Context Over the past century, nursing homes and hospitals increasingly have become the site of death, yet no national studies have examined the adequacy or quality of end-of-life care in institutional settings compared with deaths at home.

Sustained efforts on many fronts are needed to improve end-of-life care in nursing homes. Policy recommendations are suggested.

Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Objective To understand the process of instituting culture change (CC) practices in nursing homes (NHs). Methods NH Directors of Nursing (DONs) and Administrators (NHAs) at 4,149 United States NHs were surveyed about CC practices. Follow-up interviews with 64 NHAs were conducted and analyzed by a multidisciplinary team which reconciled interpretations recorded in an audit trail. Results The themes include: 1) Reasons for implementing CC practices vary; 2) NH approaches to implementing CC practices are diverse; 3) NHs consider resident mix in deciding to implement practices; 4) NHAs note benefits and few implementation costs of implementing CC practices; 5) Implementation of changes is challenging and strategies for change are tailored to the challenges encountered; 6) Education and communication efforts are vital ways to institute change; and 7) NHA and other staff leadership is key to implementing changes. Discussion Diverse strategies and leadership skills appear to help NHs implement reform practices, including CC innovations.