Running Head: PNEUMONIA READMISSIONS

The Association Between 30-Day Pneumonia Readmissions and Nursing Shortage Among

Medicare Patients in the United States

Alexandra Finch & Rosemary Kinuthia

Emory University Nell Hodgson Woodruff School of Nursing

PNEUMONIA READMISSIONS 2

Abstract

Readmission of pneumonia patients is a persistent problem that requires attention in order to

improve population health outcomes. Another issue affecting health outcomes of patients is the

nursing workforce shortage. It is likely that nursing shortage impacts Community Acquired

Pneumonia (CAP) readmissions however this relationship has not been established. The purpose

of this project is to explore the relationship between the shortage of Registered Nurses (RN) and

pneumonia 30-day excess readmissions using a representative sample of Medicare patients in the

United States.

The outcome variable used for this project was CAP 30-day excess readmissions. The predictor

variables used for this project included: RN shortage grade, discharge instructions, and care

plans. Data from 2015 Medicare condition-specific readmission measures and data from United

States Registered Nurse Workforce Report Card and Shortage Forecast were used for this project.

A multiple linear regression analysis was conducted to determine the association between the

selected predictor variables and pneumonia 30-day excess readmissions. An alpha level (p< .05)

and 95% confidence interval was used to establish statistical significance.

Using a human factors engineering approach, a comprehensive transformation plan focused on

macro and microsystem strategies of reducing nursing workloads was developed. Increased

nursing workloads (nurse patient ratios) have been shown to adversely impact patient safety

(Carayon & Gurses, 2005). Lowering nursing workloads may address the multifaceted dilemma

of CAP 30-day excess readmissions. The purpose of the transformation plan is to provide a

blueprint for system redesign at the macro and micro system levels within a given healthcare

institution; ultimately influencing workforce changes to address nursing shortages and CAP 30-

day excess readmissions.

PNEUMONIA READMISSIONS 3

The Association Between 30-Day Pneumonia Readmissions and Nursing Shortage Among

Medicare Patients in the United States

Pneumonia is one of the leading causes of hospitalization and mortality in the United

States. (Pfuntner, Wier, & Stocks, 2013). Readmission rates of patients diagnosed with

Community Acquired Pneumonia (CAP) is a major area of concern that warrants attention in

order to improve health outcomes in this patient population and improve quality of care.

Another area of concern is nursing shortage due to nurse demand exceeding supply. The

nursing shortage in the United States has been attributed to the aging of the existing nursing

workforce and the expanding elderly population (Juraschek, Zhang, Ranganathan, & Lin, 2012).

Lowering the readmission ratio of CAP patients is a challenge due to the complex and

uncertain relationship that exists between nursing processes of care and health outcomes.

Determining this relationship is a necessary first step to addressing the CAP readmissions

problem.

It is easy to assume that states with the lowest rate of RN shortages have the lowest

pneumonia 30-day excess readmission ratio, however the relationship between the shortage of

Registered Nurses and the proportion of 2014 Medicare CAP patients readmitted within 30 days

is unknown. This paper examines how RN shortage and processes of care conducted by nurses

(providing discharge instructions and creating plans) impact CAP readmissions.

Background

The Centers for Disease and Prevention (CDC) reports that pneumonia is responsible for

over 1 million hospital discharges annually, and in 2013 there were 53,282 deaths due to the

illness (National Center for Health Statistics/Centers for Disease Control and Prevention, 2014).
PNEUMONIA READMISSIONS 4

In 2010 pneumonia was the second leading diagnosis and accounted for about 2.8 percent of all

hospital stays (Pfuntner et al., 2013).

The Centers for Medicare and Medicaid Services (CMS) reports that between July 2011-

June 2012 and July 2013-June 2014, the incidence (Total N) of pneumonia cases decreased from

360,190 to 314,906 at the nations non-federal short-term acute care hospitals and critical access

hospitals (Centers for Medicare & Medicaid Services, 2015). However, even though the

incidence has trended down over the past few years, a recent study conducted by the CDC found

pneumonia remains one of the leading causes of hospitalization (Jain et al., 2015). According to

the Agency for Healthcare Research and Quality (AHRQ) pneumonia was one of the top three

conditions with the largest number of 30-day readmissions in 2011 with 88,800 cases. (Hines,

Barrett, H.J., & Steiner, 2014).

