SPECIAL ARTICLE

Health Care Professional Staffing, Hospital

Characteristics, and Hospital Mortality Rates
C. A. Bond, Pharm.D., FASHP, FCCP, Cynthia L. Raehl, Pharm.D., FASHP,
Michael E. Pitterle, M.S., and Todd Franke, Ph.D.

To evaluate associations among hospital characteristics, staffing levels of

health care professionals, and mortality rates in 3763 United States hospitals,
a data base was constructed from the American Hospital Association’s
Abridged Guide to the Health Care Field and hospital Medicare mortality rates
from the Health Care Financing Administration. A multivariate regression
analysis controlling for severity of illness was employed to determine the
associations. Hospital characteristics associated with lower mortality were
occupancy rate and private nonprofit and private for-profit ownership.
Mortality rates decreased as staffing level per occupied bed increased for
medical residents, registered nurses, registered pharmacists, medical
technologists, and total hospital personnel. Mortality rates increased as
staffing level per occupied bed increased for hospital administrators and
licensed practical-vocational nurses. To our knowledge, this is the first study
to show that pharmacists were associated with lower mortality rates.
(Pharmacotherapy 1999;19(2):130–138)

Over the last 15 years substantial changes have
occurred in the organizational structure and
staffing patterns of many hospitals. 1–3
Reorganization (“downsizing,” “reengineering,”
“right sizing”) has resulted in reduction of
professional staff, consolidation of patient care
units, and hospital mergers to produce lower
costs. Few studies have evaluated the effects of
staffing changes on quality of care or on specific
outcome measures such as hospital mortality
rates.
From the Departments of Pharmacy Practice (Drs. Bond
and Raehl) and Psychiatry (Dr. Bond), Schools of Pharmacy
and Medicine, Texas Tech University Health Sciences
Center–Amarillo, Amarillo, Texas; the Department of
Pharmacy, University of Wisconsin–Madison, Madison,
Wisconsin (Mr. Pitterle); and the Department of
Biostatistics and Biometrics, School of Public Policy and
Social Research, University of California at Los Angeles, Los
Angles, California (Dr. Franke).
Address reprint requests to C. A. Bond, Pharm.D.,
Department of Pharmacy Practice, Texas Tech University
Health Sciences Center-Amarillo, 1300 South Coulter Street,
Amarillo, TX 79106.
Recent reports of deaths attributed to less well-
trained and educated health care workers have
attracted national media attention (e.g., ABC’s
“Good Morning America,” September 30, 1996).
In the 1996 general election, about 40% of
California voters supported two ballot initiatives
that would have established staffing levels for
health professionals to ensure access and quality
of care.4 Texas recently enacted legislation to
allow patients to sue health maintenance
organizations that fail to approve or pay for
health care treatments the patient believes are
necessary.5 Although public concern that the
quality of health care has decreased secondary to
cost cutting and staff reductions is growing,
accurate measures and universally accepted
standards of quality care remain elusive.6, 7
Studies of hospital-based mortality rate were
limited to exploring associations among
demographic, teaching affiliation, ownership,
staff education and training, disease, quality of
care, and fiscal characteristics.8–16 None of these
 PROFESSIONAL STAFFING AND HOSPITAL MORTALITY RATES Bond et al
studies evaluated associations between all
professions (staffing levels) and hospital
mortality rates. Whereas mortality rates are not
specific measures of quality of care, they do have
a close association with it. 13–17 Patient care
outcome measures must adjust for patient charac-
teristics that influence the outcome measures.15,
16, 18, 19
If outcome measures (e.g., hospital mor-
tality rates) do not adjust for severity of illness,
conclusions for hospitals that treat the most
severely ill patients would be inaccurate, leading
to erroneous conclusions about quality of care.
We tested the association between mortality
rates (adjusted for severity of illness for Medicare
patients) in 3763 hospitals in the United States,
and hospital characteristics and staffing levels of
14 categories of hospital personnel (13 types of
professional staff and total hospital personnel).
We believe this is the first study to explore these
relationships in a large number of hospitals with
several categories of health care professionals.
