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Author: Bo Frith

New, Facility Specific Data on Virginia Nursing Homes

December 17, 2018

Inadequate staffing is a widespread and persistent problem in nursing homes in Virginia. We have written extensively about how there are no minimum staffing requirements for Virginia nursing homes. Despite the failure to ensure staffing at the state level, the federal Centers for Medicare & Medicaid Services (CMS) asserts “nurse staffing is directly related to the quality of care that residents experience.”[1]

The federal government recently indicated serious concerns about inadequate staffing, particularly on nights and weekends. A November 30th, 2018 letter from CMS warned about inadequate staffing at nursing homes.[2] A New York Times analysis found 11% fewer nurses providing direct care and 8% fewer aids on weekends as opposed to weekdays.[3] Nursing home residents and their families often tell us of the difficulty in getting basic help, such as assistance going to the bathroom, on weekends. The federal government is so concerned about inadequate staffing at nursing homes it recently ordered states to conduct more weekend inspections.[4]

The ability to find out staffing levels at individual nursing homes is critical to ensuring quality care for your loved one. Until recently, it was difficult for family members to determine which facilities staffed appropriately. Now, there are easy-to-use resources available. On December 11, 2018, the Long Term Care Community Coalition, an advocacy group, announced it will publish staffing information for every nursing home in the country. Simply visit their website,, to download sortable spreadsheets for every state that include:

  1. The facility’s direct care RN, LPN, and CNA staffing;
  2. The ratios of care staff to residents;
  3. Select non-nursing staff hours per day, including administrators, social workers, and activities staff; and
  4. The extent to which the facility relies on contract staff to provide resident care.

You can download the Virginia data set for the second quarter of 2018 here. Every family member with a relative in a nursing home should review this data to see if the facility they use has been staffing appropriately. 

The data are not encouraging. In the second quarter of 2018, Virginia nursing homes averaged 3.5 hours of total direct care per resident per day.[5] A landmark 2001 federal study indicated at least 4.1 hours are needed to meet a typical resident’s needs.[6] Virginia nursing homes also averaged 0.4 hours of RN staff time per resident per day, less than the 0.5 hours averaged nationally and significantly less than the 0.55-0.75 RN hours recommended by the same 2001 study.





[1] U.S. Centers for Medicare and Medicaid Services. Payroll Based Journal (PBJ) Policy Manual Updates, Notification to States and New Minimum Data Set (MDS) Census Reports, (Nov. 30, 2018), available at

[2] Id.

[3] Jordan Rau. ‘It’s Almost Like a Ghost Town.’ Most Nursing Homes Overstated Staffing for Years. New York Times (July 7, 2018), available at

[4] Id. at Payroll Based Journal.

[5] Available at

[6] U.S. Centers for Medicare and Medicaid Services. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. (December 2001). Available at

Pregnancy Deaths – A Uniquely American Problem and What Expecting Mothers Can Do to Protect Themselves

November 19, 2018

In America, thousands of mothers suffer significant injuries or die during childbirth. Each year more than 50,000 American women suffer severe injuries from childbirth. About 700 American women die each year from childbirth. A recent study from the USA Today demonstrates half of the deaths and injuries can be prevented by implementing safety practices mostly ignored by hospitals today.[1] 

In the study, fewer than half of women received prompt treatment for dangerous blood pressure readings that put them at risk for stroke. At some hospitals, less than 15 percent of mothers in peril received recommended treatment. Many of the hospitals failed to take safety steps such as quantifying women’s blood loss or tracking whether moms with dangerously high blood pressure received medication timely.

Today, the United States is the most dangerous place to give birth in the developed world.[2] From 1990 to 2015, maternal deaths in other developed nations flatted or declined significantly. Other countries reduced maternal deaths by monitoring care provided and implementing maternal safety practices.

Childbirth in America does not have to be so dangerous. Regulators and oversight groups could require hospitals to report data on childbirth complications and injuries. As opposed to the inaction in regulating births, regulators monitor elder care aggressively. For example, Medicare requires hospitals to disclose information on compilations for hip and knee surgeries. Unfortunately, there is little information available on maternal health.  No national tracking system exists for childbirth complications.

Despite the lack of information, expecting mothers can take a variety of steps to protect themselves. Mothers should know common warning signs and proper safety responses. For example, mothers are at risk of stroke once their blood pressure hits 160/110 (or either of those numbers individually). If blood pressure reaches 160/110 (or either individually): 1) the healthcare provider should retake the mother’s blood pressure within 15 minutes to ensure the reading is accurate; and 2) if still in the danger zone, the healthcare provider should give blood pressure medication to the mother within an hour.

