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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Professionalism in Health Care Organizations

Health care organizations have been under enormous pressure for the past 8 years, and it might get worse.   The Affordable Care Act (ACA) sought to alter the course of a huge ship. Soon the ship may be turning in another direction into uncertain waters. How should these organizations navigate the turbulence while maintaining the “quadruple aim” of improving people’s experience with care, improving the health of the population, reducing health care cost, and fostering job satisfaction among health care workers?

Diana Mason, PhD, RN

A new Charter on Professionalism for Health Care Organizations may provide a touchstone.


Chaos and stress have accompanied implementation of the ACA. The law aimed to transform how care is delivered and paid for, and it accelerated a movement toward value-based payments. This in turn required an overload of outcome measurements and reporting and a realignment within and across health care organizations, including expansion of accountable care organizations (ACOs). It has been a difficult transition as the medical community has tried to sort out what is worth measuring and analyzed outcomes. For example, recent evidence suggests that ACO-affiliated hospitals have not reduced racial and ethnic health disparities, but they have reduced hospital admissions from skilled nursing facilities to a greater degree than non-ACO hospitals.

This transformation was going to require time, as the Center for Medicare and Medicaid Innovation tested approaches to reforming care delivery and payment. But a first step to repeal and possibly replace the ACA has been taken.  Shortly after being inaugurated, President Donald Trump issued an  executive order that directs the secretary of the Department of Health and Human Services and other leaders with responsibilities under the law to

exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.

It is not  known what actions will result. And the uncertainty that health care organizations face is likely to affect physicians, nurses, and others who must find ways to care for patients, regardless of the chaos.

The decisions of leaders of hospitals and other health care organizations can facilitate or impede health professionals’ living up to their own professions’ codes of conduct. In 2002, a document called Medical Professionalism in the New Millennium: A Physician Charter was developed and published to guide physicians in holding to principles that altruistically put the patient’s interests before the physician’s. Viewed as medicine’s contract with society, the principles were deemed necessary during an earlier time of upheaval in health care, with health care organizations pressuring physicians to compromise the patient’s interests for those of the organization. There has been growing recognition that an individual clinician’s behavior is intertwined with the culture, policies, and behaviors of the organizations in which they work. As a result, a case was made to develop principles of professionalism for health care organizations.

The Foundation for Medical Excellence is a nonprofit organization that relies on grants and donations for educational programs, consulting, and other initiatives to improve the quality of health care and advance sound health policies. One of its initiatives has been the Organizational Professionalism Charter Project, with funding from the Commonwealth Fund, the American Board of Internal Medicine Foundation, the Federation of American Hospitals, the American Hospital Foundation, and Northwell Health System. The foundation formed an interprofessional workgroup of physicians, nurses, administrators, and patients (I was a member) that  developed and refined the Charter on Professionalism for Health Care Organizations—its rationale, process of development, goals, domains of focus, and potential obstacles for use.

The Charter

The charter has 4 areas of focus:

Patient Partnerships. An organization demonstrates a commitment to engaging patients and families in shared decision making, addressing the health of the whole person rather than just a disease, ensuring continuity of care through coordination and collaboration within and across organizations, and measuring what matters to patients. For example, Morristown Medical Center in Morristown, New Jersey, has formed family councils to advise the organization on policies and practices that facilitate or impede engagement. Carol Jones, the chief nurse officer for the hospital, credits the council for helping to develop an open-hours visiting policy that works for patients, families, and staff.

Organizational Culture. An organization’s culture is the key to professionalism. The charter calls on leaders to expect and demonstrate accountability for creating a culture of trust and empowerment among all in their organizations, including patients and families. Such a model demonstrates commitments to the well-being of all individuals, a healthy workplace, diversity and inclusivity, and teamwork. Cedars-Sinai Medical Center in Los Angeles opened relaxation rooms for staff to use, including for naps. It was also an early adopter of a national initiative called Transforming Care at the Bedside, which engages frontline staff in local changes that staff deem to be important for meeting the quadruple aim.

Community Partnerships. Health care organizations must invest in addressing social determinants of health in collaboration with the communities they serve, demonstrating a community benefit from their work and advocating access to high-value care. This includes shaping policies that affect a community’s environment, socioeconomic well-being, and social services. For example, Montefiore Medical Center in the Bronx is gathering data on obesity and access to more healthful foods in the communities it serves. It then uses bilingual staff to educate bodega owners on stocking such foods.

Operations and Business Practices. The adage “no margin, no mission”—meaning that an organization such as a hospital is not able to accomplish its core mission if it is struggling financially—speaks to the importance of delivering cost-effective care. Among other things, the charter calls for health care organizations to commit to operating ethically, protecting patients’ privacy, making conflicts of interest transparent, adhering to accounting standards, treating employees fairly, and aligning incentives with organizational values. For example, a health system might adopt a conflict-of-interest policy and procedures around purchasing of equipment and supplies that require transparency in relationships and diversity of vendors.

Using the Charter

The Foundation for Medical Excellence welcomes critiques of the charter as a way of refining it. A clear and concise document describing the principles of professionalism can remind leaders of organizational missions and accountability to the communities they serve. For example, financially challenged hospitals that cannot accomplish their mission may be doing such a disservice to their communities that they should close if others can provide needed care. Hospitals and practices that encourage implicitly or explicitly unnecessary tests and procedures to generate revenues fail on all measures of legal and ethical accountability.

Here are some ways that the charter can and should be used:

  • Boards of trustees and executives should review and discuss it, then consider endorsing it, making public their aspirations to live up to the principles it espouses and holding themselves accountable for aligning with them. The Foundation for Medical Excellence will bestow an annual award for the most influential change in practice that results from the use of the charter.

  • Policy makers ought to use the charter to reflect on what policy changes may mean for supporting or undermining health care organizations’ professionalism. Should an organization’s “deemed status” for payment under Medicaid and Medicare be partially determined by evidence of its commitment to the charter’s principles? Similarly, the Joint Commission could examine whether its accreditation standards reflect the charter.

  • Physicians, nurses, and all health care workers should examine how they exemplify the principles in the charter and use it as a framework for discussions or organizational challenges with executives.

  • Community leaders can initiate conversations with health care organization executives about partnerships that reflect the charter and their intention to hold them accountable for demonstrating professionalism.

The Charter on Professionalism for Healthcare Organizations is an aspirational guidepost. As our nation braces for the financial, structural, and access challenges that are expected to accompany repeal of the ACA, the charter reminds us of the fundamental principles of promoting health.

About the author: Diana J. Mason, PhD, RN, Professor Emerita and Co-Director, Center for Health, Media & Policy at Hunter College, City University of New York; and Senior Policy Service Professor, George Washington University School of Nursing. She is the immediate past president of the American Academy of Nursing.
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