Methods
Sources of Data
The Medicare Hospital Mortality Information
data tape for 1992 was purchased from Health
Care Financing Administration (HCFA)
providing individual hospital Medicare mortality
rates. 20 Methods used by HCFA to calculate
mortality rates are published elsewhere. 21
Hospital data including average daily census and
numbers and types of hospital personnel were
obtained from a data tape purchased from the
American Hospital Association (AHA).2 These
two data sources were integrated into one data
base, and SAS, release 6.11 implemented on a
personal computer (Pentium 166 Mz), was used
for all statistical analyses.22
The HCFA provided 1992 Medicare mortality
data for 5505 hospitals in 1995. The AHA
provided 1992 information for 6871 hospitals,2 of
which 4822 (70%) were general medical-surgical
hospitals. Hospitals included in this study had
information on Medicare mortality rates, average
daily census, and 14 hospital personnel staffing
variables. Only the 4822 general medical-
surgical hospitals in the AHA data base were used
to provide a homogeneous hospital and patient
population. Mortality rates for psychiatric,
alcohol and drug rehabilitation, or rehabilitation
hospitals would not provide appropriate outcome
measures of care. Data from the AHA and HCFA
data bases were matched for 3763 hospitals,
which constituted the study population.
131
Variables and Analysis
Hospital characteristics were occupancy rate,
teaching affiliation (membership in the Council
of Teaching Hospitals or American Osteopathic
Hospital Association), and ownership (public,
private nonprofit, private for-profit). Hospital
variables were obtained from the AHA data base.
Personnel variables from the AHA data base were
numbers of administrators, physicians, medical
residents, registered nurses, licensed practical-
vocational nurses, physician assistants, registered
pharmacists, medical technologists, dietitians,
occupational therapists, physical therapists,
respiratory therapists, social workers, and total
hospital personnel. Staffing data were for
inpatient personnel. Department administrators
(directors of pharmacy, nursing, medical
technology, etc.) were counted as departmental
personnel, not administrators.
Only full-time personnel were used from each
category for analysis, since this was the only
personnel measure common to the 14 categories
in the AHA data base. 2 Part-time personnel
information (total number of part-time
employees, not total full-time equivalents, FTE)
were available for nursing and physician staff
only. Since the number of employees (nurses,
physicians) could not be converted to FTE, we
were not able to use these data in our analysis.
Each personnel variable was divided by the mean
number of occupied beds for that hospital to
provide a staffing level based on a common
workload measure (staffing/occupied bed).
Simple and multiple regression was used.
Severity of illness was controlled by forcing three
variables into the regression analysis model:
percentage of intensive care unit (ICU) days
(calculated as ICU days divided by total inpatient
days), annual number of emergency room visits
divided by average daily census, and percentage
of Medicaid patients (calculated as Medicaid
discharges divided by total discharges). These
variables were validated as a severity of illness
measure in similar studies.9, 12, 15, 16, 19 We chose
the variables because they are the only ones
validated as adjusters for severity of illness using
these national data bases.9, 15, 16 Although other
variables have been used to adjust for severity of
illness with smaller patient populations
(APACHE [Acute Physiology and Chronic Health
Evaluation] scores, specific patient case mix,
patient age, number of surgical patients,
physician experience, length of shifts, patient
work loads, etc.), they were not available through
132 PHARMACOTHERAPY Volume 19, Number 2, 1999

national data bases. Diagnosis-related groups are Table 1. Severity of Illness and Personnel Characteristics
not reliable severity of illness adjusters since for 3763 Hospitals
many hospitals have inflated severity of illness Variable Mean ± SD
ratings. Severity of illness
ICU days/total inpatient days 0.077 ± 0.223
No. emergency room visits/ADC 0.620 ± 0.529
Statistical Analyses Medicaid discharges/total discharges 0.126 ± 0.098
Predicted mortality/1000 admissions 91.041 ± 15.182
A weighted least squares regression was used to
Hospital, % (no.)
