Recent discussions of medical professionalism have enumerated important physician competencies,1 described how unprofessional behavior endures throughout a physician’s career,2 and, most recently, emphasized how the systems in which physicians practice influence their behavior.3–5 Less has been written about the professional behaviors of those systems themselves, with the exception of their management of conflicts of interest.6 Others have described the regulation of health care organizations’ market behaviors7 or how organizations can negotiate contemporary ethical challenges by using professionalism as a guide.8 Lesser and colleagues5 have used the Physician Charter on Medical Professionalism to describe how both individual physicians and organizations can promote professionalism using a systems framework. However, we are not aware of any comprehensive framework of professionalism competencies for organizations. If there is a bidirectional influence between health care systems and the professionals who work within them, in order to maximize the professionalism of both, it will be important to answer the question, “What are the professional competencies of health care organizations?”
The answer to this question is important to nonprofit, tax-exempt health care organizations for several reasons. First, these organizations are perceived as the face of the profession by patients and the public at large. They must therefore reflect accurately the values of the profession. Second, the very nature of their tax-exempt status requires them to relate positively to society. Eligibility for this status requires that they be organized and operated exclusively to promote specific purposes, which include charitable, religious, educational, and scientific ends.9 Finally, a number of organizations, such as the Joint Commission and the National Committee for Quality Assurance, are scrutinizing the behavior of such nonprofits, looking for deviations from and compliance with professional standards.
In this article, we propose to clarify what constitute the professional competencies of nonprofit health care organizations and describe related behaviors. For the purposes of this article, a nonprofit health care organization is any nonprofit organization that provides goods or services to patients or health care professionals. Many of the competencies we will discuss are applicable to both for-profit and nonprofit organizations because they promote managerial and financial success. Nevertheless, we have chosen to focus on the nonprofit world because for-profit organizations’ responsibility to their shareholders may trump other considerations.
Because professionalism is rooted in ethical foundations, we begin with ethical values. Although the choice of ethical values may seem arbitrary, we have reviewed publications featuring medical ethics and professionalism10,11 and selected those values we deemed most relevant to the delivery of health care by organizations. Translating those values into behaviors requires developing specific competencies, which we define as that combination of knowledge, skills, and abilities that creates the capacity for performance. Rather than exhaustively enumerating them, we will explore those behaviors we deem most relevant to the current transformation of American health care (see Chart 1). We will first describe how professionalism competencies derived from ethical values can serve as organizing principles for behaviors, both inside health care organizations and in a broader community and social context. We then describe the unique competencies of leadership provided by both the management and governance structures of the organization. Lastly, we will examine how health care organizations are currently addressing professionalism challenges.
Competencies: The Link Between Values and Behaviors
Service to the patient and society is the raison d’être of medicine and, therefore, of the nonprofit health care community. This competency is derived from the ethical value of beneficence, or actions promoting the well-being of others. Although the focus of the medical profession is health, service for nonprofit health care entities can include educational and scientific activities in addition to the provision of care for the indigent.
The World Health Organization’s definition of health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”12 This definition suggests that many dimensions of community life, such as education, basic sanitation, and crime, influence the health of a population. Because some of these factors overlap the purview of government, each health care organization must determine which of its activities intersect with this seemingly broad definition. Regardless, such a conceptualization implies that an organization’s obligations extend beyond the individuals encountered within its walls to the larger community within its sphere of influence. This awareness reveals opportunities for occasionally competing organizations to collaborate for the common good. For example, competing organizations might duplicate one another’s expensive, revenue-generating services such as interventional cardiology or oncology treatment centers instead of providing less lucrative ones such as mental health services, thus shortchanging the community. Promoting health includes minimizing harm, a sometimes-unintended consequence of health care delivery. For example, health care delivery systems should mitigate the environmental impact of their paper, biological, and toxic waste.