Pneumonia readmission prevention is closely associated to the quality of care provided to

CAP patients. According to study published in the New England Journal of Medicine, 27% of

readmissions were preventable (Joynt & Jha, 2012). In an effort to improve healthcare quality

CMS began to examine 30-day readmission rates for CAP and overall rate of unplanned

readmissions following discharge from the hospital and implement financial penalties to

hospitals exceeding the national average (Demehin & Ward, 2015). Controversy surrounding 30-

day readmission penalties stem from the notion that there are community and patient related

factors that may prevent readmission (Agency for Healthcare Research and Quality, 2014).

To support this argument, a study published in the Journal of Clinical Infectious Diseases

retrospectively analyzed readmission rates of 977 subjects following discharge with non-

nosocomial pneumonia. The authors concluded that factors associated with readmission are not

necessarily correlated with variable directly controlled by the hospital (Shorr et al., 2013).
PNEUMONIA READMISSIONS 5

It is essential to address the readmission rates not only to improve health outcomes in

CAP patient populations and improve quality of care of the nation, but also to lower the rising

costs of healthcare in the U.S. According to the most recent available data, the total cost of 30-

day readmissions for pneumonia was $1.1 billion, which was the third highest cost of

readmission rates for the top 10 high-volume conditions among Medicare beneficiaries in 2011

(Hines et al., 2014).

This problem was chosen primarily due to its significance. A considerable amount of time

and resources have been invested in an effort to solving this complex problem. There is an

ongoing interest to explore possible solutions to this multifaceted dilemma.

Dataset(s)

The relationship between the shortage of Registered Nurses (RN) and the proportion of

2014 Medicare CAP patients readmitted within 30 days was determined by analyzing data from

United States Registered Nurse Workforce Report Card and Shortage Forecast (Juraschek et al.,

2012) and data derived from the 2015 Medicare condition-specific readmission measures

(Centers for Medicare & Medicaid Services, n.d). The CMS derived dataset combines multiple

individual datasets from Medicare's Hospital Compare website, which compares the quality of

care at over 4,000 Medicare-certified hospitals across the United States.

Dr. Melinda Higgins, Associate Professor of Research, Office of Nursing Research and

the Doctor of Nursing Practice (DNP) course faculty at Nell Hodgson Woodruff School of

Nursing, Emory University merged several CMS datasets to provide DNP students enrolled in

Nursing 610D: Analyzing, Evaluating and Translating Health System Evidence during Summer

Semester, 2015 with real-life experience analyzing a large dataset. These data are for illustration

purposes.
PNEUMONIA READMISSIONS 6

Inclusion/Exclusion Criteria

Only data for Medicare populations (aged 65 or older) treated for Community Acquired

Pneumonia at the nations non-federal hospitals were analyzed for this project.

Inclusion criteria for the original data set included:

Having a principal discharge diagnosis of pneumonia;

Enrolled in Medicare fee-for-service (FFS);
Aged 65 or over;
Discharged alive from a non-federal acute care hospital;
Not transferred to another acute care facility; and,
Enrolled in Part A and Part B Medicare for the 12 months prior to the date of the

admission, and enrolled in Part A during the index admission.

Variables

Table 1 provides a summary of predictor and outcome variables used for this project.

The outcome/dependent variable used for this analysis was:

Pneumonia 30-day excess readmissions - A hospitals excess readmission ratio for

pneumonia will provide us with a measure of a hospitals readmission performance compared to

the national average for the hospitals set of patients with that applicable condition.

The predictor/independent variables that were used in the analysis for this project include:

RN shortage grade- Nursing shortage is the primary predictor variable used in this

analysis. Logic may rationalize that regions with the lowest rate of RN shortages will have the

lowest pneumonia 30-day excess readmission ratio, however this relationship has not been

established. Exploring this relationship will help to shed more light and possibly solidify this

assumption.

Discharge instructions given- Determining whether there is an association between the

percentage of Medicare patients who receive discharge instructions and the pneumonia 30-day

excess readmissions ratio will advise us whether this nursing process could be improved upon in
PNEUMONIA READMISSIONS 7

order to have a positive impact on patient outcomes.

Care plan created -Determining whether there is an association between the percentage

of Medicare patients for whom a care plan is created and the pneumonia 30-day excess

readmissions ratio will advise us whether this nursing process could be improved upon in order

to have a positive impact on patient outcomes.