estimate and test the relationships among Occupancy rate 55.32 ± 19.47
hospital characteristics, personnel categories, and Teaching hospital 8.3 (313)
mortality rates. The weight used in the analysis Ownership
was the inverse of the variance for the observed Public 14.3 (539)
Private nonprofit 71.5 (2690)
mortality rate, N/{p x (1 - p)}, where N was the Private for-profit 14.2 (534)
number of Medicare admissions to the hospital No. of staff/100
and p was HCFA’s expected mortality rate for Personnel occupied beds ± SD
each hospital. Parameter estimates 95% Administrators 8.837 ± 11.622
confidence intervals were calculated for both Physicians 3.050 ± 14.418
simple and multiple regression analyses. Medical residents 3.670 ± 12.314
Registered nurses 112.276 ± 52.815
Regression results were calculated in two steps. Licensed practical/vocational nurses 35.657 ± 33.506
First, parameter estimates for severity of illness Physician assistants 0.530 ± 3.470
variables were calculated by entering each Registered pharmacists 4.790 ± 3.761
variable into the model separately. Second, the Medical technologists 15.796 ± 12.902
remaining parameter estimates were calculated Dietitians 2.006 ± 4.262
Occupational therapists 0.848 ± 1.871
by entering each of the other variables into the Physical therapists 3.149 ± 4.174
model separately after the severity of illness Respiratory therapists 5.740 ± 5.631
variables had been entered. Thus, all other Social workers 2.644 ± 5.397
subsequent parameter estimates were adjusted Total hospital personnel 528.002 ± 237.890
for severity of illness indicators. This created a ADC = average daily census.

more accurate analysis of individual measures of

association with mortality rates.
For multiple regression analysis, stepwise
procedures were used to select variables for the
model. 23, 24 Severity of illness variables were
forced into the multiple regression model before
other variables were allowed to enter, after
which, stepwise regression was used to select
remaining variables. Variables selected through
this method were confirmed by both forward and
backward regression techniques. Both tech-
niques selected the same set of variables. This
analysis was used with severity of illness
variables because HCFA’s mortality rates do not
include accurate measures of severity of illness.25, 26
The correlation matrix for independent
variables and the variance inflation factor were
used to examine possible effects of multi-
colinearities among the variables. These
indicated no apparent problems among the set of
independent variables. Hospital ownership
required the use of “public hospitals” as a
reference group. A detailed presentation of the
analysis methods employed with this study (also
compared with similar studies) was published
previously (4864 hospitals).15 Multiple regression
analysis allowed us to determine which hospital
characteristics and staffing variables explain
mortality rates in U.S. hospitals.
A comparison of personnel variables that were
statistically significant in the multiple regression
model was developed further. Mean number of
deaths/hospital/year based on staffing quintiles
are presented. Only personnel categories that
were shown to have statistically significant
associations with mortality rates (multiple
regression model) were included in the quintile
analysis. Mortality rates were adjusted using the
weighted least squares regression approach
described above. Regression was done with one-
way analysis of variance. The mean number of
deaths/hospital/year was obtained by multiplying
each hospitals death rate by the number of
hospital admissions, summing by quintile, and
dividing by the number of hospitals in each
quintile. Multiple regression analysis is the most
important of our analysis models, as it adjusted
for severity of illness and considered the effects
of other hospital personnel.