Externally, the service competency is demonstrated by incorporating indices of community health into the decision-making process for organizational initiatives. It is known that a lack of availability of mental health and primary care services is reflected in the number of uncompensated emergency room visits, whereas an organization’s efforts to improve wellness are manifested by a healthy built environment and safety net clinics. Improvement in both might be measured by a decreased prevalence of obesity and smoking and by lower infant mortality rates. Subsequently, the organization would monitor how its strategic initiatives impact the health of the community and would negotiate tensions between the two. Although the presence of laypeople on boards of directors or planning committees may improve public relations and expand the discourse within an organization, alone it is insufficient to meet community health needs. As accountable care organizations grapple with community issues that impact population health, they may need to employ novel social science technologies. For example, they may need to design approaches that impact those who, for ethnic, social, financial, or emotional reasons, are isolated from traditional health care institutions or those who seek care within an alternative health care setting.13
These service-oriented behaviors reflect the organization’s aspiration to uphold the standards of the profession as expressed by credentialing organizations and quality improvement groups, such as the Institute for Healthcare Improvement and Leapfrog. Organizations committed to service excellence also improve the profession by participating in such groups’ projects and entering related performance data into regional and national databases.
Because individual health and organizational health are interrelated, service extends internally to employees. Organizations should monitor the well-being of their employees and provide resources both to improve their general health and to relieve those who suffer disproportionately. Because those with impaired well-being or disruptive behavior affect other individuals and an organization’s ability to achieve its goals,14,15 the organization must enforce standards for behavior and provide resources for those who struggle. A business case can be made for practices that balance productivity expectations with concern for employees’ well-being.16 These practices promote loyalty, minimize turnover, and create a more positive experience for customers and patients.
Respect is derived from the ethical value of dignity. This competency esteems all voices by creating a forum for those who may struggle to be heard. Because personhood, not expertise, is the only prerequisite for respect, it reorders traditional power relationships within medical institutions. Patients and employees at all levels are as deserving of respect as physicians and chief executive officers. Respectful practices throughout an organization support the emerging dynamics of teamwork and promote cultural sensitivity.17
Internally, respect incorporates the voice of employees in organizational initiatives and rewards achievement by whatever metrics apply to a particular job. Similarly, respect incorporates the voice of the patient in clinical domains, perhaps on rounds or on relevant quality improvement committees. Such humanism in a social context leads to the next competency.
Fairness derives from the value of justice. This competency acknowledges that resources are limited and that the health of the nation depends on the ability of all citizens to meaningfully access quality health care, although a sometimes-messy political process determines how society ultimately distributes public and private dollars toward that end. Various mechanisms at the governmental, organizational, and individual levels restrain exploitation of limited resources by the powerful few.
As the nation reconfigures the health care delivery system with the goal of maximizing value, the behaviors of organizations will be important because organizations can more effectively impact the health of communities and populations than can individual physicians. Improved community health can be consistent with reduced expenditures at both a societal and organizational level. For example, rather than each health care delivery system seeking solely to maximize its own resources through competition, a region would benefit from collaboration amongst institutions to decide how they can provide the highest level of quality and efficiency together. Similarly, when institutions are financially burdened by the uninsured or mentally ill, they would benefit from coordinating safety net clinics to prevent such patients’ using more expensive services. Regionally, such cooperation reduces disparities in health. Collective advocacy by professional organizations can lead to an equitable payment policy that meets the nation’s increasing need for primary and geriatric care.
We believe that practicing fairness in the community is not possible without first examining the roles of hierarchy and power inside an organization (which we will discuss further below). A well-functioning professional organization exhibits a culture that recognizes the equal value of each human being and the critical contribution of each position, despite deserved differences in compensation based on skill, training, and levels of responsibility.
Integrity and accountability
Integrity and accountability derive from the value of honesty and make fairness apparent to others. A commitment to such transparency means that when information is useful and meaningful to stakeholders, it will be disclosed.18 The challenge, of course, is when such disclosure compromises an organization’s self-interest. We believe that withholding proprietary information is justifiable if sharing it could compromise competitiveness but would not benefit patients. Withholding information of potential benefit to patients or employees out of self-interest is not justifiable. Transparency includes making internal processes and outcomes apparent to all concerned. This starts with explicit disclosure of the metrics an organization uses to measure success. When errors occur, they should be promptly disclosed.