Women should ask if their hospital tracks patient outcome data the maternal care. The Alliance for Innovation on Maternal Health (AIM) contains many of the best maternal safety practices. Expecting mothers should familiarize themselves with the guidelines included in the AIM Program and ask whether their hospital is one of the 985 hospitals enrolled in the AIM Program.[3] 

It is regrettable the burden of receiving proper maternal care falls on patients.  But, as is so often the case in the American medical system, patients must take an active role in their treatment to ensure the best possible care.

[1] Young, Allison. Hospitals Know How To Protect Young Mothers. They Just Aren’t Doing It. USA Today (July 27, 2018), available at

[2] Id.                                                                                                                

[3] Available at

Choosing Your Doctor: The Importance of Procedure Volume at a Given Healthcare Facility

June 14, 2018

Family image 2One of the most important decisions a person can make is which doctor to trust with his or her medical care.  A recent blog post[1] on our website discusses factors to consider when selecting your doctor, including the number of times a doctor has performed the specific operation you will undergo.  If you are planning on open heart surgery, for example, it would be important to know how many times a doctor has performed that operation.  In fact, the number of times a doctor has performed a specific procedure is one of the most predictive factors in determining the success rate of future medical care.[2]  Patients, however, should not limit their analysis to just the total number of times a doctor has performed a specific operation.  A much more predictive metric is the number of times a doctor has performed a specific operation at a given healthcare facility.

As with all things, context matters — particularly in a complicated area such as healthcare where teamwork is vitally important.  In cardiac surgery, for example, a successful patient outcome depends not only on the individual surgeon, but the varied contributions of many healthcare providers such as anesthetists, intensive care specialists, intensive care nursing, ward nursing, junior medical staff, and so on.[3]

In the May 9, 2018 episode of Malcolm Gladwell’s excellent podcast Revisionist History, Gladwell discusses the effect of context on individual performance.[4]  In the podcast, Gladwell highlights the landmark 2006 study by Harvard Business School Professors Robert S. Huckman and Gary P. Pisano, The Firm Specificity of Individual Performance: Evidence from Cardiac Surgery.[5]  Surgeons often have privileges at different hospitals and facilities, meaning a given surgeon may perform the same operation at several different hospitals.  Using patient mortality as the metric, Huckman and Pisano found that the quality of a cardiac surgeon’s healthcare at given hospital improves significantly with increases in his procedure volume at that hospital, but does not improve significantly with increases in the same procedure at other hospitals. 

Huckman and Pisano demonstrate that increases in procedure volume for a surgeon at a given healthcare facility lead to a decrease in patient mortality at that facility.  However, the same surgeon doing the same procedure at a different healthcare facility may be just as deadly at operation number 1 as they are on operation number 1,000 at that facility.  Mere procedure volume is not predictive.

Huckman and Pisano’s findings are not entirely surprising because a surgeon is but one part of a team of doctors providing healthcare to a patient.  Like any person, a surgeon has strengths and weaknesses.  The team of doctors at a specific hospital may have worked together in the past with knowledge of their strengths and weaknesses with established routines to maximize strengths and minimize weaknesses.  In essence, the skill, expertise, and success rate of healthcare is team specific.

As a result, a vital factor to consider when selecting a doctor is the healthcare facility and team where the operation will be performed.  Without breaking down procedure volume to the level of a given healthcare facility, the statistic loses its predictive value.  Such a general number fails to account for the fundamental importance of a healthcare team and facility in successful patient outcomes.  As part of that, one should consider the number of specific procedures a doctor has performed at a given facility.



[2] E.L. Hannan, J.F. O’Donnell, H. Kilburn, Jr., H.R. Bernard & A. Yazici, Investigation of the Relationship Between Volume and Mortality for Surgical Procedures Performed in New York State Hospitals, Am. Med. Assoc. (1989), available at; E. Hannan, H. Kilburn, H. Bernard, J. O’Donnell, G. Lukacik & E. Shields, Coronary Artery Bypass Graft Surgery: The Relationship Between Inhospital Morality Rate and Surgical Volume After Controlling for Clinical Risk Factors, 29 Med Care 1094–107 (Nov. 1991), available at

[3] A. Merry, W. Brookbank, Merry and McCall Smith’s Errors, Medicine and the Law 366 (Cambridge University Press, 2017). 

[4] Available at