September 25, 2023
HOMERuN Collaborative: Administrative Harm Project
The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.
Moderators: Marisha Burden, MD, MBA, Gopi Astik, MD, MS, Andrew Auerbach, MD, Greg Bowling, MD, Kirsten Kangelaris, MD, Angela Keniston, PhD, Aveena Kochar, MD, MSPH, Anne Linker, MD, Matthew Sakumoto, MD, Kendall Rogers, MD, Natalie Schwatka, PhD, Sara Westergaard, MD, MPH
Administrative harm, also referred to as "adminogenic injury," has been a longstanding and pervasive problem in health care. Administrative harm encompasses decisions made by health care leaders that can have adverse effects on the health care workforce, patients, and organizational outcomes. Examples of administrative harm include a wide range of decisions, including those that may result in insufficient staffing or lack of access to care for critically important services. While morbidity and mortality conferences and patient safety reviews are commonplace to review clinical care decisions at the individual level that have led to patient harm, administrative harm remains largely unexplored.

To address this issue, we aimed to utilize rapid qualitative methods to explore common administrative harms as experienced by frontline hospitalists and hospitalist leaders including those with administrative roles. We also sought to understand how to measure administrative harm and explore potential processes for ongoing organizational learning and reduction of administrative harm. We conducted focus groups with the HOMERuN Network as well as the Society of Hospital Medicine Academic Leaders Special Interest group. We had representation from 32 organizations with 45 individuals representing physicians, advanced practice providers, patient representatives, including those with administrative duties.
"A great example of administrative harm is the theme of when we have complex systems and we require physicians to work themselves through that system because we don't have the capacity to make the system better."
Administrative harm can come from any decision maker though common culprits were felt to be higher level decision makers (C-suite). Participants noted that it was important for this to not be an "us" vs "them" as many in the focus groups also held administrative roles. Thus, administrative harm could come from as high as governmental and policy related decisions to local level committees with decision making authority.
Clouding the identification of administrative harm is that it is often hard to know when a decision is leading to harm versus when there are anticipated side effects of a decision. Similarly, feedback processes which were felt to be mostly non-existent in most organizations, are challenged by a lack of transparency (difficult to know who owns the outcomes of a decision), and power dynamics may make it less likely that high level leaders receive feedback.
"It's hard to see the harm that results from the water itself when you are swimming in it. We just accept that prior authorizations, etc., is the way it is, for example."
Key Concepts
Administrative harm is pervasive.
  • Unknown term but participants felt the second you hear it you know what it means.
  • Lack of ownership of downstream harm.
  • Perverse incentives or a lack of feedback to improve decision making.
  • Consultants (external entities brought in by organizations often to evaluate finances or staffing models) were perceived to contribute to harm — bringing in perspectives primarily focused on financials without understanding frontline work.
Organizations in general lacked mechanisms for identification, measurement, and feedback.
  • Challenging to determine administrative harm versus known side effect of a decision.
  • Organizational pressures drive administrative harms — leaders often feel the need to take action; there are also time pressures, finances, lack of organizational memory that contribute
  • Lack of transparency around decision making makes it challenging to know where the harm came from.
  • A culture of safety was not always present — some participants noted fear of retaliation for reporting harm or disagreement with their leadership.
The impact of administrative harm was noted to be wide reaching.
  • Patients: harms included readmissions, unnecessary tests/treatment, lack of getting necessary tests and treatments, increased costs to patients, patients unnecessarily stuck in the hospital.
  • Financials: while often felt to be the primary driver of administrative harm, some of the decisions that lead to administrative harm may actually be very costly.
  • Workforce: often impacted through staffing, bandwidth, attention. May lead to burnout, moral distress. Decisions can be perceived as demoralizing to the workforce.
  • Team dynamics: teams may be negatively impacted by administrative decisions. One example was the recent CMS rules around APP split shared billing.
  • Workflows: may lead to waste (included wasted time and efforts)
"I feel like almost everything we do every day, you could probably find some administrative harm, and it's actually hard to sort of unpack."
Ideas, ideas, and more ideas! Many ideas were generated during the sessions and highlighted below.
  • Feedback analysis: identify projected outcomes (including counter measures) and a commitment to do look backs to evaluate projects
  • Utilize 80/20 rule for high risk/big decisions, conduct feedback analysis, and don't sweat the small things (move on)
  • Incident reporting system that includes reporting administrative decisions that may have contributed to harm
  • Sharing the term administrative harm brings to light an important issue that is often overlooked
  • Transparency in decisions
  • Weekly leader rounding
  • Quality improvement (QI) tools such as pre-mortem "why will this fail in 6 months?" or "what harms might this cause?" taking more proactive approaches
  • QI tools — voice of the customer (thinking broadly about customers as workforce should be included)
  • Open communication channels with frontline and high-level leaders
  • De-implementation as a strategy
  • Meetings should have outcomes (if no outcome, then maybe meeting not necessary)
  • Business administrators need to understand clinical areas; more clinicians need to understand business
  • Build relationships and trust
  • Rapid qualitative and quantitative assessments of decisions
  • 10th person rule: if 9 out of 10 agree; need a 10th person to be devil's advocate about why this decision shouldn't be made.
"Part of the steps to getting there would be to try to create the culture of being a safe space where people can put their name to it and to give more details to allow something to happen, but I think there is some fear of retribution or ill feelings if you are exposing things that happen in a complex situation."
  1. O'Donnell WJ. Reducing administrative harm in medicine — clinicians and administrators together. N Engl J Med. 2022;386(25):2429-2432.
  2. Chang HJ, Liang MH. A piece of my mind. The quiet epidemic. JAMA. 2011;306(17):1843-1844.
Key Takeaways:
  1. Administrative harm is pervasive
  2. Organizations in general lacked mechanisms for identification, measurement, and feedback.
  3. The impact of administrative harm is wide reaching.
We appreciate any feedback or thoughts on the findings! Please send to [email protected].
Our next meeting will be on October 13, 2023.
Image Attributions: Vector images from
Check out the HOMERuN website for more information.
If you would like to join the HOMERuN Collaborative calls, please reach out to [email protected].