Accountability requires acceptance of responsibility for error and correcting the approach that led to it. Performance should be measured against commonly accepted standards of achievement. When discrepancies exist, the organization should strive to improve performance and eliminate deficiencies or shortcomings. Organizations should divest themselves of financial and other conflicts of interest. When divestment is a disadvantage to the patient, we believe benefit to the patient should be used as the metric to guide resolution of such conflict.
Mindfulness and self-motivation
Mindfulness and self-motivation are derived from the value of self-discipline. Successful execution of all the other competencies depends on self-awareness and a desire to close the gap between the current and ideal state. Developing mindfulness, or “awareness of self in the present moment,” has been shown to help high-reliability organizations, such as nuclear power plants and space shuttles, successfully manage unforeseen events.19 Both for-profit and nonprofit health care organizations often confront unforeseen emergencies with high-stakes outcomes. Cultivating mindfulness by the organization and by individual staff members would help them “handle unforeseen situations in ways that forestall unintended consequences.”20 In addition, for organizations to “do good” (beneficence) as well as avoid harm, they must monitor their impact on others and use external benchmarks for assessment.
Responsibility of Leadership
Nonprofit leadership provides the direction of the organization and, therefore, is responsible for seeing that organizational behavior is aligned with the principles discussed above. Leadership is the responsibility of both the governance (e.g., board of directors) and management (e.g., chief executive officer). The Healthcare Leadership Alliance definition of the professionalism competency for leaders is “the ability to align personal and organizational conduct with ethical and professional standards that include a responsibility to the patient and community, a service orientation, and a commitment to lifelong learning and improvement.”21 We propose that through combining the five ethically based competencies we have discussed above, leaders can best improve the professionalism of nonprofit health care organizations.
Leaders are ultimately responsible for balancing bottom-line considerations with the principles of organizational professionalism. As such, they must maintain and demonstrate high ethical and professional standards. Leadership should identify or construct metrics for employee and community health and implement relevant policies. They should seek efficiencies by collaborating with other organizations. Such dialogues on a larger scale raise the consciousness of the entire population regarding the interrelatedness of individual and corporate activities.
Leaders must treat all people—patients and employees alike—with equal respect, regardless of their position, education, experience, or social background.
Therefore, leadership should create policies that institutionalize such equal treatment and educational initiatives to overcome preexisting cultural biases. Diversity, by increasing the heterogeneity of a workforce, increases its flexibility and capacity to surmount complex organizational challenges.22 An important leadership task is to articulate organizational values and goals with language that engages diverse stakeholders.23
When leaders allocate resources disproportionately, the strategic imperatives underpinning such decisions should be made explicit; otherwise, they risk losing the support of those who feel deprived of “their fair share.” Selective enforcement of policies, such as when leaders tolerate disruptive behavior by high producers, undermines trust in leadership and threatens organizational cohesion. In contrast, fair treatment of employees encourages their fair treatment of customers, thus fostering a professional culture.
Integrity and accountability
Leaders must understand their responsibilities both personally and to the organization regarding conflicts of interest. Although it will not be possible to eliminate all such conflicts, we believe that should be the goal, with transparent management for those conflicts that remain.
Mindfulness and self-motivation
Whereas managers and employees may appropriately focus on particular tasks or challenges, an organization’s leaders must appraise how well routine activities reflect organizational values. Organizations struggle daily to align tactical and productivity goals with professionalism. Leadership is the conscience of an organization, which demands great courage. At some point in the evolution of most organizations, fearful voices will frame ethics and competitiveness as an “either–or” choice. Creative leaders can demonstrate how this is a false dichotomy. We believe that maintaining a professional culture has great market and competitive value by attracting and retaining talented individuals and improving the quality of the work product.
