Rebuilding Trust: Addressing Administrative Harm in Healthcare

This podcast episode explores ways to address and potentially reduce what has come to be known as “administrative harm,” or decisions made by administrators and leaders that ultimately lead to difficult working conditions for healthcare providers and possibly clinical harm to patients.  

During this episode, you will explore: 

• How taking time to analyze and identify the appropriate person to perform a task is a method to reduce administrative harm
• How patient stories may lead to modifications in administrative decisions, making them potentially less harmful
• The need to gather and analyze data surrounding administrative decisions to gain information to predict and mitigate harm
• The importance of including frontline clinicians when administrative decisions are being considered to ensure their perspective is considered   

Link to Transcript

Coverys companies are a leading provider of medical professional liability insurance for medical practitioners and health systems. Coverys provides a full range of healthcare liability insurance options, advanced risk analytics, and best-in-class risk mitigation and education resources to help clients anticipate, identify, and manage risk to reduce errors and improve outcomes.

Med-IQ, a Coverys company, is a leading provider of clinical and risk management education, consulting services, and quality improvement solutions, empowering individuals at every level of the healthcare delivery system with the knowledge they need to continuously improve provider performance and patient outcomes.

The information provided through this activity is for educational purposes only. It is not intended and should not be construed as legal or medical advice. Opinions of the panelists are their own and do not reflect the opinions of Coverys or Med-IQ. 

Transcript

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Geri Amori, PhD, ARM, DFASHRM, CPHRM: Welcome to Healthcare Perspectives 360, a podcast dedicated to exploring contemporary healthcare issues from multiple perspectives. I'm Geri Amori, and today I am joined by Marisha Burden, MD, the Division Head of Hospital Medicine and Professor of Medicine at the University of Colorado School of Medicine, and recipient of the Society for Hospital Medicine Award of Excellence in Clinical Leadership for Physicians. As a working hospitalist, her interest is in building a thriving workforce and building clinical staffing models that drive outstanding patient and institutional outcomes.

I'm also joined by Susan Dorr-Goold, MD, Professor of Internal Medicine, as well as Professor of Health Management and Policy at the University of Michigan School of Public Health. Dr. Goold has special interest in public health policy and ethics and is a practicing primary care physician. 

We're also joined by Gina Symczak, Patient and Family Advisor, serving on the Council of HOMERuN, the Hospital Medicine Reengineering Network. Gina has been an active member of Patient and Family Advisory Councils at the University of California, San Francisco, and a representative on patient-centered initiatives for national organizations since 2012. Her service follows a career in marketing and brand strategy in consumer-packaged goods industry. 

And, finally, we have Luci Leykum, MD, Affiliate Professor of Medicine, Dell Medical School at the University of Texas Health Science Center, and a general internist, as well as public health services research investigator, focusing on assessing and improving healthcare system function.

Welcome. Today, we're talking about potential ways to address what has become known to be known as administrative harm, or decisions made by administrators and leaders that ultimately lead to difficult working conditions for healthcare providers and possibly clinical harm to patients. 

Complex multi-facility, multi-specialty systems are now the common source of healthcare delivery in our country. With the economies of scale that come with large systems, there also emerges complicated, multi-layered levels of decision-making and hurdles to access. Is there a way to build a large system that operates like a small, trusted, and easy-to-access system? 

Today, we're going to ask our panelists for their ideas on what is needed to reduce the harm that comes from decisions being made far from the point of care that influence the working conditions of healthcare providers, as well as the care being received by patients.

Luci, I'd like to start with you. I'm fascinated by your interest in assessing and improving healthcare system function through recognizing and working with the complexities and interdependencies of the system. How might that work to help address the pervasive nature of administrative harm?

Luci Leykum, MD, MBA, MSc: So, in complex systems, there are lots of different parts that come together to influence how the system functions. And the way these parts come together really matters. In healthcare systems, the way people come together really matters. So, if we make it easier for people to communicate and get information from each other, they'll develop these shared understandings of what's happening that makes it easier for them to act in a coordinated way instead of a siloed way. 

