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Rhode Island: Incorporating Culture Change into the Nursing Home Survey Process

Some states are using regulatory oversight of nursing facilities to advance the culture change movement and promote resident-centered care. For example, Rhode Island's nursing home survey agency, part of its Department of Health, has prioritized measures of quality of life—in addition to measures of clinical care—in its nursing home survey and certification process.

"The patient-centered orientation of the process has helped nursing homes focus more on these issues, spreading culture change within and between them. From the perspective of the state survey agency, it has also reinvigorated the survey process, helping to make it more collaborative and innovative," said David Gifford, M.D., director of the state's Department of Health.

Rhode Island's effort began several years ago, when leadership from the state survey agency, provider community, and other stakeholders decided to learn more about national and state models for improving residents' experiences of nursing home care and develop ways to apply them in Rhode Island. That effort led to a pilot project, the Individualized Care Pilot, at 51 nursing homes from 2007 to 2008, which the state has continued to expand.  Gifford highlighted three major areas of an "independent," or resident-centered, care model:

  • Physical environment: Does the facility look like an institution, or does it feel more like an individual's home?
  • Care practices: What are the facility's policies for administering medications and scheduling meals, sleeping, and bathing?
  • Staffing models and personnel: What are the staffing patterns in a facility, and how are staff empowered to help develop and revise policies that would improve residents' quality of life?

The initial areas of focus that were added to the survey process included:

  • Waking: Allowing residents more flexibility and control over their sleep schedules, rather than waking everyone up at the same time to administer medication or provide meals.
  • Bathing: Avoiding an arbitrary schedule and being responsive to residents' preferences.
  • Noise: For example, reducing the number of announcements and pages made over loudspeakers.
  • Consistent assignment: Assigning staff to care for the same residents regularly, to strengthen relationships and improve the continuity of care.

The pilot used a variety of strategies, including on-site interviews, observations, and dissemination of information at each facility as well as additional analysis by surveyors after their site visits to assess how individualized care was being delivered. These activities were intended to ensure compliance with regulations, convey information and generate discussion with nursing homes, and gather additional non-regulatory information that could then be shared with each facility. A more detailed discussion of the survey methods is available here.

A patient-centered perspective now "permeates" the survey process, said Gifford. For example, surveyors use the facility tours they go on at the beginning of each survey as opportunities to ask about residents' quality of life and incorporate these issues into their conversations with nursing home administrators and other staff. The additional information informs all parts of the survey, including clinical topics, because asking open-ended questions that elicit information about patient-centered care yields insights into the overall functioning of nursing homes. "This was almost as much a culture change in the survey process as it was in facilities," said Gifford. The emphasis on quality of life has empowered nursing home staff as well as surveyors in the field by placing an official priority on issues they may have believed to be important but had not felt able to influence.

Gifford noted that all these changes were possible within the existing regulatory framework. In fact, they align strongly with the concepts embedded in the original federal legislation governing nursing home quality measurement. "While a few nursing homes felt early in the process that regulations could be a barrier to implementing more patient-centered care, it's usually the case that regulations not only allow but actually promote these concepts," he said. Rhode Island worked closely with CMS to determine what changes were possible within existing rules.

Rhode Island's efforts were designed to be applicable to other states. The nursing home survey agency developed a training package for other state survey agencies, and agency staff report increasing interest nationally in patient-centered nursing home care in general and in strategies that involve the survey process. "Going forward, we'll be working to expand our areas of focus, and also spread these strategies to other states that would like to implement them," said Gifford. "This is a long and at times challenging road, but we believe the investment is very worthwhile."

For more information, contact David Gifford, M.D., director, Rhode Island Department of Health, at [email protected], or see

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