Tackling administrative harm can yield better decisions for better care

Awareness of the harms to patients caused by errors in diagnosis and treatment has been front and center for nearly 25 years. A different kind of harm, this one affecting patients and clinicians, is only now getting the recognition it deserves. Called administrative harm, it directly influences patient care and outcomes, professional practice, and organizational efficiencies.

The term was coined in 2022 by physician Walter J. O’Donnell in an article in The New England Journal of Medicine. Administrative harm refers to the “adverse consequences of administrative decisions within health care that impact work structure, processes, and programs.” It is pervasive and can come from any level of leadership, from administrative leaders as well as clinical leaders.

While administrative harm may not be familiar to many, the concept and experience are well known to most people working in health care. Consolidation has made it worse. Over the last several years, fundamental changes in the organization of health care delivery has engineered a shift from smaller practices and individual hospitals to more complex, vertically and horizontally integrated delivery systems. As a sign of these changes, more physicians are now employed in larger practices than are partners in their own practices.

These changes have affected how health care organizations operate. The growth of administrators has far outpaced the growth of front-line clinicians. Venture capital and private equity firms often finance mergers, consolidations, and new market entrants, bringing a focus on short- to mid-term profitability and a different operational perspective grounded in investor expectations. Clinical delivery systems are considered cost centers to be managed and minimized. Recent data regarding the impact of private equity ownership on increased hospital-acquired adverse events speak to the potential negative consequences of changes to health care delivery system structure and organization on outcomes.

A major effect of the growth of larger, more complex health care delivery systems in which frontline clinicians are salaried employees is a growing disconnect between the administrative decision-makers, the clinicians who work in their systems, and the people and communities they serve. Without robust and established connections between C-suites and frontline clinicians and care recipients, the possibility that decisions are made without the vital input of those groups has increased, and the feedback loops of communication may not be mature enough to allow for rapid organizational assessment and understanding of impacts.

We and several colleagues wanted to explore the impact of administrative harm. In our study, published Monday in JAMA Internal Medicine, which included participants from 32 different organizations, 85% noted that administrative harm affected patients at least somewhat (44% noted it affected patient care to a great extent). Only 38% of participants reported they felt empowered to speak up and raise concerns about administrative decisions that may have potential harm. Only 19% of participants strongly felt there were clear channels of communication for reporting and addressing administrative harm within their health care setting, and just 9% felt that their organization encouraged transparency and accountability in administrative decision-making.

Human and organizational costs of administrative harm

The changing health care landscape has made many clinicians feel that they are “cogs in a wheel.” Increasing workloads and administrative duties for clinicians, leading to cognitive overload, can directly affect the care they provide their patients, and not for the better. Overwork, and the inability to provide care aligned with patient needs leads to moral injury and burnout. The consequences for organizations and patients include increased turnover risk, reduced clinical effort, poor clinician health, suboptimal patient safety outcomes, and significant financial costs at the organizational, community, and societal levels. The costs of burnout and turnover are estimated in the billions, emphasizing the need to reevaluate how organizations measure profits and success.

A solutions-oriented approach

Addressing administrative harm requires collaboration within and across health care delivery systems. The organizational behavior and theory literature can inform these efforts. Recognizing the complexity and interdependencies in health care systems is the linchpin of these efforts, as it makes clear the possibility of unanticipated consequences of changes within health care systems. Ultimately, organizations must be able to make sense of what is happening in ways that promote shared understanding and effective action.

Solutions must include the following foundational components:

Communication and representation. Frontline clinicians, care recipients, and their families and caregivers must have open lines of communication with administrative leaders. Time and space for communication must be carved out of clinical schedules to allow for the creation of relationships that support effective communication. Frontline clinical teams must have input and operational decision-making authority.

Psychological safety. Effective relationships are grounded in trust. Everyone working in a health care system must be able to speak openly about what is happening without fear. The link between psychological safety and outcomes in organizations generally, and health care specifically, is well established. Leadership at all levels must encourage others to share their observations and model positive responses to feedback.

Data systems that monitor operational, clinical, and experiential outcomes. Data that matter to all stakeholders must serve as the basis for a shared organizational mental model that allows for purposeful, effective action. These data must be transparently shared and updated based on stakeholder input. When data enable shared understandings, the rationale for decisions is understood.

Evidence-based work design. Despite abundant evidence-based practices guiding clinical decision-making, organizational decision-making around work design, like staffing models and team structures, lacks the same rigor. Research must be conducted and supported to understand what sustainable and optimal models are.

The current trajectory of the U.S. health care system is concerning. Clinicians distrustful of opaque corporate systems are undertaking actions to try to regain control, ranging from retirement to opening concierge practices to unionizing. Recipients of care no longer feel understood as people and distrust the health care system at historic levels, with disastrous effect on engagement and outcomes. These developments will undermine the sustainability and profitability that leaders are trying to achieve.

Recognizing administrative harm and combating it with active, engaging organizational practices are the necessary first steps to changing this trajectory.

Marisha Burden, M.D., M.B.A., is a professor of medicine at the University of Colorado School of Medicine, Division of Hospital Medicine. Luci K. Leykum, M.D., M.B.A., M.Sc. is an affiliate professor of medicine at Dell Medical School at the University of Texas at Austin and an investigator in the South Texas Veterans Health Care System. The views expressed here do not necessarily reflect those of the authors’ affiliated institutions.