COVID-19 has swept through nursing homes in the U.S., killing nearly 1 in 10 residents during the pandemic’s first year. Some reporting, including a New York Times article published last year, has suggested that COVID hit nursing homes especially hard because years of short staffing, poor infection-control measures, and other care-quality issues left them unprepared for the outbreak.
Amandine Ody-Brasier, an associate professor of organizational behavior at Yale SOM, set out to investigate the root causes of the problems within nursing homes from an organizational perspective—her area of expertise. Hoping to better understand the organizational context in long-term care facilities, Ody-Brasier teamed up with Aharon Mohliver of the London Business School, who has previously researched how misconduct spreads within organizations.
The researchers analyzed care standards violations documented in Centers for Medicare and Medicaid Services (CMS) inspections. As they began to study the data, they noticed some striking differences between religiously affiliated homes and secular ones. Most notably, the religiously affiliated facilities had more of the most severe types of violations than secular ones.
“Just plotting the data made it so clear that something was going on that deserved more attention,” Ody-Brasier says.
What could explain this difference in the prevalence of severe violations? Did it originate from a lower standard of care within religiously affiliated nursing homes? Or was it possible that the distinction could be attributed to inspector bias, as research on other settings has found?
Ody-Brasier and Mohliver suspected that neither of these explanations was quite right. They posited a third: in religious facilities, the likelihood of whistleblowing by a community member is lower, leaving various types of care-standard violations to fester and worsen.
“Any home where there might be a strong common identity or strong peer-monitoring dynamics would be prone, according to our theory, to residents complaining less about the issues they are experiencing.”
This third explanation is the one that is borne out by their research. In a new paper, Ody-Brasier and Mohliver show that official complaints (the type that triggers an inspection by the state regulator) are less likely to be filed against religious facilities than against their secular counterparts. This suggests that more severe violations turn up in religious homes not because care standards are different in these facilities but because, somehow, religious affiliation “[shields] wrongdoers from inspections,” the authors write.
Ody-Brasier and Mohliver point out that religiously affiliated organizations have distinct norms, routines, division of labor, and authority relations. They suggest that this unique organizational structure can create strong internal identities, potentially making complaints to outside regulators less likely.
Other types of facilities with equally strong collective identities might be subject to the same tendency, Ody-Brasier says. “Any home where, for whatever reason, there might be a strong common identity or strong peer-monitoring dynamics”—for example, a nursing home for veterans—”would be prone, according to our theory, to residents complaining less about the issues they are experiencing.”
At the heart of the researchers’ analysis was a comparison of the two types of nursing home inspections carried out by outside regulators. The first is a surprise routine inspection, which federal law mandates annually. The second type, a complaint-driven inspection, is the same in every way except in what triggers it: a formal complaint by a resident, relative, or staff member.
The researchers analyzed the reports produced by these two distinct triggers to tease out the source of the disparity in violations. They collected data on all recorded violations between 2010 and 2015 from reports by CMS inspectors. The data cover virtually all nursing homes in the U.S. and about 1.6 million residents.
Their analysis revealed that the disparity in the number of severe violations between religious and secular homes was concentrated entirely in the subset of inspector reports triggered by complaints. When the researchers looked only at those reports produced by routine inspections, there was no difference between the two types of homes.
The researchers also observed that complaint-driven inspections were rarer for religious homes; these facilities faced a 13% lower risk of this type of inspection and experienced a 15% longer lag time between any two of them.
What’s more, they found that the relationship between this lag and violation severity was positive, meaning that the longer a facility operated unmonitored, the more severe the violations became.
The upshot: “fewer complaints reduce the frequency of inspections,” the co-authors write, “allowing violations to worsen before they are detected.”
The researchers postulate that complaints are less common within religious nursing home communities because of an in-group affinity that filters how misconduct is perceived and handled. Supporting this explanation is another of the researchers’ findings: the effect does not hold for multi-denominational facilities. While religious, these organizations may experience less identity cohesion than single-denomination homes.
“This is what we would’ve expected because what we are arguing is that religion matters because it creates this pressure not to complain and a very strong identity, which we’re less likely to find in non-denominational homes,” Ody-Brasier says.
“We know that there tends to be a problem of ‘slippery slopes,’ where it becomes more normative to engage in behaviors that are not acceptable. So it is really critical to catch these problems early on.”
The researchers considered that complaints from religious care communities may have been lower because of some formal internal mechanism for addressing disputes and misconduct that kept these issues from being exposed to outside regulators. To determine whether this might be the case, they crunched data on whether or not facilities had formal internal governance systems like “family councils” or “residents councils,”—but they found that these systems could not account for the differences they uncovered.
One important policy takeaway of the research, Ody-Brasier says, is that routine, surprise inspections of nursing homes remain critical. As the researchers’ findings also show, violations left undetected appear to worsen.
“We know from research that there tends to be a problem of ‘slippery slopes,’ where it becomes more normative to engage in behaviors that are not necessarily acceptable,” Ody-Brasier says. “And so it is really critical to catch these problems early on – hence the role of external monitoring—before they worsen.”