Ascertaining how the selected predictors influence the pneumonia 30-day excess

readmissions may inform us on critical areas of focus which could be improved upon in order to

lower pneumonia readmissions and ultimately enhance population health outcomes.

Data

Definition of Variables

Pneumonia 30-day excess readmissions (variable # 36) is reported as a ratio. It is

measured by dividing a hospitals number of predicted 30-day readmissions for pneumonia by

the number that would be expected, based on an average hospital with similar patients. A ratio

greater than 1 indicates excess readmissions (Centers for Medicare & Medicaid Services, 2015).

This variable was used as reported in the data set i.e. no recoding or transformation was

conducted.

RN shortage grade (Variable #66)- Nursing shortages are generally described as

occurrences where the demand for nursing professionals exceeds supply. This variable was

created by assigning letter grades representative of RN shortage from the United States

Registered Nurse Workforce Report Card and Shortage Forecast article (Juraschek et al., 2012)

to the State variable (Variable #4) in original Medicare dataset.

The metric used for shortage grading in the Jurachek (2012) article is the RN shortage

ratio, which the authors define as the difference between demand and supply of RN jobs per 100
PNEUMONIA READMISSIONS 8

000 people. Numbers were assigned to the grades (i.e.1=D, 2=C-, 3=C, 4=C+, 5=B and 6=A)

where A represents minimal shortage and D represents severe shortage. Grouping was then

conducted as follows: 1, 2 and 3 (moderate to severe shortage) and, 4, 5 and 6 (minimal to

moderate shortage).

Discharge instructions given (Variable # 9)- The AHRQ defines discharge instructions as

guidelines provided to the patient with education on expected progression of illness or injury,

treatment and care use of medications and follow-up (Agency for Healthcare Quality and

Research, n.d.). The dataset used for this project reports, discharge instructions given as a

percentage of Medicare patients who receive discharge instructions. The variable was used as

reported in the dataset i.e. no recoding or transformation was conducted.

Care plan created (variable # 11). CMS explains creating discharge planning is essential

in order to ensure the smooth transition of patients across care settings and to their homes.

Creating a care plan begins the process of meeting the patients post-discharge needs (Centers for

Medicare & Medicaid Services, n.d). The dataset used for this project reports, care plan created

reported as a percentage of Medicare patients for whom a post discharge continuing care plan is

created. This variable was used as reported in the data set i.e. no recoding or transformation was

conducted.

Characteristics of Variables

Measures of central tendency, variability and distribution were conducted to summarize

the data for the outcome variable (pneumonia 30-day excess readmissions) and predictor
PNEUMONIA READMISSIONS 9

variables (RN shortage, discharge instructions and care plan). Table 2 summarizes the

characteristics of the selected variables.

Pneumonia 30-day excess readmissions

Central Tendency- Mean is 1.0014 and Median is 0.9951.

Distribution- The mean and median are almost equal (but mean > median), concluding that this

approximately normal distribution is slightly skewed to the right. This distribution is also

depicted in the Figure 1 histogram.

Variability- Because this is an approximately normal distribution, we looked at the standard

deviation= 0.07482 i.e. the average distance for each data point from the mean is 0.07482.

RN shortage grade

Central Tendency- Mean is 1.43 and Median is 1.00

Distribution- Looking at the shape of the histogram we can tell that this is a right skewed

distribution. We can also confirm this by looking at the mean and median. The mean (1.43) is >

than the median (1.00), meaning that the approximately normal distribution of RN shortage

grade is slightly skewed to the right. This distribution is depicted in the Figure 2 histogram.

Variability- Because this is an approximately normal distribution, we looked at the standard

deviation=0.495 i.e. the average distance for each data point from the mean is 0.495.

Discharge instructions given

Central Tendency- Mean is 94.05 and Median is 97.

Distribution- The mean and median are almost equal (but median > mean), concluding that this

approximately normal distribution is slightly skewed to the left. This distribution is depicted in

the Figure 3 histogram.

PNEUMONIA READMISSIONS 10

Variability- Because this is an approximately normal distribution, we looked at the standard

deviation=10.237 i.e. the average distance for each data point from the mean is 10.237.

Care plan created

Central Tendency- Mean is 76.12 and Median is 90.26.

