Medical Staff Organization, and Relationships Between Directors of Nursing and Medical Staff, and Nursing Home Quality

Nursing homes are critical components of the long-term care continuum. Acute care systems recognize the need for high quality and easily accessible post-acute long-term care (rehabilitation). While nursing home quality is dependent on a number of workforce factors, physicians are clearly an important part of the team. Primary care physicians often graduate and enter practice without any meaningful exposure to post-acute long-term care (PA-LTC) or to geriatric medicine in general.

Emerging evidence suggests that a conceptual framework linking nursing home physician practice to quality has three critical dimensions: commitment, physician nursing home practice competency, and organizational structure. Further, nursing home medical staff organizational structure has been shown to be an independent marker of quality, as has on-site physician availability.

This project’s underlying hypothesis is that physician care is a significant driver of NH quality. In phase 1 of our study, we aimed to more fully characterize the medical staff organization in which PA-LTC physicians practice. The principal data source for this phase included nursing home specific medical staff organizational (NHMSO) information as derived from surveys completed by medical director respondents. The NHMSO tool queries the respondent regarding the total number of attending physicians, NPs and PAs credentialed to provide care in the facility. It also characterizes extant physician payment models as well as practice patterns and relationships between the health professions. In addition, we surveyed directors of nursing (DONs) using a similar new survey tool to learn their perceptions of relationships of professionals within the nursing home.

We linked the data collected from medical directors to facility-level Minimum Data Set information about nursing homes, which is available through the Centers for Medicaid and Medicare (CMS) Nursing Home Compare website. The MDS is completed on a periodic basis for all nursing home residents and is risk adjusted based on a resident’s underlying condition and function. Those MDS measures believed most likely to be affected by physician practice patterns were prioritized and included measures such as pain prevalence, prescription of antipsychotics, restraint use, and vaccination rates. Analysis included multiple regressions utilizing nursing home facility structural characteristics and medical staff organization dimensions.


Key Questions

  • What is the correlation between the Medical Director and DON survey results? To what degree is there concordance of perceptions related to medical staff organization?
  • How is medical staff organization, as defined by both the medical director and DON, linked to clinical outcomes in the nursing home?



Wagner, L, Katz, P, Karuza, J, Sharp, L, Seet, A, Kwong, C, Spetz, J. Director of Nursing Perceptions of Medical Directors' Roles in U.S. Nursing Homes. Journal of the American Medical Directors Association, 2019, 20 (11): P1471-1473.

Wagner, L, Katz, P, Karuza, J, Kwong, C, Sharp, L, Spetz, J. Medical Staffing Organization and Quality of Care Outcomes in Post-Acute Care Settings. The Gerontologist, 2020, online November 4. 


For questions, contact: Laura Wagner, PhD, RN, Professor, Department of Community Health Systems, [email protected] or Joanne Spetz, PhD, Director, UCSF Health Workforce Research Center on Long-Term Care, [email protected].