By Kristina Fiore

Clinicians have long understood that administrative decisions can cause harm, both to themselves and to their patients. Now, a term for the phenomenon is gaining wider recognition -- "administrative harm."

Last month, a study was published with an accompanying note from two of its editors, using the term in the headline of both articles.

Study authors defined "administrative harm" as the adverse consequences of administrative decisions within healthcare.

"The term 'administrative harm' is relatively new ... but the phenomenon itself isn't new," said Marisha Burden, MD, MBA, of the University of Colorado School of Medicine in Aurora, and lead author of the study. "Our study is one of the first to understand the concept of 'administrative harm' from a research perspective in a healthcare setting."

The origin of the term itself has been credited to Walter O'Donnell, MD, of Massachusetts General Hospital and Harvard Medical School in Boston, who coined it in a 2022 article. About a decade before, two authors had characterized the concept, focusing on barriers to care imposed by insurers and pharmaceutical companies.

O'Donnell's paper illustrated the concept as applied to hospital administrators who were divorced from clinical care. He cited the case of a patient who missed out on a successful smoking cessation program because it had recently been lost to budget cuts. The patient was supposed to have a procedure to ease his leg pain, but it had to be cancelled when O'Donnell realized his wheezing required a trip to the emergency department instead.

Despite lung cancer and worsening lung disease, the patient had started smoking again. "He had sustained an adminogenic, rather than an iatrogenic, injury," O'Donnell wrote.

"More decisions are being made by people very far from patients, and there's no accountability, especially compared to physicians," said O'Donnell.

Both O'Donnell and Burden drew parallels between how physicians are evaluated on nearly all of their decision-making, but administrators are rarely evaluated on the outcomes of their decisions. On top of that, doctors are also rated on productivity, patient satisfaction, and procedural outcomes, O'Donnell said.

"In an era when so many decisions are being made far away from patients, it's at the least ironic, but certainly unreasonable, that administrative decisions don't receive the same sort of scrutiny," he explained.

Similarly, Burden noted that evidence-based practices exist in the clinical arena -- such as how to treat pneumonia, she said. But there are no evidence-based organizational practices.

"For example, what's the optimal panel size for a clinician and a clinic?" Burden said. "How many patients should a clinician see in the inpatient setting? We don't actually have answers to those questions. And I think that clouds some of our organizational decision-making as well."

Burden is trying to get a better handle on those questions. She calls the field "evidence-based work design," and she started an organization called Gritty Work, which is focused on answering these questions and creating solutions that create wins for patients, clinicians, and organizations.

"We can start using data to inform our decisions, so that we know what 'just right' is," she said. "It's not a blanket number. It's going to be context-dependent."

For their study, Burden and colleagues conducted a survey and focus groups among 41 participants from 32 organizations that spanned clinicians, administrators, researchers, and members of a patient and family advisory council. Most were doctors (91%), while 6% were administrators, and overall 44% had leadership roles.

Only 6% of participants said they were familiar with the term "administrative harm" to a great extent, but 81% said they felt they had participated in a decision that led to administrative harm to some degree.

All participants said they felt collaboration between administrators and clinicians is critical for reducing administrative harm.

O'Donnell said collaboration and teamwork between clinicians and administrators has "really broken down" in recent years. "It's worse now than I've ever seen it," he said.

Aside from collaboration, O'Donnell had concrete ideas as to how administrators might be evaluated on outcomes.

One metric could be turnover or attrition, he said: "Administrators should be rated on the morbidity and mortality of their staff, and part of that is, who is still here at the end of the year. It would be really telling if there are very different rates for different administrators."

O'Donnell said burnout rates could be another metric, though they are "crude and limited. It's kind of an extreme event."

Finally, he said, outcomes of decisions that meet a certain financial threshold should be tracked: "Not just in terms of finances, because it always helps the budget" he said, "but what did it do to the clinicians?"

Strategies can be implemented immediately by clinician-administrators to help alleviate administrative harm, Burden added, such as taking "administrative time-outs. Are you taking a pause before you make a big decision? ... We see this in the operating room, and in aviation, high-risk situations that use checklists."

A second strategy would be committing to doing look-backs, so administrators can "constantly improve and do better," Burden said.

Finally, she called for inclusive decision-making, a collaborative effort where diverse perspectives -- including those of clinicians -- have a say in how deeply an administrative decision will impact clinical care.

"Our hope is to create a win-win-win, where the workforce feels supported, they love their work, and can do their best work," Burden said. "Patients win because they have a care team with the bandwidth to provide the right care. And the organization sees the outcome they want to see, with reduced turnover, a thriving workforce, and I believe the financials follow that."