Distribution- The median is significantly greater than the mean concluding that this non-normal

distribution is significantly skewed to the left. This distribution is depicted in the Figure 4

histogram.

Variability- Because this is a non-normal distribution we looked at the interquartile range= 61.38

(25th), 90.265 (50th) and 98.99 (75th). This means that 50% of all hospitals create post-discharge

care plans for 61.38% to 98.99% of their patients.

Correlations of the Predictor and Outcome Variables

To assess the relationships between the outcome variable and each predictor variable a

Pearson chi-square was computed. The correlations are described below and summarized in

Table 3.

A Pearson chi-square was computed to assess the relationship between pneumonia 30-day

excess readmissions and nursing shortage. There was a negative weak correlation between the 2

variables (r= -0.068, p= 0.000). P is less than the 0.05 threshold therefore it is statistically

significant. A scatterplot summarizes the results (Figure 5).

A Pearson chi-square test was computed to assess the relationship between pneumonia

30-day excess readmissions and discharge instructions. There was a negative weak correlation

between the 2 variables (r= 0.003, p=0.859). P is greater than the 0.05 threshold therefore it is

not statistically significant. A scatterplot summarizes the results (Figure 6).

PNEUMONIA READMISSIONS 11

A Pearson chi-square test was computed to assess the relationship between pneumonia

30-day excess readmissions and care plan created. There was a positive weak correlation

(r=0.057, p=0.073). P is greater than the 0.05 threshold therefore it is not statistically significant.

A scatterplot summarizes the results (Figure 7).

Hypothesis

This analysis aims to address the following question:

Is there an association between 30-day pneumonia readmissions and nursing shortage among

2014 Medicare patients in the United States?

The above question was used to formulate the following hypotheses:

Ho: There is no relationship between CAP 30-day excess readmission ratio and RN shortage.

Ha: There is a relationship between CAP 30-day excess readmission ratio and RN shortage.

Statistical Analysis

All statistical analyses were performed using SPSS 23.0.

A bivariate correlation test was conducted to determine whether there is a correlation between

the CAP excess ratio and RN Shortage.

A multiple linear regression analysis was computed to determine whether there is an association

between the predictor and outcome variables i.e. to investigate the degree to which, RN shortage,

discharge instructions given, and care plan created predicts pneumonia 30-day excess

readmissions.

An alpha level (p< .05) and 95% confidence interval was be used to establish statistical

significance.

Statistical Test Assumptions

PNEUMONIA READMISSIONS 12

It was determined that a multiple linear regression (MLR) analysis was an appropriate

test to assess the association between, RN shortage, discharge instructions given, care plan

created and pneumonia 30-day excess readmissions.

Five MLR assumptions were tested for this analysis:

I. Dependent variable is measured on a continuous scale (i.e. interval or ratio).

The dependent variable pneumonia 30-day excess readmissions is a ratio. We can

therefore conclude that this assumption is satisfied.

II. There are 2 or more independent variables.
There are 3 independent variables used for this analysis i.e. RN shortage, discharge

instructions given and care plan created. We can therefore conclude that this

assumption is satisfied.
III. Linear relationship between the dependent variable and each of the independent

variables.
The matrix scatter plot (Figure 8) was used to visually inspect the relationship

between each variable. With the exception of the care plan created variable, the

selected predictors have reasonably linear relationships with the outcome variable

(pneumonia 30-day excess readmissions) and there are no obvious outliers.

IV. Data must not show multicollinearity
Testing for multicollinearity tests whether predictor variables are highly correlated;

we want to ensure that there is no perfect linear relationship between 2 or more

independent variables. A bivariate correlation of all independent variables was

conducted and the results are depicted in the correlation matrix (Table 4). The results

show that the correlations between each of the independent variables to the other

independent variables are low showing that there is no multicollinearity.

Collinearity statistics (Table 5) also reports the Variance Inflation Factor (VIF) and

tolerance from the coefficient table in the regression model. The average VIFs are

lower than 10 (1.002), the average VIF is not substantially greater than 1 (1.002) and
PNEUMONIA READMISSIONS 13

the tolerances are greater than 0.2 (0.998). We can therefore conclude this assumption

is satisfied.
V. Residual errors are approximately normally distributed.
The histogram (Figure 9) created from the linear regression analysis was used to

examine this assumption. It can be observed that the residuals follow the shape of a

normal distribution curve. Because the histogram follows a normal curve and points

on the P-P plot (Figure 10) follow the diagonal line we can conclude that this

assumption is satisfied for the MLR model.

