Does Culture Change Impact Quality of Care?

The focus of culture change models of care has been to improve the quality of life for residents, but the impact of culture change on quality of care has remained unclear in the research literature. Recently, researchers examined how nursing homes identified by experts as “culture change providers” differed in quality of care outcomes in comparison to similar nursing homes that were nonadopters of culture change policies. More specifically, researchers looked at differences in the health survey deficiencies between these two groups.

Culture change here refers to the transformation of nursing homes into person-centered homes offering long-term care services. Key aspects of this culture change include providing a more home-like atmosphere, collaborative decision making, greater resident direction, close relations, staff empowerment, and quality improvement processes. Although it could be hypothesized that the greater quality of life produced by culture change could improve quality of care, there are also reasons to worry that this may not necessarily be the case. For example, greater resident autonomy could lead to negative outcomes such as greater fall rates and resident weight loss.

By comparing nursing homes that are otherwise matched in characteristics over the same period of time, this study provided the most rigorous examination of the impact of culture change on quality of care to date. This study also has the advantage of looking at 251 facilities throughout the United States that have adopted culture change. The criteria for a nursing home to be qualified as a site of culture change included a comprehensive adoption of the tenets of culture change; the study excluded nursing homes that only partially adopted aspects of culture change.

To examine quality of life, the researchers looked at the quality indicators from the Minimum Data Set (MDS) facility reports provided quarterly by nursing homes to the Centers for Medicare and Medicaid Services. These quality indicators monitor residents’ health status and care outcomes, and are used to identify potential problem areas in facilities. In addition, they looked at nursing home data from the On-line Survey, Certification and Reporting (OSCAR) system, which contains information from state surveys of all federally certified Medicaid and Medicare homes in the United States (encompassing 96 percent of all facilities nationwide). OSCAR data includes information on whether nursing homes were compliant with federal regulatory requirements, or deficient in any way.This study focused on deficiencies found in health-related items of that survey.

In terms of matching culture change providers and nonadopting nursing homes, the two groups did not differ on chain membership, hospital-based status, ownership, faith-based status, or being part of a continuing care retirement community. However, the culture change nursing homes were slightly larger than nonadopters, averaging 141 beds compared to 133 beds for nonadopters.

The most significant results came from the analysis of the OSCAR data.  This data showed that the culture change nursing homes exhibited a 15 percent decrease in health-related deficiencies. Importantly, this difference was not associated with RN, LPN, or CNA staffing per resident. The decrease in health-related deficiencies in culture change nursing homes was also not statistically associated with an impact of total licensed staff or the proportion of licensed staff to total staff.

Turning to the 12 MDS quality indicators, which focused only on individual health outcomes rather than structures or processes within facilities, none of the individual indicators was statistically associated with a difference between culture change facilities and nonadopters. When these quality indicators were grouped together into two composite measures, again there were no statistically significant differences between the groups.

The researchers drew a number of conclusions from these findings. In light of the statistically significant differences observed in the OSCAR data, they suggested that adopting culture change may improve processes of care, since data related to processes and structures make up part of what are considered health-related deficiencies in the OSCAR survey. With regard to the lack of differences between culture change facilities and nonadopters, the researchers suggest that this may be due to the study’s use of early adopters of culture change who were focused primarily on improving quality of life instead of both quality of life and quality of care. They hypothesize that later adopters of culture change (not included due to the time period of this study) might be more focused on both quality of life and clinical outcomes when implementing culture change in their facilities. The researchers also note that there are some disadvantages to the large number of facilities included in this study. With so many facilities included, there may be considerable variability between the ways in which culture change was implemented, even though all culture change facilities were considered to have comprehensive culture change. This variation could also potentially obscure the identification of how some forms of culture change might impact quality of care as measured by items like the quality indicators on the MDS.

Clearly, further research is needed in this area to examine these hypotheses and the findings in this study. However, it should not be overlooked that the OSCAR data showed increased quality of care that was independent of the impact of staffing differences between facilities.


Grabowski DC, O’Malley AJ, Afendulis CC, et al. Culture change and nursing home quality of care. The Gerontologist (2014); Vol 54: S35–S45.

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