So, if people across the system, from the front lines to the C-suite, are able to understand how their actions influence each other, they'll be able to make better choices in terms of minimizing the potential negative impact of their actions on each other across the system. So I think the key thing is how do we set up strategies and processes for us to share those insights across the system?

Amori: That's a really good point.

Susan, the American College of Physicians has a position paper on reducing administrative burden. They're recommending, I quote, “Analyzing tasks to determine if it is worthwhile. Does it take physician judgment to do it? Does it promote timely and appropriate care and delegating the tasks to the appropriate individual? Or is it negative and can be eliminated?” 

Now, do you think this is a feasible approach? And how do you think that could even be implemented?

Susan Goold, MD, MHSA, MA : Well, I kind of have mixed feelings about it. First of all, yes, we need to ask the question, does this have to be done by a physician or could somebody else do it? But does it need to be done at all is the first question to ask, okay? Does it actually create any benefit either financially or clinically? And sometimes when we're delegating, we see a little bit too much, I think, what we might call turfing, okay? Not my job, forward it to someone else, and then it takes longer to get done, and that hurts the patient, okay? A long time ago, we used to have mandatory second opinions for some surgeries required by insurers. Then evidence showed that it didn't save any money, and it cost more money than it saved, and it rarely changed the original decision.

I have to say that when I've gone through appeals…prior authorization appeals processes and get to the peer-to-peer discussion, it's usually not another physician, I've never had them turn me down. So why are we doing that? It's just time away from patient care.

Amori: That's a really good point.

Gina, there are mechanisms for patients to register harm from a provider. Press Ganey is a basic level. There's health grades, and there's litigation. But there's no legitimate way to register harm from administrative decisions. Should there be and what might that look like?

Gina Symczak: I definitely think that there should be, Geri, since administrative harms are a growing issue for patients as healthcare becomes more and more complex. And I think that right now in most systems, a patient relations department is probably the most direct and immediate channel for bringing administrative harms to light. But sometimes even a patient relations department doesn't know who is the responsible administrator because administration is complex and sometimes way too far upstream. So I'd like to build on what Luci said about learning across the system from each other to saying that we should also learn from patients.

I think it would go a long way if administrators, just like providers, were required to consult regularly with PFACs, the patient and family advisory councils, and also if their performance management goals included patient satisfaction targets. During my 13 years’ experience interacting with providers on PFACs, I've seen how even providers with the hardest shells have been illuminated by patient stories and have committed to changing how they provide care based on those stories. So I'm confident that if administrators could directly hear from patients and hear their stories, too, they'd feel closer to patients and perhaps modify how they approach their job so that better decisions were made in the first place.

Amori: That's a really good point. And Susan, you want to say something about that?

Goold: Yeah, I love patient advisory councils…patient and family advisory councils. But I don't want them only composed of patients and family members who have the time and the money to spend doing it. So, the people who have two jobs to get by, can we find a way of hearing their voices too? So that's the only thing I worry about that.

Amori: I love that point. That is a really, really good point. Good. Thank you both.

Marisha, O'Donnell opines that outcomes of decisions that meet a certain financial threshold should be tracked, not just in terms of…this is a quote…”not just in terms of finances, because it always helps the budget, but what did it do to the clinicians?” 

Do you think that's even a possible thing to track? What do you see as measuring the impact of doing that?

Marisha Burden, MD, MBA, SFHM: First, I completely agree with Dr. O'Donnell's point. We're very good at tracking what a decision does for the budget, typically in a short-term, somewhat overly simplistic way, but far less disciplined about asking what did it cost the people doing the work? And yes, it's possible to measure that, I believe. In fact, we already have tools we can use now. And I think in the last podcast, we mentioned EHR use, pattern data, pulse surveys, patient outcomes data, in addition to the financial and operational outcomes. None of these are perfect on their own, but together they offer real signals about the human cost of financial decisions.