Results/Interpretation

A multiple linear regression was conducted to predict the pneumonia 30-day excess

readmission ratio based on the RN shortage grade, percentage of Medicare patients who receive

discharge instructions, and percentage of Medicare patients for whom a clinical care plan is

created. Assumptions of linearity, uncorrelated errors, and normal distribution of errors were

checked and met. The mean, standard deviations, and intercorrelations can be found in the

appendix.

A non-significant regression equation [F(3,943)= 2.54, p= 0.056] with an R2 of 0.008

indicates that only 0.8% of the variance in the pneumonia 30-day excess readmissions can be

explained by the model. See Table 6 for a summary of the regression model.

As seen in Table 7 pneumonia 30-day excess readmissions ratio decreased by 0.010 (B=

-0.010) due to nursing shortage, however giving discharge instructions and creating care plans

had no impact on the pneumonia 30-day excess readmission ratio (B= 0.000 for both). None of

the independent variables selected (discharge instructions, and percentage of Medicare patients

for whom a clinical care plan is created) were significant predictors (p=0.059, p=0.054 and

p=0.069 respectively) of pneumonia 30-day excess readmissions.

PNEUMONIA READMISSIONS 14

The finding from this analysis is that nursing shortage decreases the pneumonia 30-day

excess readmissions ratio. This finding is unlikely and opposite of what should be expected. This

conclusion should however be held lightly due to limitations in data available for nursing

shortage in the United States. The data from United States Registered Nurse Workforce Report

Card and Shortage Forecast (Juraschek et al., 2000) was from 2009 while the CMS Medicare

condition-specific readmission measures was from 2014. The nursing shortage data was the most

recent available data. It is likely that analyzing data from 2 different periods (5 years apart)

would yield inaccurate results due to changes that have taken place over time. These unknown

changes were not accounted for in the analysis. There was also some missing data in the

Medicare dataset, which reduces the statistical power of the analysis.

Transformation

Complex Systems

Findings from this analysis support the alternative hypothesis predicting the relationship

between CAP 30-day excess readmission ratios and RN shortage. Theoretically, we would have

expected a more definitive conclusion suggesting that higher nursing shortages are strongly

linked to higher CAP 30-day excess readmission ratios. Increased workloads among nurses are

increasingly prevalent as the result of nursing shortages. This phenomenon ultimately has

negative impacts on patient safety (Carayon & Gurses, 2005). Using a human factors engineering

approach, a comprehensive transformation plan geared towards nursing workload reduction can

be developed. Improved patient outcomes have historically been attributed to adequate nursing

staffing and lower nurse patient ratios (Aiken, et al., 1987), therefore emphasis of the proposed

transformation plan will focus on microsystem strategies of reducing nursing workloads with
PNEUMONIA READMISSIONS 15

concepts to potentially be disseminated and applied at the macro level to help address the

multifaceted dilemma of CAP 30-day excess readmissions.

General Systems Thinking

Systems can be defined as regularly interacting or interdependent groups of items

forming a whole, and are comprised of individual, unified parts with a common purpose

(Jennings, 2014). Furthermore, systems have a distinct purpose with clear elements,

interconnections, feedback loops and predictability (Meadows, 2008). Complex adaptive

systems are distinctly different from general systems in that they have multiple interconnections

and purposes and are non-linear, which adds to their complexity.

Theoretical Framework

The Systems Engineering Initiative for Patient Safety (SEIPS) model was the primary

framework chosen for the transformation plan (Figure 11). Components from the Structure-

Process-Outcome (Donabedian, 1988), and System Theory (Von Bertalanffy, 1950) were

adjunctively used to drive the systems engineering transformation process. In the SEIPS model,

the structure of a work system is comprised of technology, people, organization, tasks and

environment (Carayon, et al., 2006). Collectively, these interconnected units may ultimately

influence outcomes and processes of the entire system. The purpose of the SEIPS model is to

influence change at the structure and process level in an effort to improve system and

organizational outcomes (Carayon, et al, 2006). The SEIPS model enables the ability to assess

various components of the overarching healthcare system, thereby providing a clear depiction of

the healthcare organization.

