Culture is often considered a soft gauge of quality—difficult to define and measure, and highly qualitative in nature. But data from a broad survey of long-term care (LTC) facility staff and leaders reveal the opposite. Data-driven, evidence-based culture metrics can predict whether a unit will hold together under stress, whether a new process will stick and whether residents are consistently treated with dignity.
To start, walk into an LTC facility and ask the staff: Would you feel safe being treated here as a resident?
This question is a variation on one from the SCOR™-SF-LTC survey, a culture and well-being survey developed by Kaufman Hall, a Vizient company (see sidebar). In that survey, respondents, answering anonymously, are asked to rate the statement “I would feel safe being treated here as a resident” on a scale from “disagree strongly” to “agree strongly.”
Answers to this question, more than any other, correlated with an LTC facility’s overall cultural health or lack thereof. It indicated that culture isn’t a soft gauge of quality at all; instead, it is the foundation on which clinical, operational and financial improvements can be built. Kaufman Hall survey data indicate that culture—the shared beliefs and values that shape behavior—drives everything that matters in long-term care: turnover, care quality, resident safety and stability.
Most LTC facilities have not systematically assessed their culture. Those that have usually haven’t approached it in a benchmarkable way. Doing so can reveal uncomfortable truths.
The perception-of-safety question is revealing because negative answers surface fear, detachment from purpose and negative informal subcultures. They signal a workplace shaped by self-protection, which translates into less attention for residents, more energy poured into dodging conflict and a daily grind that quickly turns to burnout. On the flip side, positive replies indicate a healthy culture of mutual respect and safety.
Developing a deeper understanding of cultural health is essential leadership homework. If you aren’t having frank conversations with nurses and CNAs, dietary workers or the weekend supervisor, you’re guessing. Your residents pay for that.
When no one speaks up
Psychologically unsafe environments are burdened by bullying, humiliation or microaggression. In those instances, staff typically don’t go tell the boss. Instead, they shut down—all except for the loudest, most negative voices. Near misses go unreported and workers go into self-protection mode. Even the best-intentioned leaders may not realize what’s going on or may lack the skills to respond.
But listen to the silence: it signals fear, futility or outright hostility.
Turnover, which is common in LTC environments in which the pay is low and the work is difficult, exacerbates the problem. Vacancies often are filled quickly by promoting competent performers into positions of leadership when they might not have been trained to lead. Unfortunately, when formal leadership training is lacking, emotional intelligence is sometimes treated as optional. The result is predictable: cliques, favoritism, communication breakdown and widening mistrust across shifts and roles. Negative subcultures are given room to flourish.
Leaders set the tone, intentionally or not. If they are invisible, rules become suggestions. If they model defensiveness, feedback withers. If they tolerate toxic staff, fear takes over. What leaders allow or ignore becomes the culture.
What to do now
Improving a facility’s culture isn’t easy. But it’s possible. Here are five actions LTC leaders can take to build healthier, safer environments:
- Start with presence. Show up on all shifts, make yourself visible and round with purpose. Ask the hard questions of both yourself and your staff, and act on what you hear.
- Adopt appreciative inquiry. Listen—a lot. Learn the words and actions that promote voice. Ask “tell me more” or “help me understand” to uncover real issues. Don’t dismiss what you hear as mere whining, and don’t respond with excuses.
- Codify non-negotiables. Establish zero tolerance for bullying, humiliation or weaponized sarcasm. Coach when possible, but remove toxic influences, even if you’re short-staffed.
- Invest in leadership. Train for visibility, fairness, conflict resolution and feedback that lands. When feasible, tie evaluations to cultural outcomes.
- Measure progress. Use reliable instruments across roles and shifts, and track results over time. Longitudinal data shows whether interventions stick or are merely cosmetic.
This is the reckoning: confront culture or manage decline. If, as the adage has it, culture eats strategy for lunch, then leadership is the chef who sets the menu. Staff and residents see the difference.
This is why the perception-of-safety question matters. If staff hesitate, or if you do, then it’s time to act. Treat culture as the strategic asset that it is, because everything else depends on it.
How we got here: 23,000 voices telling the story
From 2022 to 2024, more than 730 LTC facilities asked their staffs to complete a culture and well-being survey developed by Kaufman Hall, a Vizient company. More than 23,000 long-term care workers completed this survey, called the SCOR™-SF-LTC (Safety, Communication, Operational Risk, Resilience/Burnout – Short Form – Long-Term Care), which was created with input from researchers at the Duke Center for Healthcare Safety and Quality at Duke University.
The original 83-item tool was streamlined to 43 high-signal questions that focus on what matters most for cultural health. This rapid assessment provides a clear picture of where an LTC organization stands with its employees. It measures indicators specific to LTC environments. The result is the only known benchmarking database of long-term care culture in the United States.
Organizations use SCOR results to establish a baseline, see how culture varies by role or shift, and track whether targeted interventions result in improvement. Because the database spans multiple years and hundreds of facilities, leaders get both longitudinal and comparative context they cannot achieve locally, learning what is typical and what is exceptional.
The dataset, while not public, gives LTC facilities practical visibility into cultural progress and risk areas. The takeaway: culture is the foundation on which clinical, operational and financial improvements rest.
