The Systems Change Tracking Tool

Overview of the Systems Change Tracking Tool

Designed to transform hospital-like institutions that approach elders as medical patients into communities, nursing home comprehensive culture change initiatives are the definition of radical change. Staff are trained and coached to not only provide medical and supportive services, but also on how to consistently prioritize resident choice and quality of life. Although over the last four decades significant work to develop approaches that foster a person-centered model of care have been designed, little has been done to measure the effectiveness or standardize different culture change protocols.

Altarum’s Delivery Systems Transformation team is committed to implementing, evaluating, and advocating for best practices that ensure quality of life in old age. To advance the work on person-centered care we developed the Systems Change Tracking Tool (SCTT). A uniquely purpose-designed QI instrument that allows all members of the nursing home staff, from administrators through care aides and household staff to track their accomplishments and challenges implementing person-centered care over time. By completing and reflecting on the SCTT regularly, staff understand more clearly where they are moving the needle on person-centeredness and how they can make culture change a reality for their residents.

The need for more person-centeredness in the nursing home sector has become starkly clear during the COVID-19 pandemic. Nursing homes nationwide struggled not only to curb high rates of morbidity and mortality, but also with significant resident decline and premature death directly traceable to social isolation and loneliness. As residences where 1.3 million elders live their final years, those in public health are called to refine and amplify practices and protocols that can be used to enhance residents’ quality of life. With the further benefit of making the job of care aides more rewarding.

How the Systems Change Tracking Tool Works

As culture change training proceeds, the SCTT assesses changes that occur in the residential long-term care setting by measuring staff-led shifts in person-centered practices and protocols using 58 items. To ensure its cogency and usefulness, the SCTT underwent cognitive testing and an iterative review process by long-term care, culture change, and survey methodology experts. Importantly, the tool’s instructions acknowledge that not all changes discussed in the instrument will happen quickly—and some may not happen at all. 

The SCTT features questions that are grouped into six domains, as established by the Holistic Approach to Transformational Change (HATCh) theoretical model.

The six HATCh domains (1,2) are:

  • Care Practices Continuous improvement of clinical and non-clinical care (for example, consistent staffing among residents)
  • Workplace Practices Endeavors that affect residents through their impact on staff (for example, access to information about resident preferences)
  • Environment Creating a home environment that is comfortable and comforting to the residents that live there (promoting feelings of home and comfort)
  • Family/Community Resident activities to benefit personal and social interactions; opportunities to engage residents (for example, being able to listen to music of their choice or dine at a local restaurant)
  • Leadership Developing culture change among all staff levels, including offering skill-building trainings for direct care staff and inclusive decision making for care plans
  • Stakeholders Institutional and regulatory factors that influence culture change; working with stakeholders so these are in harmony with what residents need

Completed quarterly, the tool has four possible responses options: the home has a plan for implementationthe home has a plan that is partially implementedthe home has a plan that is fully implemented; or the home has no plan for implementation.

Working with Altarum to Measure Nursing Home Culture Change Using the Systems Change Tracking Tool

The SCTT tool is publicly available and free to use. We invite anyone who is interested in learning more about how we implemented the SCTT protocol in our own on-going comprehensive culture change initiatives to reach out. We would be pleased to discuss how other organizations might use the tool for their own purposes including for Quality Assurance and Performance Improvement (QAPI) projects. We believe this tool can be a valuable asset in advancing best practices in eldercare nationwide.

  1. White-Chu, et al. (2009). Beyond the medical model: the culture change revolution in long-term care. Journal of the American Medical Directors Association, 10(6), 370–378.
  2. Healthcentric Advisors. (2015). Holistic Approach to Transformational Change®. Retrieved from


Anne Hicks-Dorantes
Long-Term Services and Supports Specialist
Colleen Quintal
Quality Improvement Advisor, Delivery System Transformation