Macro System Approach

PNEUMONIA READMISSIONS 16

Structure- For the proposed transformation plan, the macro system will be defined as an

individual healthcare institution. From a financial perspective, a healthcare organization may not

have sufficient financial resources to support adequate nurse-patient ratios, thereby directly

increasing workloads. From an organizational perspective, shorter hours for physicians and

advanced providers may consequently increase workloads for nurses, as nurses may be requested

to work over-time and/or manage larger patient loads which can compromise patient safety. As a

result, inadequate care and discharge teaching may inadvertently contribute to rising pneumonia

readmission rates.

Process- The first step proposed in addressing macrosystem structural problems will

involve thorough analysis of past and present company financial documents including balance

sheets, income and cash flow statements. These analyses will shed light on available resources

to address staffing within the institution. Although external factors (i.e. shortage of nurses in a

particular region and physician workforce policy regulations) may also contribute to the financial

state of the organization, this is a necessary first step in addressing nursing workforce related

issues. After obtaining a clear depiction of financial state, the subsequent step would involve

evaluation and re-allocation of institutional resources to provide additional staffing (nursing and

ancillary). Thereby reducing workloads, which will enable nurses to deliver adequate patient care

to patients at risk for readmission.

Micro System Approach

Structure- For the proposed transformation plan, the micro system will be defined as

individual nurses and their work environments. The initial step to the approach will be to assess

how nurses interact with their environments and how these interactions influence workloads. For

an individual nursing unit within a healthcare organization, this may involve conducting a unit
PNEUMONIA READMISSIONS 17

level cultural assessment in addition to direct observation of nurses and physical workstations

throughout multiple shifts. Interviews, focus groups, flowcharts and surveys of nursing staff

may also be included in the structural assessment of the work system.

Process- After structural influences contributing to workloads are identified; microsystem

redesign would be the next step in the transformation plan. Data from the structural work system

assessment would ideally guide planning and interventions. In the perfect environment, sources

of excess workload would be removed from the system. Due to the complex nature of the

individual microsystem (i.e. fiscal and human resources, competing demands, etc.), reinforcing

and balancing mechanisms may serve as alternative approaches in managing workloads. An

example of a conceptual approach may be to offer social support for staff such as resources that

may enable them to manage workloads (i.e. increased volunteer services to answer patient call

bells) and practical support (i.e. workshops on creative time management) to assist nurses with

workflow organization. Availability of stress reduction programs (i.e. on-site meditation, yoga

and quiet rooms) may be of benefit as increased levels of stress may contribute to challenges

with management of workloads. Team collaboration, input and involvement are key components

to implementation at the micro level. Due to the inability to accurately measure proposed

components of the transformation plan, financial estimation of transformation plan

implementation at the macro and micro levels is unknown at this time.

Evaluation and Sustainability

Program sustainability involves maintaining and continually building upon program

progress. Using the Institute of Healthcare Improvement (IHI, 2008) recommendations for

sustainability, supportive management structure, robust feedback systems and staff engagement
PNEUMONIA READMISSIONS 18

will serve as foundational principles for sustainability. The first principle of supportive

management structure will involve ensuring C level executives and trustees are committed and

understand the importance of workload and healthcare quality. Public display of improvement

data in addition to ensuring data measurement systems that generate various levels of

performance data are recommended. Ensuring that all members of the team have a clear

understanding of the plan and their role will increase the likelihood of project sustainability to

address workloads and CAP 30-day excess readmissions.

Conclusion

A single solution for addressing the complexity of CAP 30-day excess readmissions does

not currently exist. Despite study limitations, this analysis may prompt future exploration of

ways in which nursing processes of care and shortages influence CAP 30-day readmissions.

Findings may also be useful for research exploring the relationship between CAP 30-day

readmissions and nursing shortage. Future study recommendations include analysis with recent

datasets (within 2-5 years) in addition to investigating development of wide scale transformation

plans. Findings may be of interest to healthcare administrators, policy makers and anyone with

interest in exploring a systems engineering approach for transformation.

