Nursing Home Culture of Safety

It goes without saying that most residents of nursing homes are disproportionately older and have chronic conditions, and often enter long-term care after an acute hospitalization. This makes nursing home residents especially vulnerable to safety problems in the course of their care. A systematic approach to resident safety is of the utmost importance. On this week’s episode, nursing home abuse attorney Rob Schenk welcomes Dr. Nicholas Castle from the University of West Virginia’s Department of Health Policy and Management to discuss his research into patient safety culture in nursing homes.

Schenk: Hello out there. Welcome back to the show. My name is Rob Schenk. Today we’re going to be talking about what is nursing home safety culture, in other words, what does a nursing home do? How do they operate? How do they function? How do they communicate in terms of staff, communicate with each other such that the nursing home overall can reduce the amount of harmful events that take place in the nursing home?

And that seems very academic. I don’t mean for it to sound very academic. But to elaborate on this, we are going to have an academic, a really great man named Dr. Nicholas Castle, PhD, to talk about safety culture in nursing homes with us today. And let me just say Dr. Castle is a very great guy, very experienced in this area. In fact, I found him online by – I was reading one of his studies that was published in 2006 called “A Culture of Patient Safety in Nursing Homes,” and I was like, “I’ve got to have this man on the program to talk about this as soon as possible.”

But a little bit more about him, Dr. Nicholas Castle is a professor at the University of West Virginia in the Department of Health Policy and Management and Leadership. Dr. Castle’s research has examined the quality of long-term care settings, including nursing homes, assisted living facilities and elderly high rises. He currently has over 200 publications in peer reviewed journals. Much of Dr. Castle’s work has specifically examined staffing issues in long-term care. This includes the impact in staffing levels, turnover, stability, agency staff use and consistent assignment.

As part of this research, he has worked with numerous long-term care facilities and workers over the past 20 years, has surveyed by mail more than 50,000 long-term care facilities, 300,000 discharged residents and interviewed face-to-face more than 500 caregivers. This guy knows his way around a nursing home and he is clearly qualified to talk to us about nursing home safety culture, and it is an absolute honor and privilege to have him on the show. Dr. Nicholas Castle, welcome to the show.

Nicholas: Well it’s a pleasure to be here. Thank you.

Schenk: Great. Great, great, great. So Dr. Castle, I wanted to have you on the show specifically because a lot of times, we’ll read in the newspaper or online about how it seems that nursing homes as skilled nursing facilities are becoming, it seems, less and less safe depending on how you look at it. Understaffing a lot of times might lead to incidents of falls or things of that nature. But I noticed that you had a very in-depth, fantastic study that was published in 2006 regarding the culture of patient safety in nursing homes, and so that’s why I wanted to get you on. Before we go into that, I would love it if you could just talk about what does safe culture actually mean in a nursing home setting?

What does safety culture mean in a nursing home setting?

Nicholas: Oh sure. So I should say before I give the definition that your listeners might be interested to know that safety culture did come from two government reports from the Institute of Medicine, and one is “To Err is Human” and the other is “Crossing the Quality Chasm.” They were written in 2000, 2001. And together, what they seem to conclude is the healthcare system in general seems to have safety problems and quality problems, and that goal forks in government and academia to try and look at these problems and of course try to make improvements.

One thing that came out of this was that patient safety culture had quite – seemed to have a large impact on healthcare outcomes, especially in hospitals. And again, it was a concern because part of the conclusion of the study was about 100,000 people each year die as a result of a medical mistake or an error, and that study again, it’s dated, it’s written around the year 2000 or earlier, and it didn’t include nursing homes and some folks disagree with some of the findings, but it’s at least 100,000 folks each year that have medical errors resulting in death.

So clearly the government wanted to do something about this. So again, this thing called patient safety culture came up as something that could be useful to start to address patient safety problems in hospitals and then subsequently what we use it for is nursing homes.

So I do have the long definition of patient safety culture, which is moving towards a safer healthcare system that includes looking at opportunities to improve systems and prevent harms, how the perceptions and behaviors and competencies of individual groups determine an organization’s commitment, style and proficiency in safety management. And that is quite a mouthful. What somebody really distilled this to was it’s the way things are done around here. I fell in love with that definition.

