Rethinking Nursing Home Regulations in Support of Culture Change
By Richard Shank
An issue brief released by The Commonwealth Fund advocates a new partnership model for nursing home regulations. This model would find a balance between traditional regulatory approaches that emphasize the use of surveys and code enforcement with a more collaborative model. Authors Robyn Stone, Natasha Bryant, and Linda Barbarotta suggest that this balance is imperative for the success of the nursing home culture change movement.
Pioneer Network defines culture change as a change that builds on the belief that empowering older adults and those who work with them will create a “culture of aging that is life-affirming, satisfying, humane, and meaningful.”
Recent research suggests that nursing home regulations have made culture change difficult to implement. The research also identified a number of states, however, that have adopted a more collaborative approach to regulation so that culture change could be implemented more smoothly.
In the 1960s, a series of nursing home scandals was reported by the media. Since that time, several attempts have been made to address what has been labeled “the nursing home quality problem.” In 1987, the Omnibus Budget Reconciliation Act (OBRA-87) required all nursing homes to “attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.” This act led to the current reporting system that utilizes standards of care, resident assessments, and surveys.
The response of many nursing homes was to maintain compliance on paper through routine assessment and surveys. Research demonstrated that the new regulatory environment minimally impacted the actual quality of care. Currently, state regulatory agencies rely on deterrence to weed out poorly performing nursing homes.
Stone, Bryant, and Barbarotta advocate what they call The Smart Model for nursing home regulation. The traditional regulatory approach emphasized sanctions at the expense of culture change. This new model is built on a more balanced approach that emphasizes collaboration alongside the deterrence model.
There are two key issues that will impact how to best structure a partnership model of regulation. The first is how to best organize the regulatory functions. Often, it helps to incorporate both the traditional regulatory and technical assistance functions of state agencies into one organization. Traditionally, technical assistance has been a shortcoming of organizations seeking to improve quality of care. Examples, however, such as the state of Kansas, demonstrate that it’s possible to provide both deterrence and technical assistance to culture change initiatives.
Secondly, the new model introduces training issues that must be addressed both within the regulatory agency and at the level of care. State regulators and nursing home staff members need to be trained in tandem in order to develop shared culture change principles and how to best implement them into the everyday life of their care environment.
For more information, access the issue brief at http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2009/Oct/Supporting-Culture-Change.aspx.
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