PNEUMONIA READMISSIONS 19

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PNEUMONIA READMISSIONS 22

Table 1

Summary of Predictor and Outcome Variables

Predictors LOM Outcome LOM

RN shortage grade Ordinal
Discharge instructions given Ratio
Care plan is created Ratio Pneumonia 30-day excess Ratio
readmissions

Table 2

Summary of Characteristics/Statistics of Predictor and Outcome Variables

Pn RN DC Instructions Care Plan

Excess Shortage Given Created
Readmiss
ions
N Valid 3029 4620 2835 1048
Missing 1655 64 1849 3636
Mean 1.0014 1.43 94.05 76.1263
Median .9951 1.00 97.00 90.2650
Std. Deviation .07492 .495 10.237 29.24663
Range .50 1 100 100.00
Percentil 25 .9519 1.00 93.00 61.3875
es 50 .9951 1.00 97.00 90.2650
75 1.0461 2.00 100.00 98.9875

Figure 1
PNEUMONIA READMISSIONS 23

Histogram of Pneumonia Excess Readmissions Variable

Figure 2

Histogram of RN Shortage Variable

Figure 3
PNEUMONIA READMISSIONS 24

Histogram of Discharge Instructions Variable

Figure 4

Histogram of Care Plan Created Variable

Table 3
PNEUMONIA READMISSIONS 25

Correlations Matrix of Outcome and Predictor Variables

Pn Excess RN DC Care Plan

Readmissio Shortage Instructions Created
ns Given
Pn Excess Pearson 1 -.068** -.003 .057
Readmissions Correlation
Sig. (2-tailed) .000 .859 .073
N 3029 3022 2779 980
RN Shortage Pearson -.068** 1 -.040* -.022
Correlation
Sig. (2-tailed) .000 .036 .473
N 3022 4620 2828 1043
DC Pearson -.003 -.040* 1 .042
Instructions Correlation
Given Sig. (2-tailed) .859 .036 .202
N 2779 2828 2835 945
Care Plan Pearson .057 -.022 .042 1
Created Correlation
Sig. (2-tailed) .073 .473 .202
N 980 1043 945 1048
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

Figure 5

Scatterplot Depicting Correlation Between CAP 30-Day Excess Readmissions and RN Shortage
PNEUMONIA READMISSIONS 26

Figure 6

Scatterplot Depicting Correlation Between CAP 30-Day Excess Readmissions and Discharge

Instructions

Figure 7

Scatterplot Depicting Correlation Between CAP 30-Day Excess Readmissions and Care Plan
PNEUMONIA READMISSIONS 27

Figure 8

Scatter Plot Matrix Of All Predictor And Outcome Variables

Table 4

Correlations Matrix of Independent Variables

PNEUMONIA READMISSIONS 28

RN Shortage DC Care Plan

Instructions Created
Given
RN Shortage Pearson 1 -.040* -.022
Correlation
Sig. (2-tailed) .036 .473
N 4620 2828 1043
DC Pearson -.040* 1 .042
Instructions Correlation
Given Sig. (2-tailed) .036 .202
N 2828 2835 945
Care Plan Pearson -.022 .042 1
Created Correlation
Sig. (2-tailed) .473 .202
N 1043 945 1048
*. Correlation is significant at the 0.05 level (2-tailed).

Table 5

Summary of Collinearity Statistics (VIF and Tolerance) of Independent Variables

Model Collinearity Statistics

Tolerance VIF
1 (Constant)
RN Shortage .998 1.002
DC Instructions Given .998 1.002
Care Plan Created .998 1.002

Figure 9

Histogram of Regression Standardized Residual

PNEUMONIA READMISSIONS 29

Figure 10

Normal P-P Plot of Regression Standardized Residual

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Table 6

Regression Model Summary

Model R R Square Adjusted R Std. Error of the

Square Estimate

1 .090a .008 .005 .07951

a. Predictors: (Constant), CarePlanCreated, StateRNShortage_TwoLevels,

DCInstructions_Given
b. Dependent Variable: PnReadmit_Excess

Table 7

Regression Coefficients
Coefficientsa
Model Unstandardize Standardized t Sig. Collinearity
d Coefficients Coefficients Statistics
B Std. Beta Toler VIF
Error ance
1 (Constant) .993 .030 33.097 .000
RN Shortage -.010 .005 -.062 -1.888 .059 .998 1.002
DC .000 .000 .019 .578 .564 .998 1.002
PNEUMONIA READMISSIONS 31

Instructions
Care Plan .000 .000 .059 1.822 .069 .998 1.002
Created
a. Dependent Variable: PnReadmit_Excess

Figure 11

Systems Engineering Initiative in Patient Safety (SEIPS) Model