Schenk: Right, I was going to say, can you put that in layman’s terms, and that’s exactly – that seems exactly layman. That’s exactly right.

Nicholas: Yeah. It’s the way things are done around here. That is especially true with nursing homes if you go to nursing homes. I’ve been to more than 500 now in my career. You can tell by walking around, asking a few questions, that the way things are done has a tremendous impact on staff, residents, quality of life and patient safety.

Schenk: So that makes a lot of sense. And before we jump into the conclusions and the meat of the study, why did you actually decide to go forward with the study in 2006? What was lacking or what was the reason for doing that on top of what was done in 2000, 2001?

What are issues with safety culture in nursing homes?

Nicholas: Okay. So again, the 2000, 2001 reports were primarily based in hospital settings, which is often the case with government reports, and this is a particular issue with nursing homes, and it didn’t really address issues and problems in nursing homes. And I’ve made a career the past 30 years looking at the quality of nursing homes and how to improve the quality of nursing homes and patient safety and patient safety culture is related to quality in many ways. You can think of them as overlapping dimensions of how to make a good nursing home. And after looking and helping a little bit with the hospital survey on patient safety culture, it seemed to me like somebody could and should try to use it in nursing home settings and see what results we got, and compare and contrast that with what we were finding in the hospital setting.

There were other reasons beyond that. We needed – I felt we needed a large survey or a larger survey to get some baseline data, so first of all, we know where nursing homes stand, but then if nursing homes themselves wanted to use this instrument, they could benchmark themselves and see how they did with respect to a larger group of nursing homes and see which areas they needed more of less improvement in.

So at point in time, about 2006, this instrument hadn’t been used in nursing homes. I think we were one of the first flocks in the country to actually edit the survey a little bit and send it to a large group of nursing homes.

Schenk: Got you. Again, so that’s “A Culture of Patient Safety in Nursing Homes” and it’s from 2006. Can you just unpack a little bit for the data nerds and the study nerds out there, the academics, kind of what were the methods, how many nursing homes, what were the nursing homes? How did you acquire the data?

How was the Culture of Patient Safety in Nursing Home study conducted?

Nicholas: Yeah, I’m actually probably best qualified to do that, being a data nerd myself. So the data, we used the hospital survey on patient safety culture, which was developed by the Agency of Healthcare Research and Quality in the hospital setting. It’s what we called a valid and reliable instrument. It was very well tested by the AHRQ, that’s the Agency of Healthcare Research and Quality. So for us, that means we don’t have to necessarily go through the expense and time to test our own instrument.

So we – I was going to say stole it – it was freely available, it is on the AHRQ website. It’s a publicly available tool to be used. So we took the items and we modified them a little bit. So what I mean by that is in hospital survey, you use the word “patient.” Clearly in nursing homes, you often use more of the word “resident.” So we changed some small wording items like that. But for the most part, we kept the instrument intact.

And then we’re blessed in the nursing home world in the fact that we have a lot of what we call secondary data sources that give us information on nursing homes that the government provides. One of them comes from, it used to be called OSCAR but now is called CASPER, but essentially what it does is it lists 97 percent of nursing homes in the United States and gives you things like the address. So what we’re able to do is use that address information and send survey to – in this case, we sent it to nursing home administrators. In some previous work, we did sent it to certified nursing assistants, but this particular study was nursing home administrators, and we asked them to complete the survey and send it back to us.

We’ve had good success with instruments like this over the years. We find if we do this and we state to the administrator that if they give us this information, we can put it on a website or we can send you back the results and you can use the information, we guarantee anonymity of the nursing homes, so we got back 2,840 surveys, which was a 71 percent response rate, which is pretty decent for these kinds of surveys. So with almost 3,000 nursing home administrators giving us information, we think it’s sort of, at least at the time period, probably quite accurate with respect to patient safety culture of nursing homes of the time, and I do need to do the caveat that from the perspective of the nursing home administrator, which is probably something I might get back to later on. Some of the results you get do depend on who you ask the questions to, which is sort of pretty obvious here, but we got the information back and then we summarized it and produced average scores, and we compared those average scores with the published scores that exist on the AHRQ website, which came from more than 100,000 responses from hospitals, so again, we were comparing nursing home scores with hospital scores.

