Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

Published:October 17, 2022DOI:



      To examine perceptions of patient safety culture (PSC) among assisted living (AL) administrators and direct care workers (DCWs), and their associations with state regulations.


      We conducted a survey using the PSC instrument developed by the Agency for Healthcare Research & Quality. Secondary data on ALs and residents were derived from the Medicare Master Beneficiary Summary Files. Other data sources were the Area Health Resource Files, a previously compiled national AL directory, and the US census. Data on state AL regulations were available from a prior study.

      Setting and Participants

      Participants included administrators and DCWs working in assisted living communities serving Medicare beneficiary residents.


      We employed exploratory factor analysis, examined Pearson correlations, and obtained standardized Cronbach alphas to test the PSC instrument. We estimated linear regression models with the dependent variable being the proportion of positive PSC assessments, for each PSC domain, with SEs clustered at the AL level.


      Surveys were completed by 714 administrators and DCWs in 257 ALs. The PSC instrument tested reliable and valid for AL communities. Administrators’ and DCWs’ perceptions of PSC differed significantly across almost all domains. A 1-unit increase in state regulatory specificity for DCW staffing was associated with a 4.13–percentage point (P < .05) increase in the PSC staffing domain. Associations with regulatory specificity in staff training were also found for other PSC domains.

      Conclusions and Implications

      PSC is an important metric for assessing organizational performance. DCWs have significantly worse perceptions of PSC than do administrators, suggesting it is crucial to understand the source of these differing perceptions. Because state regulations relate to PSC, achieving a comprehensive focus on patient safety in AL may require regulatory action, particularly increasing specificity with regard to staffing and training.


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