Hospitals that reported a zero response (no
personnel in a category) were excluded from this
 PROFESSIONAL STAFFING AND HOSPITAL MORTALITY RATES Bond et al 133
Table 2. Simple Regression Results Controlling for Severity of Illness Variables (3763 hospitals)
Variable Slope SE Significance 95% CI
Hospital
Occupancy rate -0.00009 0.00002 0.0001 -0.0001, -0.00005
Teaching hospital -0.0059 0.0007 0.0001 -0.0007, -0.0005
Ownership
Public (reference group)
Private nonprofit -0.0035 0.0011 0.001 -0.0057, -0.0014
Private for-profit -0.001 0.0014 0.453 -0.0029, -0.0009
Personnel/occupied bed
Administrators 0.0034 0.0031 0.27 -0.0027, 0.0095
Physicians -0.0064 0.0019 0.001 -0.0101, -0.0027
Medical residents -0.0170 0.0016 0.0001 -0.0201, -0.0139
Registered nurses -0.0063 0.0006 0.0001 -0.0075, -0.0051
Licensed practical-vocational nurses 0.0061 0.0013 0.0001 -0.0036, -0.0086
Physician assistants -0.0138 0.0162 0.40 -0.0456, 0.0180
Registered pharmacists -0.0752 0.0103 0.0001 -0.0954, -0.0550
Medical technologists -0.0248 0.0034 0.0001 -0.0315, -0.0181
Dietitians -0.0482 0.0147 0.001 -0.0770, -0.0194
Occupational therapists -0.0337 0.0162 0.04 -0.0655, -0.0019
Physical therapists -0.0300 0.0100 0.002 -0.0496, -0.0104
Respiratory therapists -0.0200 0.0063 0.002 -0.0323, -0.0077
Social workers -0.0500 0.0102 0.0001 -0.0700, -0.0300
Total hospital personnel -0.0019 0.0002 0.0001 -0.2292, -0.1508

part of the analysis, as the association between
the presence and number of personnel/occupied
bed and mortality rates had already been
established. If zero responses had been included,
it would have distorted actual staffing levels,
causing the reported staffing level/occupied bed
to appear falsely low. Quintile analysis presents
actual staffing levels. It also presents data from
the multiple regression analysis in a format that
makes them interpretable at the individual
hospital level. Although quintile analysis is less
accurate than multiple regression analysis, its
utility lies in the application of multiple
regression results to individual hospitals for
comparison purposes. The a priori level of
significance for all tests was set at 0.05.
Results
A total of 3763 (78%) hospitals of the 4822
general medical surgical hospitals2 from the AHA
data base met inclusion requirements. The mean
number of occupied beds/day was 114.9 ± 135.4.
The mean number of admissions/year was 6346 ±
6639/hospital or 23,879,998 total admissions
(71% of total U.S. admissions). 27 The mean
annual mortality rate for the hospitals was 93.4 ±
27.1 deaths/1000 patient admissions or 593
deaths/hospital/year.
Table 1 shows severity of illness, hospital, and
personnel staffing variables described by their
mean ± SD/100 occupied beds. Mean values for
personnel are lower than what would actually be
observed in hospitals employing health care
professionals in these categories, since hospitals
were included if they reported a no personnel in
one or more categories. Table 2 shows simple
regression analysis for hospitals, each staffing
variable, described as slope (rate of change),
standard error (SE), probability, and confidence
interval. Except for administrators and licensed
practical-vocational nurses, all other variables
had an inverse relationship with mortality rates
(as personnel staffing increased/occupied bed,
mortality decreased).
Table 3 shows multiple regression analysis for
personnel variables, hospital characteristics,
severity of illness variables, and mortality rates.
For each parameter estimate, slope (rate of
change), SE, probability, and confidence interval
are presented. Statistically significant associations
were found with seven types of personnel:
administrators, medical residents, registered
nurses, licensed practical-vocational nurses,
registered pharmacists, medical technologists,
and total hospital personnel. As the number of
administrators and licensed practical-vocational
nurses increased/occupied bed, mortality rates
increased. In contrast, as the number of medical
residents, registered nurses, registered phar-
macists, medical technologists, and total hospital
personnel increased/occupied bed, mortality rates
134 PHARMACOTHERAPY Volume 19, Number 2, 1999
Table 3. Multiple Regression Model for Hospital Personnel (3763 hospitals)
Variable Slope SE Significance 95% CI
Severity of Illness
ICU days/total inpatient days -0.0057 0.0035 0.098 -0.01256, 0.00116
No. emergency room visits/ADC 0.0154 0.0011 0.0001 0.01324, 0.01756
Medicaid discharges/total discharges 0.0267 0.0033 0.0001 0.02023, 0.03317
Hospital
Occupancy rate -0.0001 0.0001 0.0019 -0.00030, 0.00010