Schenk: And so, and Dr. Castle, just to reiterate, even though the promise of anonymity there, this was still I guess what you would call a self-reporting, so we are going by the reliability of the administrator. But at the same time, would you agree that the administrator, I don’t know, would have incentive to make the facility look more safe than it really is? What’s your thought on the accuracy because I know you touched on that, but can you kind of unpack that a little more? Like how would we rely on that?

Are self-reported safety studies accurate?

Nicholas: Yes, so that actually is an important limitation of this particular study. So you’d expect something called positive response bias. So what I mean by that is if I ask you how good a golfer you are, you probably might overestimate a little bit. That’s quite normal. So we would expect that on this particular survey, which actually is interesting based on the findings we got, I’m sure I’ll get to the findings in a minute, but the findings were particularly poor. So if you think there was a positive response bias, what that means is the findings are probably even worse than what we got.

Schenk: Yeah, I was going to say, you’ve got to be worried then.

Nicholas: Yeah. Yeah, so and then the other thing again is it came from the nursing home administrator, and typically for folks that do this for purposes of improvement and to actually start to make changes, especially in hospitals, they would do this kind of survey using multiple staffs. Again, we did some work using CNAs, but if a facility really wanted to use this instrument and get some very accurate data such so they can put resources behind to really make improvements, they probably should go to the CNAs, the LPNs, the RNs and other staff. We have staff and other workers in the facility and get what we call a 360-degree view of patient safety culture and then go forward with improvements. They probably shouldn’t base this just on their own opinion.

But anyways, I sort of digressed in here, what we found is there are 12 large groups – we call them demands – large areas within the hospital or patient safety culture instrument. We found almost all 11 out of the 12 that nursing homes scored substantially lower than hospitals. By substantially, I mean often in the realm of 20 to 30 points below what the average is for hospitals. So the scale goes from 0 to 100 with 100 being the best. Most of the hospital folks or the benchmarks for the hospitals scored 50 and 60. Most of our areas of the nursing homes scored between 20 to 40, so they were substantially lower than hospital settings.

And then what we did is a couple of follow up items on the instrument that asked, “Please give us your overall grade with respect to patient safety,” and that goes from excellent, very good, acceptable, poor or failing. We found that 70 percent of nursing home administrators rated themselves as a C, which is acceptable, or D, which is poor. So there weren’t very many at all that said that their patient safety was excellent or very good, which is sort of a little disconcerting, I would say.

Schenk: Right.

Nicholas: And then we also asked in the past 12 months, can you list off how many patient safety events or issues you had? And the average came up close to 10. So they could remember or at least put down they had 10 patient safety issues in that facility in the past year. We didn’t ask what kind because that’s a little detailed, but we’re probably talking about falls, medication errors, and I’m guessing that since they remembered them, they were probably life-threatening, or in some cases, probably life-ended for some residents.

Schenk: Did you get any pushback with regard to the argument that you’re comparing apples to oranges as using the hospitals for a base? What’s a response to the fact that acute care is different than long-term care?

Is safety culture in nursing homes different than in acute care settings?

Nicholas: So I entirely agree. Acute care is different from long-term care, which is actually one of the other reasons why we did this.

Schenk: Right.

Nicholas: Acute care and hospitals have a lot more resources and they have different staff to do both quality and patient safety whereas nursing homes, as you know, are primarily based on a certified nurse aid model. They give 80 percent of the care with less direction – not less direction – compared to hospitals at least, less direction from LPNs and RNs and medical directors. And so because the makeup is different, you would expect some of these scores to be different. But the actual items within the patient safety culture instrument do apply to nursing homes very well with respect to whoever’s giving the care, and I’m sorry if you can hear me turning my pages right now, I don’t have all of the domains listed, but I was going to read off a few of them for you.

Schenk: Please.

