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December 16, 2014

Are Staffing Levels Really the Root Cause of Poor Quality?

In peer-reviewed literature, the correlation between staffing levels and quality outcomes is unclear. While staffing levels can be a legitimate issue pertaining to patient outcomes, sometimes they are given more weight than necessary. Soyring Consulting conducted a review of a rural community hospital to determine how much of an impact staffing levels really have on common issues related to patient outcomes.


Accrediting Body Survey Findings

When reviewing staffing impact on quality, one of the easiest places to begin is reviewing past surveys from accrediting bodies. Most issues identified have no correlation with staffing levels, but instead more closely relate to problems within the environment of care or adherence to best practices and policies/procedures. For this reason, it is important to review some key areas more carefully to ensure that staffing levels are not negatively affecting quality outcomes.

The following are four areas that are often uncovered during a survey and could potentially be affected by staffing patterns:

  • Documentation
  • Patient falls
  • Medication errors
  • Inpatient readmissions



Root causes of documentation inadequacy could relate to a lack of time to complete required documentation and/or deficiencies in training.

Within these categories, documentation errors often range from documenting only select instances and events to no documentation at all. When analyzing staffing impact on documentation adequacy, the root cause analysis should review staffing as a potential culprit. Oftentimes, inadequate documentation is related to low priority focus or education needs, as opposed to time allotment.

To determine if staffing is impacting documentation, a review of documentation issues should be correlated against staffing patterns to determine if—on tighter staffing days (based on acuity and staffing ratios)—documentation is impacted.


Patient Falls

Patient fall rates should first be benchmarked against industry standards to determine your facility’s existing standard. A sample analysis is below.

  • Fall rates range between 1.3 to 8.9 falls/1,000 patient days (AHQR)
  • The hospital’s fall rate was 4.2 falls/1,000 patient days
  • This hospital’s fall rate was lower than many facilities, though there is opportunity for improvement

A staffing analysis should be conducted to determine if the departments experiencing falls are understaffed. This review should look at vacancies, use of agency, and staffing patterns by day as they relate back to fall reports. If staffing levels around incidences of a fall are low, then a more detailed analysis should be conducted to understand the cause. Some potential staffing-related issues include skill mix issues, inadequate call coverage, and staffing ratios, among others. If staffing levels around the incidence of a fall are normal or high, then it is unlikely that staffing is affecting this quality measure.


Medication Errors

Determining medication errors consistently across organizations is difficult. Errors could be caused by long work hours, distractions (alarms, overhead speakers, visitors with questions, etc.), poor labeling, look-alike or sound-alike medications, gaps in training, etc. Due to these and other confounding factors, national benchmarks are less useful when analyzing staffing impact. In fact, higher medication error rates on average may actually be an indicator of a robust reporting system that is working well, rather than an indication of poor practice. This organizational factor should be taken into account when conducting an analysis.

Most medication errors are traced back to inpatient units or the pharmacy, though they can obviously occur elsewhere within the facility. Staffing adequacy for medication error rates should focus most on adequacy of staff in the pharmacy and for nursing education and training programs, though drawing any direct correlation is unlikely.


Inpatient Readmissions

Some studies have tied readmission rates to nurse staffing levels. However, between 2009 and 2011, hospitals gradually began to increase RN ratios. During that same period, readmission rates largely remained the same. This indicates that determining the staffing ratio impact on readmission rates is more complex than conducting a simple review of nurse staffing. This is particularly true when considering that readmissions are closely correlated with patient acuity (particularly chronically, critically ill patients), patient management, and length-of-stay.

Staffing analysis of readmissions should focus on functions that directly influence the numbers found in relevant literature. Staff activities that are pertinent to items such as patient literacy and education, discharge follow-up, case management, utilization review, population health management programs, etc. should be reviewed as they relate to staffing levels and readmission results. This focused analysis will be more impactful than a review of general staffing ratios.



Staffing level impact on quality outcomes is a complex subject with different analytical techniques needed depending upon the quality issue being examined. It is important to evaluate whether your facility is meeting proper benchmarks, especially in areas that lower staffing levels can easily affect quality outcomes. In all areas, staffing should be a part of root cause analysis to determine if it is affecting outcomes.

For more information about the four quality areas listed above, download Soyring’s complimentary white paper, which includes additional details and recommendations for improving in these crucial areas.

Download here »

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