When I was the CEO of a large academic hospital we were constantly concerned to properly balance nurse staffing. More staff than needed meant wasted money and too little staffing risked lesser quality care and nurse disharmony and even resignations. But adjusting the staffing levels of multiple units, each with differing patient types and needs was a major effort and easily thwarted by rapidly varying census numbers, patient admissions and transfers to other units, nurse shortages, and many other factors. In retrospect it is remarkable that it worked as well as it did. But the risk management group was ever concerned that if the staff levels were too thin it was possible that adverse events could occur. Now there is a new study reported in this week’s New England Journal of Medicine that links deficiencies in nurse staffing with increases in patient mortality. The investigators evaluated an unnamed academic hospital with a strong record of high quality and lower than expected patient mortality. They looked shift by shift and noted whether that shift was at targeted levels based on patient acuity, over or under. They also looked at the level of patient turnover during each shift. Quoting from the article, “In an institution with a history of success in meeting staffing levels and with a level of patient mortality that was substantially below that predicted by its case mix, we found that the risk of death increased with increasing exposure to shifts in which RN hours were 8 hours or more below target staffing levels or there was high turnover. We estimate that the risk of death increased by 2% for each below target shift and 4% for each high turnover shift to which the patient was exposed.” [Italics mine] The take away message to me is that hospital executives and boards need to be sure that they are managing nurse shift decisions carefully. In any hospital, personnel constitute about 60% or more of expenses and nurses represent about one half of that so the dollars are not inconsequential and need to be managed appropriately. Clearly, “appropriately” also means assuring that each unit has the necessary complement of registered nurses on each shift. From the article, “Our findings suggest that nurse staffing models that facilitate shift to shift decisions on the basis of an alignment of staffing with patients needs and the census are an important component of the delivery of care.” It also means that hospitals need to look at their approach to transferring patients from unit to unit. Often times this is necessary such as movement of an unstable patient to an ICU. But this study makes the point that excess transfers can be detrimental to patient welfare and may require more than the usual staff numbers. “Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover on patient outcomes.” How a hospital aligns its nurse staffing is an important element of quality in addition to cost management. Getting staffing right is critical. When it is correct, mortality will be lower. Further, although not measured, if mortality came down in this study, it is fairly safe to assume that other quality measures were improved as well.