Nicholas: It’s things like the frequency of events that were reported, management expectations in this area, organizational learning, teamwork within units – that is especially pertinent to nursing homes because as far as I know, most of them are based on units, communication and openness, feedback and communication about errors, non-punitive response to errors – I know that can be an issue for nursing homes if you look at the score here, nursing homes got a score of 28 whereas the average for hospitals is 50. I know several nursing homes have more of a punitive approach to many areas of care for the staff. Then there’s the staffing, which might include staffing levels, types of staff, management support for safety, which is something that I’d love to talk more about, and teamwork across units. And then handoffs and transitions. So all of the areas, even though this is based again on the hospital settings, I would definitely argue it applies to the running of management at nursing facilities.

Schenk: That makes absolute sense Dr. Castle and I mean like at least on critical, critical components, it’s apples to apples. I mean having adequately trained staff, having, particularly as you said, communication between shifts and between staff is more important, it seems like, in a long-term care setting than it is in acute settings. So I do feel like that is a good response to that argument. But please go ahead with your conclusion.

What were the conclusions of the study regarding nursing home safety culture?

Nicholas: Oh, so the conclusion, again, was that maybe at least tentatively, again with the caveat that this was based on nursing home administrators, that nursing facilities may want to start looking at their patient safety culture and from these 12 major demands or areas, possibly – not possibly, definitely make improvements if they were getting more scores than either their peers and/or hospitals.

And again, I sort of reiterate that we got very similar results from certified nursing assistants themselves, so again, somewhat of a consistent picture that this could be something that could or should be addressed in nursing homes. Now the caveat to this is that this is an older study and if you asked me has anyone done this more recently and have things changed? I don’t know of many additional studies using these instruments in nursing homes. I know somebody did a review in this area in the academic literature and only came up with 25 studies in the past 20 years, so it is under-researched. And then one of the steps that could be done or should be done is this is the patient safety culture. It’s an indicator. It’s a first step in where you should improve. Do you really find negative events with a low patient safety culture in nursing homes?

One of my colleagues, Alice Bonner, Dr. Alice Bonner, did her dissertation in this area and has published in this area and has produced, as far as I know, one of the few reports that have actually said, “Yes, patients in low safety culture in nursing homes is associated or related to negative medical events or things like falls or medication errors.”

But does this exist today? I’d say you’ve got to be careful when I’m speaking in generalizations about the average scores you’ve got for nursing homes. There were some nursing homes even back in 2006 that scored quite well, and I’m sure there are a decent number today that would score quite well also. I think the trends within facilities over the past 10 years have been towards better quality, better patient safety. I think when you started, you mentioned there is a lot of press about issues in nursing homes and negative events. Some of that I think is to do with the fact that we get to know these things a little bit more frequently now in 2019 than we did in 2005, 2006, but yeah, I still think there are many facilities that could make improvements and I think if we were to repeat this survey, some of the scores may have gone up and I think that we might get more facilities on the top end, but I think we would still find many facilities that could do with improvements with respect to patient safety, patient safety culture and quality overall.

Schenk: I was going to say at the end of the day, there’s definitely a lot of room for improvement. But could you unpack what your study, what your conclusion is with regard to having an adequate amount of staff in regards to overall safety of the residents? What’s the correlation?

How does having an adequate amount of staff factor into nursing home safety?

Nicholas: Yes, so actually this is something that really gets into my work overall, so I’d say the past 20, 30 years, most of my work has been on quality of nursing homes, but really with respect to the staffing makeup, which is the staff and the top management. And I would say that for the most part, we get a self-evident relationship that if you increase staffing levels, you are more likely to have better patient safety culture and better patient safety outcomes and quality outcomes.

But the question itself is a little bit more nuanced than that. What we also find is that it’s a little simplistic to talk about just staffing levels. I call it the staffing equation. There are other parts to staff such as the use of agency staff, turnover of staff, the training of staff, absenteeism of staff. I go to many facilities where 20 percent of more of the CNAs have called off that day, so you have to use temporary agencies, and then also the stability of the staff.

So each of these interacts and can have an influence on quality and patient safety, so clearly, if you have high staff, high staffing level, you’re probably at increased odds, probability of having better care, but we’ve done work to show that you can be at the high end of staffing and if 25 percent of your staff are agency staff, you can be at the low end of quality. It’s how you use staff, how you manage the staff.

