Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

Abstract

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

“…First, we identified high and low performers on clinical care quality and RCC using previously published methods. 10 , 15 Next, we selected CLCs based on these data and conducted primary data collection by means of staff interviews at 12 CLCs and systematic content analysis of the transcripts. The purpose of the qualitative in-person site visits was to investigate the “how” and “why” some CLCs are able to deliver high levels of RCC and high MDS-based quality of care.…”

“…As previously reported, due to changes in performance status between initial site selection and qualitative data collection, our final data set included 5 high- and 5 low-performing sites. 15 Because available quality and RCC data were 2 years older than when the site visits occurred, we triangulated the qualitative data we collected with site visitor impressions of performance on RCC and quality at the time of data collection. Comparison of the data with the impressions resulted in the recategorization of 2 mixed sites.…”

“…We developed our interview questions based on the literature including structural characteristics and organizational infrastructure. 12 - 38 We created an interview guide consisting of 33 semi-structured questions corresponding to these domains. We also asked questions regarding clinical care and RCC processes to understand how care was provided at the CLC.…”

“… 10 , 11 Sullivan et al noted there were a few CLCs that were consistently high and low performers on care quality and RCC measures (ie, “high”- and “low”-performing facilities). 15 In the high-performing facilities, improvements in RCC were associated with increases in quality, whereas in the low-performing facilities, declines in RCC were associated with decreases in quality. These findings suggest that there may be system factors that distinguish between high-performing facilities (ie those that perform well on both quality and RCC) and low-performing facilities (ie those that perform poorly on both quality and RCC).…”

“…Furthermore, qualitative research in NHs has centered on examining factors associated with either care quality or RCC. The literature regarding factors affecting NH performance are influenced by 2 facets: (1) structural characteristics, including patient mix, 12 - 14 staffing levels, 15 , 16 administrator tenure, 17 - 19 and monetary resources, 20 , 21 and (2) organizational infrastructure, including organizational culture, 22 - 24 utilization of quality improvement/systems redesign infrastructure, 21 , 25 - 27 alignment/coordination, 20 , 22 , 28 - 31 teamwork and communication, 32 - 34 and supportive leadership. 25 , 35 - 38 …”