For example, high workloads might look efficient on a spreadsheet because you're paying for fewer salaries, but research, consistent research, including work by my colleague, Dr. Masoud Kamalahmadi shows that pushing workloads too high can actually cost hospitals millions of dollars, often through longer lengths of stay, and that's in the hospital. But you probably see it in clinics too. If you keep cutting appointment times shorter and shorter to boost volumes, what happens? Do you see more referrals, more repeat visits, more downstream costs? You don't know unless you measure it.

So, the problem isn't that we can't measure these impacts, it's that we often don't. We're missing a clear framework and real accountability. In clinical care, we'd never introduce a new treatment without tracking whether it works and what the side effects are. And we should apply the same mindset to organizational and financial decisions, especially when they're labelled as cost-saving measures, because the hidden costs can be much greater than the savings that we see upfront.

Amori: Wow. Okay. That makes a lot of sense.

Luci, what do you see might be some direct strategies for ameliorating administrative harm?

Leykum: So, the good news is that there actually are effective strategies for organizations to use, and they all promote better communication more in real time. So one is having explicit processes for including frontline clinicians, patients, families in the front end of decision-making processes in really a human-centered design approach. And this includes engaging all of these frontline participants in mapping out workflows so that they're optimized rather than disrupted. 

Another strategy is kind of a stop the line type of strategy where anyone, again, clinician, patient, family, can say, hey, we need to stop what we're doing here because what we're doing is not working well, and we need to regroup on what's happening. 

And finally, I think we've all spoken to this in terms of really trying to understand how decisions affect care delivery, utilizing things like after-action reviews, getting information about how things are going and not just focusing on the financial aspects. 

So, you can see that all of these strategies are really complementary because they work at different points in the decision-making processes so that if organizations use them together, it can be very effective and powerful.

Amori: Okay.

Susan, the boards of directors are generally kept separate from the day-to-day operations of the organizations. So often they operate in a vacuum of what they are told in reports, right? So how might you suggest that boards be both educated and held accountable for the presence and nature of administrative harm in the organization?

Goold: Well, I'll say that this will be…what I'm going to suggest would be easier for locally present administrators. That is, spend a half a day a month shadowing a clinician; a nurse, a doctor, a therapist. Well, be careful about privacy, okay. In primary care, in other outpatient practices, in the ICU, in the medical inpatient, in radiology, I suppose, in the surgeon's office, or even the OR, shadow. Find out what happens. Find out what they have to do to take care of patients. And, like I said, that's easier for the people who are close geographically, a little bit harder for someone in the, you know, central BlueCross BlueShield office or CMS or other payers.

But I still think that… I mean, Luci referred to people have to talk to each other. And this is a way for people to be able to talk to each other about how medical care happens and how administrative decisions affect it. 

Amori: Thank you. Gina, you look like you have something you want to say about that.

Symczak: I would just add to that, shadow a patient, you know. Spend a day with a patient and see what they go through and the different departments they have to visit, the different phone calls they have to make, and see how that impacts their lives.

Goold: I once had somebody tell me that he had three chronic conditions, said, this is a full-time job.

Amori: Mm-hmm. Mm-hmm. Yes. Being a patient can be a full-time job, and it can be a very confusing job, too.

All right. And I guess at that point, Marisha, you and Luci have listed several approaches to reducing administrative harm in research that you have conducted together. Can you name the main ones and opine on the feasibility of their implementation in most organizations?

Burden: Yes. Great question. The work really helped us to identify several core strategies to reduce administrative harm and I think also highlights the power of research and the voice of the participants in that research. And, so, some of the key strategies, approaches that came from that work, first is, defining and naming administrative harm…like clinical harm. We need a shared language to talk about it. It's hard to talk about harm. So, this is a new concept. It's not easy, but without naming it, we really can't normalize the conversation around it.

