“Rules and regulations, who needs them? Throw them out the door.”
— Graham Nash (lyrics), from “Chicago,” sung by Crosby, Stills, Nash & Young

Business entrepreneur and billionaire Michael B. Kim recently was quoted as saying: “Leadership without ethics is a body without a soul.” Kim donated $25 million to his alma mater, Haverford College in suburban Philadelphia, Pennsylvania, to start a new Institute for Ethical Inquiry and Leadership. His goal is to renew society’s focus on ethics, even dispatching “ethics missionaries” throughout the world.

A good first place to embed ethics missionaries is health care, where “administrative harm”—the negative impact on patients and health care providers caused by bureaucratic processes, policies, or inefficiencies within the health care system—is pervasive. Examples include unrealistic staffing models, burdensome regulations, out-of-touch administrators, lack of frank feedback to leaders, and unhelpful consultants. Administrative harm can manifest in excessive paperwork, rigid protocols that do not allow for individualized patient care, and resource limitations that prevent timely and adequate treatment.

Worse yet, there is no method of tracking these harms, mostly perpetrated by bottom-line-oriented hospital administrators. Given that there are approximately 10 administrators for every physician in the U.S., how can we effectively track these harms? Since the implementation of managed care in 1970, the number of doctors in the U.S. has increased by approximately 200 percent. In stark contrast, the number of health care administrators has surged by over 3,800 percent. During the same period (1970 to 2019), health care costs have escalated by 3,100 percent, rising from $353 per person in 1970 to $11,582 per person in 2019, adjusted for inflation.

Despite the significant expenditure on health care, the U.S. overall Global Health Security (GHS) index score in 2023 was 73.3 out of 100 points. This ranking is 69 out of 167 total countries rated and is even unfavorable compared to many third-world countries. The U.S. has the lowest life expectancy among large, wealthy countries while it far outspends its peers on health care. These poor rankings are partly a result of administrative harm, or what some also refer to as “management malpractice.” As more funds are diverted to maintaining an inefficient administrative infrastructure, less money is available for actual health care services. This is a disgraceful situation.

The impact of administrative harm on patients can be seen virtually everywhere:

• Patients are missing out on successful disease management programs that have been subjected to budget cuts.
• Increasing patient transfers into hospitals with prolonged waits in emergency departments (ED).
• Increasing use of ED boarding of mental health patients, particularly those from racial and ethnic minority groups, leads to adverse outcomes, violence, and disparities in care.
• Lack of reliable data to determine when patients are medically ready for discharge.
• Lack of specialized staff or understaffing leads to unsafe practices and harm to patients (and staff).
• Insufficient patient information due to different electronic health record systems that don’t communicate with each other.
• Duplicate records cause patients to repeat treatments and tests.
• Over-engineered systems are impacting patient flow.
• Delays in care are secondary to insufficient hospital and residential beds, lack of weekend services, and untimely responses to insurance authorization requests.
• Mergers that neglect local culture and lead to financial strain and hiring freezes.

Administrative harm can be considered a subtype of moral injury insofar as it often arises when health care providers feel they cannot provide the level of care they believe is necessary due to systemic constraints or administrative decisions. When practitioners are forced to navigate these administrative barriers, they may experience a conflict between their professional values and the realities imposed by the system. This conflict can lead to feelings of frustration, helplessness, and guilt, which are key features of moral injury.

Administrative harms are destroying the practice of medicine or at least taking away the pleasure and privilege of serving patients. In a 2011 editorial titled “The Quiet Epidemic,” the authors focused on barriers to care imposed by insurers and pharmaceutical companies. They wrote: “The components of what we used to call comprehensive, multidisciplinary team care seem to have been replaced by only those services that are allowed or reimbursed. The world, at times, seems to have gone mad with senseless (at least from a clinical point of view) administrative rules.”

The good news is that some harms may be preventable, largely through improved communication and collaboration between practitioners and administrators. The authors of a recent editorial wrote: “Administrators can listen to their clinicians and find ways to make it easier, not harder, for them to practice. They can also empower clinicians to identify problems that require solutions and speak up when interventions are not working. Given that U.S. medicine is less and less practiced in individual physician-run offices and more and more in larger practices and health systems in which physicians are employed, such efforts will be critical to avoid administrative decisions that cause more harm than benefit to clinicians and patients.”

Another physician noted, “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 [as physicians].” Perhaps administrators should be rated on the morbidity and mortality of their own staff – those who remain at the end of the year and those who have been swept away for unethical decision-making and other reasons. Different turnover rates would be very telling. Unscrupulous decision-makers need not apply for the job of hospital administrator.

Who would have guessed that Michael Kim’s first novel, Offerings, the story of an investment banker from Seoul who works on Wall Street and closely mirrors his own life, is now being made into a movie? His Institute for Ethical Inquiry and Leadership should be required training for all health care administrators. They should also adopt Kim’s motto to live by: “Be grateful. Be humble. Be seated.”

This essay is cited in the KevinMD record on physicians and administrators.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Narrative Medicine: Harnessing the Power of Storytelling through Essays.