There is widespread consensus that implementation of culture change
has the potential to significantly improve the quality of residents' lives. Nevertheless, several substantial impediments to a more
universal and enthusiastic adoption of the person-centered paradigm persist.
One of those barriers is provider apprehension about the present regulatory
labyrinth that engulfs every facet of nursing home care.
The pertinent regulatory web, with its heavy emphasis on risk aversion, is embodied in extensive federal Medicare/Medicaid Conditions of Participation (running roughly 70 pages), the complicated survey and certification process intended to measure providers' compliance with those requirements (the relevant portion of the federal State Operations Manual exceeds 660 pages), and the separate licensure statutes, regulations, and guidelines of each state. Moreover, the civil law tort
(personal injury) system, as enforced through the courts by the levying of
monetary damages against defendants, is another form of regulation that may be
used to penalize providers for deviation from then-standard practices.
There are some promising developments on this front. In 2011, the
federal Centers for Medicare and Medicaid Services promulgated new procedural
guidelines to be used in its nursing home survey process -- the Quality Indicator
Survey (QIS). The QIS is intended to focus surveyors' attention more on
person-centered outcomes -- for example, whether residents are well nourished -- and
less on the process of care, such as what time of day the meals are served.
The QIS encourages surveyors to interview and observe residents and their
families to understand goals and preferences specific to each resident. The
problem, however, is that despite a revamped survey process, the underlying
protection-oriented regulations and interpretive guidelines that dictate
provider behavior remain unchanged.
Examples of the incompatibility between current regulations and
meaningful culture change in nursing homes abound. For example, requirements
that beds must be placed only within certain spaces in a resident's room make
it impossible for residents to rearrange their furniture as they wish.
Regulatory prohibitions on open kitchens prevent residents from fixing snacks
whenever they wish. If we are serious about making nursing homes more
comfortable and homelike, a review of existing regulations and amendment or
removal of those regulations that impede culture change must be put into place.
Sometimes, though, the biggest barrier to culture change in nursing
homes is not the actual wording of the regulations but rather the often
inconsistent, incoherent, and uninformed way that the regulations are
interpreted and enforced by government employees who regularly survey
facilities and cite them for perceived noncompliance. The new QIS process may help. But it will in
no way diminish the imperative for intensive, ongoing education of government
surveyors to inculcate them with the principles and goals of culture change and
a commitment to performing their quality oversight function in a less punitive
and more collaborative mode. Pilot efforts in this regard established by the Rhode Island health department's nursing home survey
agency may serve as a useful model for other states.