Top Management Stability’s
Impact on Turnover and
Deficiencies
Christopher E. Johnson, Ph.D.
Associate Professor
Director, MHA Program
Department of Health Policy and
Management
Acknowledgements
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Research team
• Kathryn Hyer, Ph.D. - University of South Florida
• Jeffrey Harman, Ph.D – University of Florida
• Mishu Popa – University of South Florida
• Robert Weech-Maldonado, Ph.D. – University of
Florida
• Lloyd Dewald – University of Florida
The research reported here was supported by The
Commonwealth Fund and the US Administration on
Aging.
Background
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Multiple studies have examined staffing turnover
and how it impacts quality in nursing homes.
A few studies have examined administrator and
director of nursing tenure’s impact on turnover and
quality in nursing homes.
Almost all of these studies are cross-sectional.
Almost all of these studies use primary data
collection tools to gather turnover/tenure
information.
“Bad” vs. “good” top management turnover.
Research Questions
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What are the impacts of top management
stability on nurse staff turnover in Florida
nursing homes?
What are the impacts of top management
stability on the number of licensing survey
deficiency cites against Florida nursing homes?
Data
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Florida’s Nurse Staffing Reports 2002 - 2004
Florida’s Medicaid Cost Reports 2002 - 2004.
CMS OSCAR data was used for structural
characteristics.
Area Resource File was used for county level
demographic data.
Dependent Variables
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CNA Turnover – total terminated divided by yearly
average employees.
LN Turnover – total all licensed nurses terminated
divided by yearly average total licensed nurses.
Quality of Care Deficiencies – Total annual quality of
care citations.
Quality of Life Deficiencies – Total annual quality of
life deficiencies.
Total Deficiencies – Total of all annaul deficiencies cited
against facility.
Explanatory Variables
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Stable management – dichotomous variable
that measures if both administrator and DoN
were employed continuously during the year.
Stable administrator – dichotomous variable
that measures if an administrator was
continuously employed by facility during the
year.
Stable DoN - dichotomous variable that
measures if a DoN was continuously employed
by facility during the year.
Control Variables
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Organizational characteristics – CNA hours per
resident day, RN hours per resident day, for profit
ownership, size, Medicaid ratio, Medicare ratio, acuity
index, system membership, and occupancy rates.
Market characteristics – located in metropolitan area,
county African American population, county Hispanic
population, county population women work, Medicaid
market, county RNs per 1000, county LPN per 1000,
average RN county wage, average CNA county wage,
and county personal income per capita.
Methods
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CNA and LN turnover were classified as high,
medium, or low.
Ordered logit for turnover models.
• We believe that the relationship between
stability and turnover is ordered as opposed
to multinomial.
Negative binomial regression for deficiency
models.
• Chosen because of the number of zeroes in
the dependent variable.
Descriptive Statistics
Dependent Variables
Variable Definitions
Data Source
Mean or % (SD)
CNA Turnover
1, 2, or 3 for low, medium, and high
CNA turnover. Turnover is defined
as sum of annually terminated
CNAs divided by Average CNA
employment during the year. Does
not include CNAs terminated during
the first three months.
Nursing Home Staffing
Report
39% (26)
LN Turnover
1, 2, or 3 low, medium, or high LPN
and RN turnover. Turnover is
defined as sum of annually
terminated direct care RNs and
LPNs divided by Average total RN
and LPN employment during the
year. Does not include RNs or
LPNs terminated during the first
three months.
Nursing Home Staffing
Report
41% (29)
Quality of Care Deficiencies
Total of quality of care deficiencies
cited against nursing home annually.
OSCAR
1.33 (1.48)
Quality of Life Deficiencies
Total quality of life deficiencies
cited against nursing home annually.
OSCAR
0.96 (1.15)
Total Deficiencies
Sum of all deficiencies cited against
the nursing home annually.
OSCAR
2.29 (2.22)
Descriptive Statistics
Stable Management
1 if same administrator and DoN
were employed continuously for the
previous 12 months.
Nursing Home staffing
Report
57%
Stable Administrator
1 if same administrator was
employed for the previous 12
months.
Nursing Home Staffing
Report
77%
Stable DoN
1 if same DoN was employed
continuously for previous 12
months.
Nursing Home Staffing
Report
74%
Results - Turnover
Stable management
CNA Turnover
Stable
Stable
Management Admin/DoN
0.76**
LN Turnover
Stable
Stable
Management Admin/DoN
0.49**
Stable administrator
1.01
0.82
Stable DoN
0.90
0.56**
Results - Deficiencies
Quality of Care
Stable
Management
Stable management
Quality of Life
Stable
Admin/DoN
0.84**
Stable
Management
Total
Stable
Admin/DoN
0.83**
Stable
Management
Stable
Admin/DoN
0.83**
Stable administrator
0.85**
0.90
0.87**
Stable DoN
0.89*
0.84**
0.87**
Discussion
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Top management stability appears to have
some impact on turnover and deficiencies cited
against nursing homes.
This sort of “bad” turnover among top
management could be used as a flag for policy
makers when trying to identify potential
problem facilities in their states.
Nursing homes may want to consider ways of
hiring top management teams that will be in
place for 12 continuous months.
Conclusion
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Limitations
• Turnover is calculated post three months
employment.
• Endogeneity relationship between stability
and turnover.
Future research
• Multi-year stability and
turnover/deficiencies
• Impact of stability on quality indicators
• Impact of stability on change in quality
Questions?