Teaching hospital -0.0007 0.0009 0.45 -0.00246, 0.00106
Ownership
Public (reference group)
Private nonprofit -0.0049 0.0011 0.0001 -0.00706, -0.00274
Private for-profit -0.0043 0.0013 0.0015 -0.00685, -0.00175
Personnel/occupied bed
Administrators 0.0069 0.0031 0.0249 0.00082, 0.01298
Physicians -0.0017 0.0020 0.4161 -0.00562, -0.00222
Medical residents -0.0085 0.0023 0.0002 -0.01301, -0.00399
Registered nurses -0.0026 0.0010 0.007 -0.00456, -0.00064
Licensed practical-vocational nurses 0.0047 0.0015 0.0015 0.00176, 0.00764
Physician assistants 0.0298 0.0165 0.071 -0.00255, 0.06215
Registered pharmacists -0.0381 0.0114 0.0009 -0.06045, -0.01575
Medical technologists -0.0086 0.0039 0.0274 -0.01625, -0.00095
Dietitians -0.0164 0.0148 0.2661 -0.04542, 0.01262
Occupational therapists 0.0193 0.0185 0.2956 -0.01697, 0.05557
Physical therapists -0.0033 0.0109 0.7583 -0.02467, 0.01807
Respiratory therapists 0.0025 0.0066 0.7029 -0.01044, 0.01544
Social workers 0.0005 0.0112 0.9667 -0.02146, 0.02246
Total hospital personnel -0.0082 0.0003 0.0169 -0.00879, -0.00761
ADC = average daily census.

declined. These seven personnel variables
provided the best regression equation (fit) for the
14 personnel variables studied. This regression
model accounted for 17.26% of total explainable
variance associated with mortality rates.
Table 4 shows the 14 personnel categories,
number of hospitals hiring at least one full-time
professional, and mean number of personnel/
occupied bed. A few hospitals that shared
professionals (i.e., one administrator for two or
more hospitals) may appear as if they did not
have any personnel in some of the categories.
These figures are more reflective of actual staffing
levels than those in Table 1, since they refer only
to hospitals that employed at least one
professional in the personnel categories.
Table 5 shows actual staffing (by quintile) and
corresponding mean number of deaths/hospital/year
for the seven personnel categories that were
statistically significant in multiple regression
analysis. The mean number of deaths/hospital/year
corroborated the findings of multiple regression
analysis; as the number of administrators and
licensed practical-vocational nurses increased/
occupied bed, mortality rates (per quintile)
increased. As the number of medical residents,
registered nurses, registered pharmacists, medical
technologists, and total hospital personnel
increased/occupied bed, mortality rates (per
quintile) decreased. Multiple regression analysis
was a more accurate measure of association, but
cannot be used to present and compare actual
staffing levels, as the quintile analysis can.
Discussion
This study determined associations among
hospital characteristics, mortality rates, and
staffing levels for professional health care
workers in U.S. hospitals. Seven types of hospital
personnel (administrators, medical residents,
registered nurses, licensed practical-vocational
nurses, registered pharmacists, medical
technologists, total hospital personnel) were
associated with hospital mortality rates in our
multiple regression model. Higher staffing levels
of medical residents, registered nurses, registered
pharmacists, medical technologists, total hospital
personnel, and lower staffing levels of
administrators and licensed practical-vocational
nurses were associated with lower hospital
mortality rates. Staffing levels for these seven
personnel categories were likely quality of care
 PROFESSIONAL STAFFING AND HOSPITAL MORTALITY RATES Bond et al
Table 4. Staffing in Hospitals Employing at Least 1 Full-Time Person/Personnel Category
Personnel
Administrators
Physicians
Medical residents
Registered nurses
Licensed practical-vocational nurses
Physician assistants
Registered pharmacists
Medical technologists
Dietitians
Occupational therapists
Physical therapists
Respiratory therapists
Social workers
Total hospital personnel
indicators.13–17
Associations among occupancy rate, ownership,
and hospital mortality rates were consistent with
previous studies.9, 10, 15–17 Teaching hospitals were
previously associated with lower mortality rates,9,
14–18, 28
decreased length of stay, 28 and higher
quality of care.10, 13–17 Membership in the Council
of Teaching Hospitals or American Osteopathic
Hospital Association was not statistically
significant (p=0.4509) in multiple regression
analysis, but the number of medical residents/
occupied bed was (p=0.0002). Thus, the size of
the medical residency program appears to be
more important than hospital teaching affiliation
when evaluating mortality rates.
