The Relationship Between Registered Nurse (RN) Skill Mix and QM Star Ratings in Nursing Homes

Nursing homes are under immense pressure to improve quality. The purpose of this study was to determine if there is a relationship between registered nurse (RN) skill mix (proportion of RN hours among all nursing staff hours) and higher quality measure (QM) star ratings. Data sets from 2021–2022 were utilized from the American Community Survey, Centers for Medicare and Medicaid Services (CMS), Medicare Cost Reports, Payroll-Based Journal, and Care Compare. The final analytic sample was 14,556 unique nursing homes. Ordered logistic regression was used to examine the relationship between RN skill mix (independent variable) and QM star ratings (dependent variable). The study found that RN skill mix is positively associated with QM star ratings. For a 1% increase in RN proportion, the odds of being in a higher QM star rating category increase by 4% (OR = 1.04, p < .001). This study fills two significant gaps in prior literature by relying on more accurate nurse labor hours through electronic payroll records vs. self-reported data, and by using the government standard of 15 quality measures vs. a few selected metrics. The results have implications for policymakers to incentivize improved quality, and for nursing home administrators to improve QM star ratings.