The CANS newsletter will feature a socioeconomic journal club. We will review articles in the broader policy context, with both a resident and attending providing their perspectives.

This month, we review the JAMA Internal Medicine article “Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders.”

“David vs Goliath; bureaucracy; red tape; man in the ivory tower; the powers that be; cogs in the machine…” These allusions reference a common thread that is explored in this JAMA article on Administrative Harm. This relatively new term, coined by Walter O’Donnell in a 2022 NEJM article, is defined as the “adverse consequences of administrative decisions within health care [that] directly influence patient care and outcomes, professional practice, and organizational efficiencies…” In my last SES journal club, I discussed the concept of moral injury, in which harm that comes about from systemic issues can lead to greater rates of burnout in physicians and health care providers. This article focuses specifically on issues that arise from the administrative level—the institutional bastion that often feels like an oppositional force in the face of limited hospital beds, nursing shortages, supply chain issues, and profit-based financial incentives. The rationale for exploring Administrative Harm comes from the fact that while multiple studies have investigated the impact of clinician behaviors (e.g. communication, medical decision making, etc) on patient outcomes, the impact of administrative decision-making on patient outcomes has limited data.

Using a qualitative survey and focus group discussion involving 2 hospital communities that included hospitalists, administrative leaders, researchers, and patient and family advisory council members, the article highlights several key main points:

Administrative Harm (AH) comes from all levels of leadership with wide-ranging impact throughout the health care system. Through both survey results and group discussions, participants reported that AH can come from any level of leadership that has decision-making authority—not just established executive positions. One of the key themes that

• arose from this exploration was that there was frequently a dissolution of partnership between the administration and the day-to-day workers where clinicians felt the need to bypass established protocols to provide patients the care they needed.
• AH is difficult to measure and its ambiguity can lead to a lack of accountability and feedback for organizational change. Most participants in the survey and focus groups (94%) had not even heard of the term, “Administrative Harm”, and current leadership structures were noted to avoid accountability for AH through “decisional distancing,” where the effects of decisions were made apparent much further downstream in the everyday workplace that involved clinicians’ decision making. This figurative spatial distancing as well as no clearly established methods for reporting adverse events in response to administrative decisions made it difficult to provide feedback in an effective or timely manner.
• Characteristics of administrative decisions that ultimately led to AH were defined as those actions that were made in the setting of pressing issues without including the voice of patients and clinicians, failure to incorporate balancing measures with significant policy shifts, subsequent overcorrection of previous policies, and neglecting to evaluate potential fallouts from their decision making. Principle in propagating AH was a lack of communication and information sharing between clinicians and administrators.
  
  

This study has several limitations including a lack of standardized metrics for measuring administrative burdens and their impacts as well as subjective reporting by hospitalists and leaders, which introduce bias and affect the reliability of the findings of this qualitative study. Furthermore, while the study offers multiple solutions, they are of limited scope and do not address the complexity of addressing AH across institutional levels.

However, the importance of this study comes from highlighting the lack of organizational systems that can identify, measure, and provide feedback to administrators for actions that result in AH. To do so, system-level changes would need to have a dedicated team to report on direct and indirect patient outcomes secondary to these administrative decisions. But therein lies one of the greatest challenges for accountability:  when patients are harmed, it is much easier to trace these events back to the clinician who misdiagnosed the disease or the nurse who drew up the wrong amount of medication. It is harder to trace these

actions back to strained healthcare working conditions with overburdened censes that resulted in these errors. Hence a dedicated team that specifically and critically traces these outcomes all the way up through systemic high level institutional changes would need to be implemented. This would require such an initiative to be valued in the first place by the administration, as well as a culture of being receptive to whatever feedback would result from these investigations.

Ultimately, these issues coalesce into a dangerous mentality: that of “us vs them”. The David vs Goliath allusion referenced at the start of this discussion has spurred several new trends across the health care landscape, though to what extent the impact of these changes will benefit patients and clinicians has yet to be seen. Increased unionization efforts may provide further checks and balances into organizational decision-making, but the increase in private equity investment in health care that has been noted in recent years can further capitalize in bureaucratizing hospital systems.

At the risk of overstating the obvious, it should be noted that one of the key issues arises from a disconnect between the administration and clinicians’ objectives. While the mission statement of every health organization on paper is to provide compassionate and effective medical care for their patients, administrative success often involves maximizing profit and minimizing financial losses. The simple answer that is posited by this study is that there is a holistic middle ground in which organizational decisions incorporate financial sustainability, workforce health and safety, and optimal patient care outcomes. But this is easier said than done. To do so, institutions need to explicitly align their values for patient care from the ground up—from the clinician and nurse who is working with patients daily to the CEO of these health institutions that have multiple divisions under their purview—and have channels of communication that enable feedback for any decisions that run contrary to these shared values.

Anthony DiGiorgio, DO, MHA

Dr. Choi does an amazing job summarizing the article on Administrative Harms (AH). 

The authors of the study deserve commendation.  As Dr. Choi mentioned, it is extremely difficult to measure AH.  While the article has no groundbreaking findings (it consists solely of a survey of 32 people), publishing this article is the first step to measuring a phenomenon we all know exists.  I’d like to see more of this, which real quantifiable measurements of AH.  It is a very real thing and, if we are going to fix it, first we must learn to measure it.  A survey of 32 people isn’t much, but at least it’s a start.