It is not surprising that we did not find an
association between number of staff physicians
and hospital mortality rates. Fewer than one-
third of study hospitals reported having a full-
time physician on the payroll. Most practicing
physicians were not full-time employees. 2
Whether the lower rates in hospitals with larger
numbers of medical residents were due to better
care, involvement of more physicians, or simply
decreased resident case load is unknown.
Although we did not specifically measure
medical resident’s patient load, these data suggest
that it was probably associated with mortality
rates; that is, hospitals with larger medical
teaching programs were associated with lower
mortality rates and may provide higher quality
patient care.
This is the first study to show a negative
clinical outcome associated with hospital
administrator staffing levels. Reasons for this
relationship are unknown. Over the past 10
years American businesses have become smaller,
often eliminating midlevel management positions
135
No. of Hospitals Staff/100 Occupied Beds ± SD
3493 9.520 ± 11.790
1159 9.904 ± 24.646
635 21.748 ± 22.492
3753 112.996 ± 52.567
3620 37.056 ± 33.390
472 4.222 ± 8.976
3065 5.881 ± 3.309
3519 16.891 ± 12.630
2464 3.063 ± 4.950
1379 2.314 ± 2.483
2551 4.645 ± 4.329
3038 7.109 ± 5.435
2604 3.820 ± 6.132
3762 528.142 ± 237.766
to decentralize and improve corporate decision
making.29 Whether similar improvements could
be obtained in hospital administration is
unknown. Given the administrative inefficiency
of our health care system, 30 high hospital
administrative costs (accounting for 26% of total
hospital costs),31 and importance of adminis-
trators in setting the direction and operation of
hospitals, further study is necessary to validate
our findings and identify the causes.
The nursing literature reported that both
higher nursing education and staffing levels were
associated with reduced hospital mortality
rates. 32–36 However, these studies generally
considered only nurse staffing measures; and not
all of them found an association between nursing
variables and mortality rates. 37, 38 Because the
largest expense item in a hospital budget is
nursing (52%), the relationship between
registered nurses (inverse) and licensed practical-
vocational nurses (positive) and mortality rates is
important since plans for staff reductions often
replace registered nurses with less skilled nursing
personnel.34
The reasons why increased numbers of
pharmacists were associated with lower mortality
rates are unknown. Pharmacist-provided patient
care services could account for the association, as
up to 28% of all hospital admissions are attrib-
uted to drug-related morbidity and mortality.39
Their increased numbers on hospital staffs may
allow pharmacists more time to provide patient
care services. Adverse drug events in hospitals
are often preventable if detected early, 40 and
could be reduced by better information systems.41
By providing clinical pharmacy services
(preventing and detecting adverse drug reactions,
pharmacokinetic dosing service, admission drug
136 PHARMACOTHERAPY Volume 19, Number 2, 1999
Table 5. Personnel Staffing and Mortality Rates/1000 Admissions
Mean ± SD
Staffing Quintile 0–20% 21–40% 41–60% 61–80%
Administrators
No. of hospitals 698 699 699 699
Staffing 2.267 ± 0.657 4.028 ± 0.486 5.933 ± 0.654 9.430 ± 1.550
Mean no. deaths/hospital 319.335 ± 464.651 347.503 ± 384.421 511.726 ± 403.325 736.462 ± 581.365
Medical residents
No. of hospitals 127 127 127 127
Staffing 2.907 ± 1.204 7.216 ± 1.402 14.003 ± 2.828 25.253 ± 4.193
Mean no. deaths/hospital/year 1473.73 ± 716.648 1277.64 ± 761.813 1145.11 ± 674.788 1072.34 ± 804.06
Registered nurses
No. of hospitals 751 751 750 750
Staffing 56.323 ± 14.171 84.659 ± 6.043 105.383 ± 6.144 129.033 ± 7.738
Mean no. deaths/hospital/year 550.269 ± 611.666 589.461 ± 588.081 629.204 ± 565.131 564.748 ± 530.893
Licensed practical/vocational nurses
No. of hospitals 724 724 724 724
