The Five-Star Quality Rating System is constantly changing and expanding, with the most recent changes implemented at the beginning of this year.  However, it helps to start at the beginning, so here’s a quick refresher and overview of the program before we  discuss its effects.  

What is the Five-Star Quality Rating System?

In December 2008, The Centers for Medicare and Medicaid Services (CMS) created the Five-Star Quality Rating System in order to provide patients and their families with a simple way to assess the quality of nursing homes.  The rating system provides an overall score of one star to five stars with a specific focus on the following areas:

Based on the outcomes from annual state health inspections focusing on the number, scope, and severity of deficiencies identified during the three most recent inspections. Deficiencies are weighted by scope and severity and the rating also takes into account the number of revisists required to ensure resolution of each deficiency.  

Based on nursing home staffing levels that look at registered nurse (RN) hours per resident per day, and total nurse staffing hours per resident per day.  Total nursing hours is the aggregation of RN, LPN, and CNA hours and does not include non-clinical staff in the rating calculation.    

Based on Minimum Data Set (MDS) and claims-based quality measures (QMs) that are derived from nine long-stay measures and six short-stay measures as indicated on the Nursing Home Compare section of the Medicare website.  Long-stay is defined as any stay of 100 days or more in a nursing home.  
For those interested, technical specifications for the above listed measures can be found on the CMS website.
While this system was not intended to be an all encompassing, ultimate authority for selecting one nursing home over another, it did provide easy to understand facility performance metrics that would inform patients and their families on the quality of each nursing home.  

So, why should you care?

Low star quality ratings can lead to lost business revenues from reductions in referrals and lower occupancy rates, as families look to other facilities to rehabilitate their loved ones.  In turn, you may also have an increase in turnover as employees won’t want to be associated with an organization with a bad employment brand.  As your vacant positions start to increase, you’ll likely find it more challenging to backfill those open positions.  According to Glassdoor, 69% of job seekers would turn down a job offer from a company with a bad reputation, even if they were unemployed, and 84% would consider leaving their current job if offered a job by a company with an excellent reputation.  
Since you can’t fill your open positions, your labor costs will go through the roof as you increase overtime or use agencies to fill the gaps in your staffing needs.  As employees work more overtime to appropriately staff according to your census, it will eventually lead to burnout and increase turnover rates even more.  As a result, overall resident care suffers, which leads to poor patient outcomes, drives down patient satisfaction scores, and damages your reputation and employment brand even further.  This is what we call a “snowball effect” because once you start down this path, it becomes exponentially harder to slow the momentum down and make the necessary changes to get your organization back on course.  The end result being a giant and unruly mess where the business is at risk of insolvency if drastic changes aren’t effectively implemented.       
High ratings (four or five stars) are clearly very good for your business and are what each individual location should strive for, but these ratings also have ramifications beyond consumer use as indicated in the example above.  According to the American Health Care Association (AHCA), state regulators, health care insurers, lenders and investors reference the five-star rating to determine incentive payments, referral networks, and financial loans.  These ratings could also affect your ability to grow your business to scale and should not be neglected.  

It takes time, but you can turn things around!

If your agency has been affected by a low rating, it’s not the end of the world. There are actions that you can take today to mitigate some of these wide reaching issues and get back on track.

Adequate staffing levels is one of the measures that factor into the five-star rating, so making sure that you have a healthy pool of qualified candidates to draw from becomes even more important.  You don’t have to have an open role to passively recruit candidates either.  The intent is to make sure that you can quickly and easily find qualified candidates that have been partially vetted for organizational fit should anything happen to your current staff.  For example, what happens if one, two, or three of your staff contracts COVID-19 and must quarantine for 14 days?  Maintaining a pool of passive candidates to quickly plug into your schedule will help mitigate those unforeseen circumstances and take the strain off the rest of your staff to backfill those staffing gaps.  

The biggest difference here is between quality and qualified.  A qualified person will check all of the appropriate boxes in terms of job or industry experience.  However, all of that experience does not necessarily qualify an individual to be effective or to be a good fit for your organization.  It’s imperative that you implement quality assessment tools throughout your hiring and recruitment process to better evaluate candidates.  Ensure that you are taking full advantage of reference checks, job fit and skills assessments, and background screenings to help reduce the incidence of making a bad hire.  Each one of your clinical positions is different from the rest, so you should have a tailored process for each of these positions and include your current staff in the evaluation process.  Getting honest feedback from your team will let you know if the candidate will be a good organizational fit, and if they think the applicant could handle the day-to-day of the position..           

We’ve all been there: the first day on the job at a new company where you’re given a big packet of paperwork to fill out and some pre-recorded videos to watch as part of a training program.  As soon as you’re finished, you are released into the wild as a full-fledged new employee — and that is the extent of your new hire “training”.  What message does this type of bare bones training regimen send to your employees?  Training is your opportunity to really instill your company’s core values in new employees, and to be clear about what your expectations are as a representative of your organization.  Don’t squander this chance to train employees about the importance of the five-star quality rating system and the factors that make it up.  You want to make sure that these performance metrics are understood and send the message that all employees are expected to meet these standards. 
Training, also, shouldn’t just be a one-time event that occurs during onboarding.  Training should be an ongoing process where you and your team are always on a quest to improve your performance.  For example, train employees how PPE works and how to treat high risk patients while keeping yourself and those around you safe.  Give your employees access to the tools that will make them most effective and participate in these programs to drive the behaviors that you want your employees to exhibit.  

This last suggestion might seem like common sense given the fact that it is one of the main functional areas that is used to evaluate the quality of nursing homes.  However, I would like to take this a step further to really explain the impact that this recommendation has on your entire organization as it relates to staffing mixes and addressing turnover issues.  A research article in The Gerontologist examined the influence of caregiver staffing levels on the quality of care in nursing homes and determined that the biggest contributors to quality were actually staff consistency and staff mix — not just staffing levels alone.
Unraveling this a bit more, the article found that maintaining consistency among staff members and having the right mix of RNs, LPNs, and nursing aides contributed more to  nursing home quality than basic head count.  As the number of nursing aides increases per 100 residents, overall quality increased while turnover decreased — not only for nursing aides, but also for RNs and LPNs as well.  Nursing aides take necessary strains off your other clinical staff and have more frequent touch points with your residents.  Both of these facets directly relate to your ability to offer high quality service to patients while maintaining high levels of employee satisfaction and reducing turnover and burnout.  While nursing aides can’t replace more specially trained staff members, they are an integral part of your operations and should be treated as such.              
In summary, make sure you are constantly recruiting so that you aren’t left short-handed when the unthinkable happens.  When you are actively hiring, make sure that you are screening for qualities that aren’t readily apparent on a resume, like aptitude, drive, and organizational fit.  Invest in your training programs for new hires and current employees to ensure that your team is always up to date with the latest safety, compliance, and quality measures.  Lastly, review your current staffing mixes and make the appropriate adjustments to drive better patient outcomes and improve employee engagement and satisfaction.    
To see how Hireology can help you hire your best team, you can request a free consultation here.