A Qualitative Analysis of Safety Culture in Minnesota's Assisted Living Facilities

The number of assisted living facilities and people living in them is growing; however, there is considerable variation in state regulations for assisted living. Therefore, it is important for states with new or changed regulations to provide lessons learned for regulation and patient safety purposes.

Using qualitative thematic analysis, we applied the Agency for Healthcare Research and Quality's safety culture domains to regulators' health inspection reports from the first round of surveys post-implementation of Minnesota's 2019 Elder Abuse and Prevention Act. In accordance with the Iceberg Model, we focused our analysis on inspectors' stories of violations with severity of level three (defined as harming a resident's health or safety) because they represent the visible part of the problem.

Three, at times overlapping, safety culture themes emerged as underlying level three violations: staffing, compliance, and communication. Having enough staff, adequacy of staff training, development of internal policies that align with regulations, awareness of those policies, and the communication of caregiving activities contribute to the presence of patient-harming violations in Minnesota.

This is the first study to qualitatively examine the context behind citations that result from licensing surveys of assisted living facilities considering established indicators of quality. These findings provide baseline data on health inspections at a time when several states are considering changes to their assisted living regulations. Additionally, the results are suggestive of ways in which training and assistance, quality measurement, and staffing can be improved.