Staffing 7.786 ± 3.558 18.246 ± 3.000 29.304 ± 3.623 44.584 ± 5.447
Mean no. deaths/hospital/year 270.561 ± 298.924 435.612 ± 453.766 58.440 ± 526.481 717.246 ± 648.058
Registered pharmacists
No. of hospitals 613 613 613 613
Staffing 2.960 ± 0.570 4.166 ± 0.295 5.170 ± 0.289 6.491 ± 0.499
Mean no. deaths/hospital/year 705.981 ± 524.173 729.076 ± 559.367 671.236 ± 524.992 652.949 ± 599.076
Medical technologists
No. of hospitals 704 703 705 704
Staffing 6.41 ± 2.01 16.72 ± 0.964 14.24 ± 1.06 18.94 ± 1.77
Mean no. deaths/hospital/year 678.198 ± 538.505 704.045 ± 574.985 629.980 ± 558.959 494.7457 ± 569.042
Total hospital personnel
No. of hospitals 752 752 753 752
Staffing 325.631 ± 60.741 424.349 ± 19.565 490.574 ± 20.251 570.507 ± 28.555
Mean no. deaths/hospital/year 483.478 ± 451.787 605.438 ± 520.753 637.926 ± 544.617 562.231 ± 549.652
Data are for hospitals employing at least one full-time person in the category, personnel/100 occupied beds.

histories), pharmacists may improve patient care
outcomes. Staffing levels of hospital pharmacists
and some hospital-based clinical pharmacy
services were associated with reduced mortality
rates in one study involving 718 hospitals.9
The reason for the inverse relationship between
number of medical technologists and hospital
mortality rates is also unknown. Perhaps
hospitals with more medical technologists may
be able to respond to physicians’ orders for
laboratory tests more quickly or perform tests
faster than those with fewer of these staff
members. Other factors such as improved quality
control or improved evaluation of aberrant
laboratory values may also be applicable.
It is possible that better models for adjusting
mortality rates for severity of illness using more
precise clinical and socioeconomic variables may
be developed. Since we could not obtain part-
time FTE data for personnel categories from the
AHA data base, part-time employment levels may
have influenced our findings. The total variance
explained by our regression model (17.26%) was
consistent with other reports of 11%,12 14–25%,42
and 21%.18 It is possible that staffing levels in
1992 do not reflect levels today. Future studies
with much smaller numbers of hospitals could
employ more specific patient, hospital, and
personnel data to determine the precise reasons
why professional staffing is important for patient
care. It is not known how staffing in 1998 might
compare with our results, since the AHA stopped
publishing professional staffing data (except for
physician and nursing personnel categories)
shortly after these data were collected. Caution
should be employed in applying our findings to
individual hospitals.
In summary, higher staffing levels of medical
residents, registered nurses, registered phar-
macists, medical technologists, and total hospital
personnel, and lower staffing levels of adminis-
trators and licensed practical-vocational nurses
were associated with lower hospital mortality
rates. These staffing levels likely reflect better
quality of care. Hospital performance is deter-
mined by structure, process, and outcome. We
examined one measure of structure (staffing
levels) and one outcome measure (HCFA’s
 PROFESSIONAL STAFFING AND HOSPITAL MORTALITY RATES Bond et al 137
Table 5. Personnel Staffing and Mortality Rates (cont.) longitudinal study. NLN, 1987;(20-2191):331–45.
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Significance pharmacy characteristics associated with mortality rates in
81–100% (ANOVA) United States hospitals. Pharmacotherapy 1994;14(5):620–30.
10. Kelly JV, Hellinger FJ. Physician and hospital factors
698 associated with mortality of surgical patients. Med Care
25.956 ± 18.070 1986;24:785–800.
11. Rhee SO. Factors determining the quality of physician
962.484 ± 643.623 F(1,3493) = 53.54, p<0.0001
performance in patient care. Med Care 1976;14:733–50.
12. Shortell SM, Hughes EFX. The effects of regulation,
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