The Charter on Professionalism for Health Care Organizations.

In 2002, the Physician Charter on Medical Professionalism was published to provide physicians with guidance for decision making in a rapidly changing environment. Feedback from physicians indicated that they were unable to fully live up to the principles in the 2002 charter partly because of their employing or affiliated health care organizations. A multistakeholder group has developed a Charter on Professionalism for Health Care Organizations, which may provide more guidance than charters for individual disciplines, given the current structure of health care delivery systems.This article contains the Charter on Professionalism for Health Care Organizations, as well as the process and rationale for its development. For hospitals and hospital systems to effectively care for patients, maintain a healthy workforce, and improve the health of populations, they must attend to the four domains addressed by the Charter: patient partnerships, organizational culture, community partnerships, and operations and business practices. Impacting the social determinants of health will require collaboration among health care organizations, government, and communities.Transitioning to the model hospital described by the Charter will challenge historical roles and assumptions of both its leadership and staff. While the Charter is aspirational, it also outlines specific institutional behaviors that will benefit both patients and workers. Lastly, this article considers obstacles to implementing the Charter and explores avenues to facilitate its dissemination.

Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the health care system, but without it, the health care enterprise is lost.

— Lesser et al[1]

The concept of professionalism for health care providers and organizations can offer guidance for decision making in a fiscally difficult, rapidly changing, and ethically challenging environment. Professionalism is based on a specific set of principles and commitments that provide an orientation to the thoughts and actions of a given profession. These principles for physicians were enunciated in the Physician Charter on Medical Professionalism 13 years ago.[2] That charter has been widely accepted by physicians, but its impact on the quality of health care and patient experience is increasingly recognized as intertwined with the professionalism of health care organizations.[1,3]

Indeed, structural factors in the health care system may impede physicians from living up to the charter.[4] Health care is now a three-trillion-dollar industry,[5] with an estimated one-third of all spending being deemed “systematic waste,” including unnecessary and possibly harmful care.[6] Hospitals and health care systems are focused necessarily on their own financial health during a time of major reform in care delivery and payment models; but at the same time, they can ensure the primacy of their missions, ethical and efficient operations, and patient and provider welfare. Professional ideology recognizes a high priority for useful and needed work and its social benefits. It does not avoid economic rewards. It simply requires that these rewards be acquired with appropriate attention to professional service and social responsibility.

Health care systems increasingly dictate the practices of health care professionals, for better or worse, as an increasing number of physicians are employed by hospitals and hospital systems.[7] As such, health care organizations have an opportunity to positively and negatively influence the behavior of their employees and affiliated physicians. Most members of the health care team are motivated to do the right thing. There are, however, many opportunities for health care providers and organizations to engage in activities that are not in concordance with the principles of medical professionalism.

This Perspective includes a Charter on Professionalism for Health Care Organizations (referred to as the “Charter”; see Appendix 1) with the aim of stimulating health care leaders, health professionals, policy stakeholders, and society to evaluate their current and preferred ways of operating, to ensure best practices in providing health care and improving health. We also describe the identification and resolution of a number of issues that arose during the creation of the Charter. These include the rationale for a charter for organizational professionalism; the charter process, goals, domains, and obstacles; and finally, what we hope the Charter will accomplish. Our Perspective is offered by a subset of the Charter authors to provide its social context. It represents the ideas of the authors, not their institutions or the organizations that sponsored the Charter project.

Why a Charter on Organizational Professionalism?

A charter is a reflection of values and can be effective in bringing about positive changes in a target audience. Evidence indicates that such a document can stimulate conversation and affirmation of the stated values. For example, since its publication in 2002, the Physician Charter on Medical Professionalism has been endorsed by over 130 organizations,[8] and the number of related professionalism articles has quadrupled to over 600 annually.[9] A charter or mission statement that incorporates social, ethical, or societal goals can also positively influence organizational success. Kanter’s[10] research on financially successful companies revealed that an expressed commitment to social responsibility creates a buffer against uncertainty, evokes positive emotions, and stimulates motivation among employees. Along similar lines, Paine[11] argues that companies reap financial rewards when their programs feature such elements as community involvement and ethics. These views are supported by the growing list of companies seeking B company certification, which attests to a company’s commitment to society and the environment.[12] Additionally, Nielsen’s 2014 survey of 30,000 consumers found that 55% of respondents were willing to pay extra for products and services provided by companies committed to positive social and environmental issues.[13]

For these reasons and others discussed later in this article, members of the health care professions, patients, and representatives from hospitals and health care systems have collaborated to create a charter that outlines behaviors that support an organizational culture of professionalism. The Charter on Professionalism for Health Care Organizations is aspirational, supports a learning health system, and places the patient first. It seeks to ensure that the concept of fiduciary responsibility of health care organizations is broadened to include not only the financial health of the organizations but also the health of the patients, the well-being of the organizations’ employees, and a responsibility to the community.

Charter Process

The Organizational Professionalism Charter Project was funded by grants from the Commonwealth Fund, the American Board of Internal Medicine Foundation, North Shore Long Island Jewish Health System, the Federation of American Hospitals, and the American Hospital Association. The authors of the original organizational professionalism publication[3] and representatives of the grantors formed a Steering Committee to direct the project. The Steering Committee nominated individuals for the Writing Group who were approved by consensus and created the Charter. These writers represented a variety of disciplines, points of view, and stakeholders in health care. They included nurses, health system leaders, medical ethicists, and consumer advocates. Although some participants felt that they were to represent the organization that nominated them, the Charter was not subject to approval by any grantor or organization. Over a period of almost two years, the Writing Group met twice in person, first to decide what domains were important to address and that it would make decisions by consensus, and then to plan the writing of the Charter. The Writing Group refined the document by conference calls and e-mail. As might be expected from such a diverse group, compromise was important for the final Charter to be approved by consensus. The issues that required the most vigorous discussions were whether health care is a “right,” whether to stipulate a specific percentage of margin that a health care organization ought to return to the community, and the obligation of health care organizations to address the social determinants of health.