Schenk: Okay, so just to be clear…

Nicholas: That might be a longer answer than you wanted, I’m sorry.

Schenk: No, that makes sense. I wanted to make something clear for the listener that when you’re talking about agency and contractors and turnover, these, you’re saying, are a negative influence in the quality of care that is being received. So in other words, when the loved one a resident goes and visits and sees CNAs that they haven’t seen before and they’re new or that kind of thing and they’re seeing a lot of turnover, that is potentially a negative in terms of quality of care. That’s the outcome.

How does staff turnover affect nursing home safety?

Nicholas: Yes. It is definitely a negative on quality of care. Now you are talking to an academic. There are limitations to that. Staffed facilities necessarily have to use some agency staff and there is some turnover in all facilities. It’s the level that’s important. Once you get to high levels of agency, high levels of turnover, I’d say you get into potentially unsafe environments and potentially unsafe safety culture or environments.

Now there is something I wanted to pick up there on what you said if family go to a facility and they see a new nurse aide or a new RN taking care of their loved one, there is something called consistent assignment. Some facilities use that. I think the majority have started to. If you see a new CNA or a new RN, it might not be agency staff, it might not mean turnover. It might mean just somebody in the facility is looking after the loved one, but consistent assignment is also known to be a positive thing on caring for residents.

So a lot of how it works is if you’ve got stable staff and consistent assignment of staff, they get to form a relationship with the resident so they know when they’d like to get out of bed, they like what food, they know what kind of food they like, they know the kinds of medical care they’re receiving such that they don’t have to look it up each time and that bond, as it were, does look like it improves the quality of care and safety of care.

Schenk: That makes absolute sense that when the resident is comfortable with someone, to shake that up would potentially, not every time, but potentially would have a negative impact on the overall quality. Dr. Castle, in the few minutes that we have left, can you talk about in your experience, not just necessarily what you learned from the study, but in your experience, what are some of the factors that can improve safety culture in nursing homes other than having, as you said, a certain amount of staff that are not agency, not turnover, properly trained, that kind of thing? What are some of the factors that would lead to quality outcomes?

How does management affect safety in nursing homes?

Nicholas: So the first thing is the list that I listed off earlier. If you go down that list, why they’re actually included on this hospital survey, patient safety culture instrument is that they go on to influence patient safety and outcomes and, to a degree, quality. So if I was to know too much about this, I would go, well, what are management’s expectations? Is there organizational learning? Is there teamwork within units? Is there communication openness? But that’s what the instrument is designed to do. If you want to ask me if I went to a facility, what do I see that I can’t see on this instrument, the main proof patient safety and overall quality, one thing I’d say, is there consistent assignment? Second thing is management.

The attention of management, and what I’ve found over the years is that we pay a lot of attention to CNAs and RNs, and rightly so, but it’s the way the facilities are run, we do have many, many great nursing home managers in the country. We have others who maybe could do a little bit training and improvement. So I would say manager’s attention to this is an issue and to the resident’s quality of life and safety in general is an issue.

What is Quality Assurance and Performance Improvement?

The other thing is facilities now do a thing called QAPI, which is Quality Assurance and Performance Improvement. The CMS mandates that that should be done, I would say, within those QAPI committees and groups, if more patient safety issues were listed, the patient safety culture was addressed within those groups, that may be of use. But also not just in the committee structure – I’d say using a particular methodology for improvement, and I know this is sort of nuanced, but you can look at quality data and you can look at patient safety data and say, “Yes, let’s look at the benchmark. Yeah, we need to make improvements. What are we going to do?” I think if we use validated tools such as we to go into the facility and go from CNAs up and to make this something that the facility does on a routine basis, it won’t then just come up with the quality improvement committees. It will be addressed before the issue happens or it will be addressed on an ongoing basis. So I think that’s something that I would look for. Again, I’m sorry if that was a protracted answer.