Second, foster psychological safety and collaboration. Create a culture where the frontline clinicians, the healthcare workforce can safely speak up about the impact of administrative decisions. And I think to Susan and Gina's point, leader rounding, going to where the work's being done is a great strategy to help understand when you implement something, what did you see as the outcome of it in real life?

Third, build structured decision-making processes, just like clinical decisions. We use checklists and timeouts. The same should happen in high-risk administrative decisions. You need to focus in on what could be the potential untoward effects of an outcome from a new initiative.

Fourth, develop measurement and data strategies, leverage tools like the EHR, use data, rapid feedback methods, and even qualitative data to track the real-world impact of decisions on clinicians and patients alike. And then finally, establish reporting and learning systems. We use morbidity and mortality conferences to understand where clinical harm may have come from. Imagine applying a similar framework to organizational decisions that have led to harm, learning in real time, and improving systems. 

And then, as for feasibility, many of these strategies are very low cost and, I would argue, high impact, but they require intention, leadership commitment, and a willingness to shift culture.

Amori: Willingness to shift culture. It means recognizing that you have a culture that needs shifting to begin with, right? That's the first step in the whole thing.

Okay, so we've reached the part in our conversation today where I get to ask my favorite question, which is, if you had one thing that you would want our listeners today, and our listeners include, you know, physicians and administrators and patients… if you had one point you'd want them to remember and take away from listening to our podcast today about rebuilding trust and fixing the administrative harm, what would that be? So, I would like to start with you, Gina.

Symczak: Well, Geri, what I would say is just remember there's a human who's suffering in some way on the other side of your desk, your phone, your computer screen, your decision. And by definition, they don't want to be interacting with the healthcare system because that means they're not well. So as an administrator or someone working in an administrative role, everyone from the person who designs the phone system to the cashier in the cafeteria to the person who trains the billing team, you, too, are involved in patient care, and you can make a real difference in their well-being. So the bottom line is you should listen to patient stories and incorporate their well-being and satisfaction into your goals.

Amori: Okay, all right, good. That's good. Luci, what would you like to say? 

Leykum: I'd like to highlight the importance of people from across the system talking to each other about how things are working. Each person has a role and an important perspective, and they have to be able to use their voice to share their insights with each other.

Amori: Thank you. And Susan, what would you like to say?

Goold: Well, first of all, I want to say that I love the idea of a morbidity mortality conference for administrative decisions. I think that's wonderful. And Gina, I think one of the things you were talking about was the culture of putting patients first, which is why sometimes I don't delegate because that'll just take too long for the patient, right?

But the one thing is that we really need evidence-based policymaking just like we need evidence-based medical care at all levels, the federal level, the state level, at the medical practice, group practice level, or whatever. And that evidence needs to include…yes, it needs to include finances because guess what? We spend a lot of money on health care, and we need to make sure that we're spending it wisely and fairly, okay?

But it also needs to include evidence about the impact of policy decisions, administrative decisions, on patient care, on providers of all sorts, and on the health of the communities that are served.

Amori: Thank you so much, Susan. And Marisha?

Burden: Yes. My team's work and others across the country, including those on this call that work on administrative harm, has focused on trying to make the invisible visible, showing how upstream decisions shape care, impact clinicians, and affect patient outcomes. The next step is clear. We need to bring the same rigor we expect in clinical care to how we design and manage our work systems. And I hope that we can get to administrative success. 

Amori: Thank you all. This has been a very, very rich discussion, including perspectives from the physician perspective, administrative perspective, complexity perspective, research perspective, and patient perspective, and ethical perspective.

So, thank you to our panelists for being here with us today. And thank you to all of you who listened to us. We appreciate you, and we're glad you're joining us. And we look forward to seeing you again when we once again look at a healthcare issue from a Perspective 360.

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