Integrating the Five Competencies to Achieve Organizational Professionalism
Although we have, for clarity, discussed these capacities separately, their thoughtful, systematic integration into all operations of an organization will promote professionalism as an emergent quality of routine interactions. Mindfulness at the leadership level is the capacity to hold and balance all of these ideas simultaneously. An activity that increases accountability and alignment at all levels of organizational activity is the discipline of collective self-reflection,24 in which leaders routinely ask such questions as “How well are we working together?” and “How well do our actions align with our mission and professional values?”
An important responsibility of any health care organization’s leadership is to project this integrated vision externally, to convey how the organization’s values connect with those of the larger society. Because the allegiance of professionals tends to be stronger to their own professions than to their organization,22 this articulation of organizational vision can create an important alliance between health care professionals and administrators, who might otherwise deride each other’s lack of concern, or preoccupation with financial considerations, respectively.
Blackmer8 outlines four strategies to reinforce the ethical foundations of a medical organization. These are “Conducting a formal process to clarify and articulate the organization’s values …, facilitating … learning about ethics and professionalism …, creating structures that encourage and support the culture …, [and] creating processes to monitor and offer feedback on ethical performance….”
We believe the intricate mix of nonprofessionals and diverse professionals within health care organizations is unlikely to support a monolithic local vision of how social goals should be achieved. Complexity theory suggests that an organization’s identity is the culture that emerges from multiple conversations among its diverse members.25 Although these conversations routinely transpire during the workday, separate facilitated conversations can create oases in daily routines that can help leadership discern evolving internal challenges and their relationship to the organization’s broader social context. Leaders can succeed in creating an ethical culture only insofar as they can create the vessel for its members to enact that ethical vision. To achieve this goal, leaders must maintain currency in the profession and exhibit the articulated expectations of conduct.
Discerning how to adapt professionalism principles to the culture and purpose of a particular nonprofit organization is a core task of leadership. Yet, providing a road map for implementing the behaviors we have described is beyond the scope of this paper. Organizations will take myriad paths. Established management principles will be generally applicable; unique circumstances will require imaginative adaptation.
Organizational Professionalism in the 21st Century
The daily experience of patients will reflect the professionalism of organizations more than their mission and vision statements. Those experiences will depend on an organization’s culture more than its policies and procedures. Indeed, organizational culture may predict clinical outcomes better than evidence-based protocols and processes.26
How are organizations doing in dealing with these challenges? It seems unlikely that any organization will be able to embrace all of the behaviors that constitute professional behavior. Moreover, the challenges will be different for different members of the nonprofit medical world. Particularly troublesome for some organizations will be dealing with the provision of service to the community, conflicts of interest, self-discipline, transparency, and ethical stewardship of resources.
Service to the community, a requirement for the nation’s roughly 2,900 nonprofit hospitals, was surveyed in 2009 by the Internal Revenue Service.27 Hospitals spent an average of 2.5% of their total expenses (excluding bad debt) on providing charity care. This compares to the 5% figure proposed by Senator Chuck Grassley to define whether hospitals could claim exemption from taxes. On a more positive note, adding unreimbursed Medicaid expenses and research, education, and the clinical expenses for which the provider takes a financial loss (all community benefits recognized by the federal government) to spending averages, the figure reaches 8.3%. Although the “correct” percentage remains undefined, it is of interest that of the hospitals providing an above-average amount of charity care, 75% turned a profit.
Issues related to conflicts of interest have been particularly vexing for physician membership organizations and academic medical centers. A 2008 Association of American Medical Colleges Task Force report signaled that many medical schools are adopting new policies that allow them to better manage and sometimes prohibit relationships with industry that create conflicts of interest that compromise professionalism.28 Professional medical associations face a particularly difficult challenge. There have been some notable attempts to address conflicts and some successes, although no consensus has been reached about best practices.29 Many would argue that physicians and other providers need such organizations to represent their political and economic interests and that such advocacy often improves patient care and the interests of patients. Perhaps the best way to deal with this conflict is to separate the responsibilities, with one group representing the economic and political interests of physicians and a second group representing the educational, professional, and patient-oriented interests. Above all, professional medical associations should, in the words of John Ring,30 be “working for the good of our patients, rather than [as] a pressure group aiming for political power as a way to build organizational prominence, to create personal prestige, or to line our pockets.”
