“Administrative harm is destroying American medicine” is the title of a provocative article published in the July 13, 2024, issue of KevinMD by Arthur Lazarus, MD, MBA. He references business entrepreneur and billionaire Michael B. Kim, who said: “Leadership without ethics is a body without a soul.” As examples of administrative harms, Dr. Lazarus cites “unrealistic staffing models, burdensome regulations, out-of-touch administrators, lack of frank feedback to leaders, and unhelpful consultants.” He states that such harm is “manifest in excessive paperwork, rigid protocols that do not allow for individualized patient care, and resource limitations that prevent timely and adequate treatment.”
On June 24, 2024, “Identifying and measuring administrative harms experienced by hospitalists and administrative leaders” was published online by JAMA Internal Medicine. The 13 co-authors from seven states indicate administrative harm is important because “the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs are pervasive in medicine, yet poorly understood and described.” They assert these consequences “influence patient care and outcomes, professional practice, and organizational efficiencies regardless of employment setting.”
The article includes specific comments from 32 individuals responding to a 12-question survey. Representative responses were:
1. “Months into the pandemic, we had gotten very good at all the things to do to deal with surges. Someone in the risk management department at the health system said they wait a minute; we do not have evidence that the physicians and APPs have completed the required training as they do for hand hygiene and sharps, injury prevention, etc. And so, there was an urgent email that went out basically saying you have 72 hours to complete this one-hour-and-15-minute training on COVID safety or your credentials will be suspended.”
2. “We had a new CEO come in, and we already have a strained emergency room, but he really wanted to ramp up accepting transfers into the hospital, which just further burdened us, and everybody wants to please the new CEO. So now we have a pipeline of people coming from states away to just sit in our emergency room in the hall ….”
3. “We couldn’t get echos on the weekend … and the way that administration solved that problem was if someone really needed an echo, there is always a cardiology fellow who can just come in and work extra hours for free and do that. I’ve seen many examples where inadequate staffing is tolerated by administration because we know that thing needs to be done, and we will get it done somehow and you can always get an underpaid trainee to do the work. Administration really has no particular reason to change that if patients are still getting the care they need.”
4. “It was a business decision made by business folks without any clinical input … Where does that come from? It’s folks not understanding, not being at the bedside, not engaging frontline workers, not having a clinical background, and not reaching out to understand, ‘If I made this decision, yes, it fixes my budget, but what ramifications does it cause downstream?’ That’s where I think a lot of these decisions happen—because people are making them in a silo.”
Numerous studies have suggested burnout and moral distress among health care professionals seem ubiquitous, resulting in more absenteeism, increased turnover, people working part-time, and earlier retirement. The research reported in the JAMA Internal Medicine article is somewhat unique because administrative harm represents a new label for the assortment of factors negatively affecting staff, patients, and organizations.
The authors determined that such harm affected writing clinical orders, scheduling personnel, discharging patients, and providing resources. The perception of administrative harm ranged “from an inevitable byproduct of decisions (an acceptable status quo) to recognizing it as a symptom of a dysfunctional management system that can be rectified (reversible or avoidable harm).”
Among the concerns highlighted were the difficulty of measuring administrative harm, a lack of an avenue to report harm, a fear of possible retribution, ineffective collaboration between administrators and clinicians, and an absence of leadership responsibility and accountability.
Coincidentally, on July 31, 2024, STAT News reported a remarkable example of administrative harm. The article’s title was “Mount Sinai mounted aggressive campaign to stifle debate over revelations about its controversial brain research.” The article’s author, Katherine Eban, stated, “Mount Sinai, a leading hospital network in New York City, has mounted an extraordinary behind-the-scenes campaign to blunt the fallout over revelations about its controversial research project in which brain biopsies are taken from patients undergoing deep brain stimulation.” She wrote that an FDA review “concluded that Mount Sinai researchers were misleading patients and using a false justification to obtain the biopsies.” Not surprisingly, Ms. Eban noted several medical ethicists agreed the consent process was unethical.
The need for an effective action plan to prevent administrative harm
Although the term administrative harm is unfamiliar to most health care executives, the justification for evaluating what practical steps can be taken to minimize such harm is undeniable. The following steps are worth deliberation:
- Discuss the concept of administrative harm with the institution’s governing body and in a senior leadership meeting.
- Encourage members to offer illustrations of administrative harm.
- Explore possible options for preventing such harm.
- Determine how incidents of administrative harm can be identified.
- Consider how medical staff members can be engaged in examining this topic.
- Develop an educational program for supervisors and clinicians.
Both employees and physicians must be comfortable in reporting perceived incidents of administrative harm to leaders without fear of retribution. In some cases, it could be appropriate to formally recognize those who report administrative harm to incentivize others to do so. Of course, essential to this process is an organizational culture that promotes collaborative relationships and trust among staff.
Paul B. Hofmann is a health care consultant.
