The Relationship of Culture Change Constructs and Survey Deficiencies in the Nursing Home Setting

In response to the anticipated growth of the over-65 age group and a demand for an altered approach of care delivery in long term care, providers have responded by implementation of culture change strategies. Support from the Centers of Medicare and Medicaid Services (CMS) has provided the impetus for tremendous interest and implementation of various culture change initiatives, but the research supporting the culture change movement has been limited. The findings from the presented study were derived from expanding the seminal work of Bott (2007a, 2009) utilizing the Kansas Culture Change Instrument (KCCI) to measure culture change. Bott’s (2009) findings were compared to a Louisiana sample of nursing homes leaders using the KCCI instrument to explore the relationships between two levels of culture change (limited and extensive) measuring total culture change, the seven constructs of culture change (resident directed care, home environment, relationships, staff empowerment, decentralized management, CQI processes) and specified health deficiency categories. To explore a more in depth analysis of specified health deficiency categories, the scope and severity levels were analyzed for the relationship to the level of culture change (limited and extensive) and in relation to the seven constructs.

Study results will be presented from the first designed study to classify a sample of Louisiana nursing homes into three levels of culture change and collect data using the KCCI instrument to measure culture change. This study expanded the review of deficiency variation to examine the difference in type of survey (annual versus complaint) and also offered a proposed model of the interrelationship of construct variables and deficiency outcome studies.

Shier, et al. (2014) called for research on outcomes of culture change to determine the impact on quality and provide guidance to policy makers and providers. The authors noted the call for research is more than academic. Providers need evidence-based guidance for decision making and use of scarce resources; consumers need guidance for selection decisions; and policy makers and payers need guidance on promoting practice through regulation and reimbursement.

The literature identified stronger culture change homes have lower deficiencies but the literature had not identified the number of complaint surveys and severity of these surveys as statistically significant differences (Bott et al., 2009; Grabowski, O’Malley et al., 2014). This additional information can direct research to identify processes that vary between the two clusters which impact complaint surveys and severity of the surveys.

The study presented will share statistically significant findings comparing extensive and limited levels of culture change as measured using the KCCI instrument. Significant results included: (a) differences in the mean number of deficiencies; (c) differences in three of the four categories of deficiencies (QOC, Resident Behaviors and Resident Rights); (d) differences in the scope and severity score; (e) differences in the number of complaint surveys, complaint deficiency citations and severity of citations; (f) Relationship construct and number of QOC deficiencies; (g) Home Environment and QI constructs with Total deficiencies; and (h) QI construct with Total and QOC deficiencies.

The purpose of this study was to add to the scientific knowledge of culture change in LA and provide comparison assessment from the prior work of Bott et al., (2009). The data supported the value of considering culture change as a model of care delivery as measured by deficiency data. Additional insights were gathered as the author examined the relationships of the findings and compared them to the literature. This examination led to an initial proposed model for the interrelated variables in this study. Providing data to support the practices of providers and nurse leaders striving to achieve higher quality through implementation of new culture change models was achieved. Providing providers and nurse leaders with insight into the variation between clusters as it relates to number of surveys, number of deficiencies and scope of deficiencies may reduce the barrier of regulation concerns when considering adapting the model.

The need to address nursing’s role in culture change was recognized as early as 2008 when a meeting was held with national experts to explore barriers and plan action steps for the future (Burger et al., 2009). The role of nurses was identified as critical to the success of culture change as a model of care delivery. As coordinators of care who have trained on the holistic approach to working with patients, it was evident the nurse not only must be involved and an active member, but needs to take a significant role in facilitating the success of any new model of care delivery.

The role of the registered nurse in the nursing home setting is critical to the quality outcomes of the facility (Castle et al., 2007b; Castle et al., 2011). Implementing and advocating for practices that improve quality for the resident is an essential role for the RN in this setting. The role of the RN in the culture change model is one of "expert clinician, educator, coach and counselor" which is in perfect symmetry with the professional nursing practice model. (Burger, et.al., 2009, p. 12). As noted by the authors, "the professional nurse practice model is not only congruent with culture change: arguably, culture change is an expression of the professional nurse practice model" (Burger, et.al., 2009, p. 17).