time and part-time staff are classified as more than 32 hours per week or less than or equal to 32 hours per week, respectively, which means that a health professional who works 8 hours per week and another who works 30 hours per week are counted equally.7 That leads to a lack of precision in staffing metrics.
Other researchers have shown dialysis staffing varies with the proportion of minority patients cared for at dialysis facilities,10 raising important concerns about the role of staffing in equitable care.
In justifying the change to real-time payroll based reporting of nursing home staffing, CMS noted it “has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care.”3 While a similar relationship is logical in any other health care setting, including dialysis, and while dialysis staffing mandates were recently considered by the California legislature,11 without accurate and specific data, the impact of staffing on patient outcomes in any setting has been difficult to study.9
We should continue to explore the role of staffing in the quality of care for patients on dialysis. We may never understand the relationship completely without accurate data; therefore, we should consider efforts to increase the precision of dialysis staffing data, perhaps through more frequent or more specific reporting.