The central element of self-governance is the requirement for self-discipline through policing and corrective or punitive actions. Physicians recognize their obligations and society’s interest in being shielded from negligent and unethical practitioners. These tasks have been relegated to various accreditation, certification, and licensing bodies. For the year 2007, the Federation of State Medical Boards reported that 2,743 disciplinary actions against physicians were taken by the member U.S. boards.31 This rate of 2.92 serious actions per 1,000 physicians has raised questions by some as to whether the profession has been complacent or simply too lenient in carrying out its obligations. The Washington Post reported that between 1999 and 2004, 972 physicians who had been disciplined in one state were able to continue to practice by relocating to another state.32 Additionally, a report from Health Matrix by Jung and colleagues33 indicated that 67% of those convicted for insurance fraud and 36% of those convicted in relation to misuse of controlled substances received only nonsevere penalties from their medical boards. At the core of this issue is the need for the profession to develop and implement a code of its own which constitutes a set of agreed-on shared values.
Medical professional organizations are beginning to deal with issues of transparency and accountability.34 Implementing these principles should provide important tools to improve quality, safety, and outcomes and also to control costs. Currently, patients have little information to inform their choice of health care provider. There remain valid barriers including the fact that most publicly reported data are not statistically valid for ranking either physicians or hospitals.35 Eventually, however, improving the reliability of data should allow patients to evaluate their options and, in the meantime, will assist them in managing and improving processes and outcomes. An example of the latter is the improvement by hospitals in evidence-based acute myocardial infarction management (88% in 2005 to 98% in 2010) resulting from eight years of data collection and six years of public reporting by the Joint Commission.36
Stewardship of medical resources will require a balance of what is best for the individual patient and what is best for society. Key to this effort will be for medical organizations to deal with the issues of disparities in care and of overuse. The issues of disparities are complex and will ultimately require the implementation of social policies well beyond the scope of activities of medical organizations. Current programs driven by the profession that should facilitate improvement include diversification of the workforce, teaching cultural competency, and development and implementation of guidelines and public reporting of outcomes.37,38 With regard to overuse of health care, an estimated $600–700 billion annual item,39 again solutions are complex but include access to patient-centered primary care and the establishment of guidelines and publicly reported outcomes.
Medical professionalism has most often considered the behavior of individuals, less often the collective behavior of physicians. We believe that focusing on the professional behavior of medical organizations can be fruitful because they represent the effective link between individuals and society. Professional behavior at the societal level is challenging for both individual physicians and medical organizations: Individuals have little leverage to impact society; organizations are easily distracted by operational and business concerns. Because ethics-based entreaties risk dogmatism and irrelevancy, we have chosen to frame the discussion of organizational professionalism by translating traditional ethical values into contemporary organizational behaviors.
Just as personal well-being creates resiliency, organizational professionalism can establish homeostatic mechanisms that buffer internal and external stressors. Preventive efforts to create a self-regulatory culture can forestall the need to confront emergent threats. Unprofessional behaviors can then be normalized locally. The goals of creating attractive work environments and judiciously using resources can be accomplished by nonprofit health care organizations that are oriented toward the public good, mindful of each human interaction, and reliant on principles of professionalism to organize the intermediate processes.
The evolution of health care will be governed by three forces: professionalism, finance, and regulation. The proper role of regulation is to align the incentives of professionalism and finance to produce population health and a responsive, sustainable health care delivery system. The ethical foundation of professionalism serves as a powerful counterbalance to financial and political self-interest. Agreement to anchor future health system design and care deliveryon principles of professionalism can only benefit those who deliver and receive health care. There are increasing appeals for medicine to play a broader role in negotiating these forces,40,41 and some imaginative approaches have emerged.42,43 Failure of such efforts will inevitably result in more regulation; success will lead to renewed faith in medical professionalism.
Acknowledgments: The authors wish to thank Anthony Suchman, MD, for his support and suggestions.
Other disclosures: None.
Ethical approval: Not applicable.
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