Schenk: No. That’s perfectly fine, Dr. Castle. That’s fantastic information for our listeners, and again, usually our audience is made up of loved ones of nursing home residents that are just kind of seeking out more information about things and this episode has been a great resource for them. And I’m going to post in the show notes a link to the actual study, so people if they’re interested, they can actually read the hardcore data that’s contained in it.

Nicholas: Can I make one comment there too? I know your show is about families and loved ones. I would say there’s one thing that not everybody can do but I would certainly hope that if you could, you should. It is visiting the facilities frequently and if you’ve got a loved one going to a new facility, certainly visiting it, but CMS on the Nursing Home Compare website has a checklist. So I’m sure your listeners know that Nursing Home Compare has quality measures and you can look up the facilities’ qualities and their standings with respect to their peers. But I really highly recommend the checklist, you print it off and you take it with you to the facility, and it has things on it such as, “Does the facility smell?” “To the residents in the corridors, do the residents look happy?” “Do the staff look happy?” I think it was put together by CMS and I think it would help folks.

Schenk: Exactly. That’s excellent advice. We actually in previous episodes have had entire episodes dedicated to how to navigate the Nursing Home Compare website and how to survey a potential nursing home. I know we’ve had Richard Mollot of the Long-Term Care Community Coalition on to decipher that website and offer guidance, just as you had said, about kicking the tires on a new nursing home. But always good advice, what you said – print that document out with the checklist and go and actually go ask questions. Be present with your loved one as often as you can and that’s going to be very critical in lowering the likelihood of problems. That’s great advice.

Nicholas: Well thank you.

Schenk: Well Dr. Castle, it has been an absolute pleasure. We really appreciate you coming on, sharing your knowledge and being a resource for our listeners.

Nicholas: Well I really appreciate being asked and I hope that some of my comments help some of your listeners and I certainly wish them luck with themselves and their loved ones, so thank you.

Schenk: All right, thank you. As I mentioned at the top of the show, Dr. Castle has in the past 20 years done 50,000 surveys by mail of long-term care facilities. He’s talked to – yeah, surveyed 300 discharged residents and has interviewed face-to-face over 500 nursing home staff regarding all matters of nursing home operations but particularly safety culture. That’s why he has a breadth of knowledge on this topic. We really appreciate him coming on this show. I think it’s really interesting intuitively when you go into a nursing home and you are always seeing different people, you scratch your head and go, “That can’t be good,” and his studies are showing that in fact, it is probably not good.

But what I want to make note right now, what Dr. Castle talked to me about off the air, is that a lot of times on this podcast, we are aggressively pointing the finger at nursing homes, and he reminded me to say that not all nursing homes are bad. There are a lot of nursing homes out there that are providing excellent, excellent care. And I agree with that statement. I think sometimes because of our perspective, we lose sight of the fact that there are nursing homes doing good jobs, and I just want to give a shout-out to that via Dr. Castle’s prompting of me, but he’s absolutely right. I don’t want to lose sight of the fact and I don’t want you out there as the listener to lose sight of the fact that there are a lot of nursing homes that put in a lot of work and do care about resident safety.

On that note, I just wanted to point out that in fact, this episode marks our three-year anniversary. I cannot believe it – Episode 139. We’ve entered into the third year. We’re a little baby. We’re walking around. I don’t know what 3-year-olds do, but I guess they’re walking around. You walk around at three? Yeah, yeah. You walk around. At this point I guess you’re pointing at things and going, “I want that,” like little candy bars and stuff if this podcast was a kid.

But our first episode I think – what do we’ve got here? January 16th of 2017 was the first episode of the Nursing Home Abuse Podcast. At first, we were weekly. Now we’re bi-monthly. I don’t necessarily see major changes like that in the future, but we are certainly happy, on behalf of Will, to keep putting out these episodes for you because I feel like it does the community good to learn a little bit more every other week about nursing home care. But I can’t believe that we’re hitting three years of this. It’s pretty wild.

But at any rate, we really appreciate you, those that have stuck around for three years, or if you’re new, we appreciate that as well. But as always, you can catch the Nursing Home Abuse Podcast online and watch it on YouTube or on our website, which is NursingHomeAbusePodcast.com, or you can check us out wherever you get your podcasts from. And with that, we will see you next time.