Do you recognize “administrative harms” in health care?

THE HASSLES INVOLVED in providing hospital care are seemingly endless—but at least they now have a name: “administrative harms.” Daily huddles that don’t get much done. Individual hospitalist census that creeps up as a (counterproductive) response to slim financial margins. A push to transfer in more patients, only to board them in hallways because bed management can’t keep up.

Defined in a study published this summer by JAMA Internal Medicine as “the adverse consequences of administrative decisions within health care,” administrative harms affect not only patient outcomes but the health care workforce and the organizations they work for. And before you assume that such harms all trickle down from the C-suite, the research makes it clear that harms can come from anyone with decision-making authority—administrators and clinicians alike.

“If you have decision-making authority, whether through a formal or informal leadership role, you can contribute to administrative harm.”

Marisha Burden, MD, MBA
University of Colorado Anschutz

In the study, researchers held two focus groups with two national networks of hospitalists, along with an embedded survey. The study included 41 individuals, most of whom were hospitalists, from 32 different organizations. But administrators and at least one APP were also part of the mix, and more than 40% of participants identified themselves as having some kind of leadership role.

Only a tiny minority (6%) were familiar with the concept of “administrative harm” to a great extent. But once they understood the term, more than 80% admitted that they themselves had been part of a decision that had increased the level of those harms in their own shop.

The research uncovered several themes. First, administrative harm is pervasive across all levels of health care leadership.

Also, most organizations have no mechanisms in place to even gather feedback about administrative harms, let alone identify and measure them. Organizational pressures—time, money, the competing priorities of health care systems vs. local practices—contribute to administrative harm, as does a lack of psychological safety. And many decisions in health care are implemented without real clarity as to who’s really making that decision. That makes understanding where a harm is coming from even more challenging.

Lead author Marisha Burden, MD, MBA, hospital medicine division head at the University of Colorado Anschutz Medical Campus in Aurora, Colo., has made a research career out of studying how health care leadership and work design affect workflow and wellbeing. Dr. Burden spoke with Today’s Hospitalist.

How long have you been aware of this umbrella term?
Certainly since a perspective piece appeared in the New England Journal of Medicine in 2022, which used that exact term. Then I went to a conference on administrative harm, and that’s when I really started thinking about it.

The term may be less familiar, but the concept—whether you’re a patient, a family member, a clinician or an administrator—is something we all experience.

Right now, we’re trying to understand what those lived experiences are and to think about them within a research framework so we can begin to address administrative harms across health care systems. Our work highlighted the fact that if you have decision-making authority, whether through a formal or informal leadership role, you can contribute to administrative harm.

One sobering statistic from the study is that only a minority of participants—38%—said they’d feel comfortable enough within their organizations to even raise concerns about administrative harms.
That’s one really big takeaway. If no one feels they can give you feedback as a leader, you won’t be able to understand the impact of your own decision-making.

It also really speaks to the organizational power dynamics that a lot of participants noted. If clinicians don’t feel safe pointing out how a decision negatively affects their work or their patients, that limits organizational learning. It also limits learning for individual leaders who may continue to make the same mistakes.

It also underscores the need to have input from frontline clinicians in decisions that have an impact on work design and patient care. We heard comments about, for instance, the harms from various decisions around staffing and workloads. That indicates that organizations may not be looking at the consequences of those decisions.

That’s one advantage of using the word “harm.” It’s associated with something important that has real-world impact, not just on finances, but on patients and the health care workforce. Decisions can lead to not only patient harm but also to moral injury and burnout.

How should people begin to address this?
We have many robust processes in the clinical arena that trigger real-time learning with review and conversation.

Think about what happens when we have a patient case that doesn’t go as planned or when a group could improve on a clinical metric like readmissions or length of stay. As clinicians, we take a deep dive into why we may not have had the best outcome.

But we don’t have similar administrative processes to holistically look at how some decisions, financial ones in particular, impact care.

My hope is that our research will spur conversations around simple things we can do to address administrative harm. One thing I do every week with our division administrator is to round on our clinical teams. This helps division leaders understand if the work model we have implemented supports our clinicians to do their best work. How is our team doing and are we seeing the outcomes that we want to see?

Because it really has to be a partnership—and that is something else we heard from study participants: They want to collaborate with leaders, both clinical and administrative. The goal is not to create a divide between clinical and administrative leaders but to work together to make better decisions.

What are the implications for research?
I think there are many. We have to start to build evidence-based practices around work design, for one. I think the reason why organizations tend to repeat mistakes and cause harm is that we don’t actually know what best practices are.

What’s the optimal workload, for example? We don’t actually know, so workload decisions default to budgets or to low-yield strategies that force frontline clinicians into workarounds.

That puts really smart people in tough situations, making them navigate a flawed system. Without clear, evidence-based guidance, we risk decisions that undermine patient care and threaten the sustainability of our workforce. Getting organizational decision-making right around work design couldn’t be more important to address administrative harm.

Phyllis Maguire has been Executive Editor of Today’s Hospitalist since 2006. Based in Bucks County, Pa., her health care interests are hospital medicine and long-term care options. She also likes zydeco, hiking, and reading memoirs and romances.