Abstract
OBJECTIVE: Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes. DESIGN: We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes. SETTING AND PARTICIPANTS: The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods. METHODS: We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases. RESULTS: NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices. CONCLUSIONS AND IMPLICATIONS: This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.