Charter Goals

The purpose of the Charter is to describe professionalism behaviors to which for-profit and not-for-profit hospitals and hospital systems may aspire. As the work unfolded, the Writing Group recognized that the principles were relevant to any health care organization. This article describes the evidence-based rationales for the behaviors of hospitals and hospital systems implied by these principles.

No organization can fully embody all of these behaviors. However, if they share the values elaborated in the Charter’s preamble, they may identify activities described in the subsequent domain sections that align with their strategic initiatives. We offer evidence that implementing these behaviors would improve health care as well as the experience of working or being cared for within health care organizations. Engaging outside partners—the community, government, and other organizations—creates the potential to affect population health, because partnerships among these are essential for addressing the social determinants of health.

At times, different sections of the Charter will suggest competing actions. For example, touchstones of the Charter are to prioritize the health of individual patients and to improve the health of the community. However, being a steward of limited resources may conflict with optimizing the health of each individual patient. Organizations may ethically take different actions based on their different missions and cultural values.[14] Transparent discussions that include patients and local communities will themselves have social benefit, because they may help health care organizations choose paths that reflect both organizational and local values. However, when ethical dilemmas arise from conflicts between an organization’s self-interest and those of the community or patient, the community or patient interest takes precedence. While this premise of the Charter may seem controversial, it is central to its content, consistent with the seminal Physician Charter on Medical Professionalism,[2] and the source of its greatest potential social benefit.

Charter Domains

The discussion in the following domain sections provides the rationale and evidence to support the commitments requested in the Charter.

Patient partnerships

In 2001, the IOM report Crossing the Quality Chasm: A New Health System for the 21st Century created a sense of urgency for reinventing a health care system built around six aims for improvement considered essential for better meeting patient-family needs.[15] Among these six aims is patient-centered care, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”[15] It requires collaboration among health care teams and effective partnerships with patients, families, and other caregivers.[16,17] Successful navigation from the traditional “doctor knows best” approach to one that engages patients and families to participate in their care and decision making is contingent on a culture of organizational leadership that values multidirectional collaboration and communication.[17]

The foundational characteristics of this vision for health care transformation are well aligned with the precepts of professionalism. Over time, organizations that integrate person-centric principles can experience greater patient trust and loyalty and teams that function in a more coordinated manner.[18] Effective engagement with patients and families can have a measurable impact on organizational improvement and has been cited as having the greatest potential for sustaining long-term system-wide transformation.[19] Health systems and organizations that intentionally invite patients and families to participate in rounds, committees, and advisory panels and to share their stories in the boardroom have accelerated improvements in the quality of care they provide.[20]

In the last decade, many factors have influenced the expectation that patients and families take an active role in decisions that impact their health and health care,[21] and studies demonstrate that this practice benefits all involved.[22-24]

Executive leadership is essential for achieving the cultural transformation needed to support genuine partnerships with patients and families throughout their organizations.[25] Leadership that is engaged and provides the resources needed to sustain strategies for patient-family input is critical for successful adoption of these practices. Organizations and systems that uphold patient partnerships as an integrated core value will exemplify professionalism and stand apart from others.[20]

This domain is aligned with Medicare’s adoption of measures of patient experience measures as an important element of value, and thus payment. Although the exact measures of patient experience and engagement remain controversial, the expectation of patient- and family-centeredness as a core value of health care organizations is here to stay.[26]

Organizational culture

Successful transformation of health care systems will likely depend more on the social capital of organizations than their financial capital.[27] While many professional entities provide guidelines for the behavior of individuals within their disciplines, it is the responsibility of leadership to describe a health care organization’s desired culture, articulate its rationale, and create the structures that support it and ensure accountability. With this guidance, organizational culture is cocreated by patients, nonemployed workers, employees, and leadership. Trust in leadership requires that management behavior be consistent with the organizational mission, professional values, and expectations of employees.[28] That trust in turn empowers individuals to propagate consonant behaviors into the various units where they work. Organizational culture is thus viewed as a complex adaptive system composed of interrelated microcultures.

There is increasing evidence of relationships between the culture of senior management,[29] organizational culture,[30] and the performance of health care organizations. Organizational leadership style influences both physician[31] and nurse satisfaction and burnout.[32] Although physician burnout has not been consistently tied to the quality of care,[33] nurse burnout has.[34] Physician well-being is correlated with lower rates of turnover and can be improved through focused organizational interventions.[35] A Rand study on physician well-being concluded that “the same considerations that apply outside medicine—for example, fair treatment; responsive leadership; attention to work quantity, content, and pace—can serve as targets for policymakers and health delivery systems that seek to improve physician professional satisfaction.”[36] Achieving the “triple aim” may indeed require incorporating “care of the provider” into a “quadruple aim.”[37] A healing environment can best be achieved when all those in the organization are afforded the same value and respect that clinicians aspire to give to patients. This requires soliciting, respecting, and incorporating the perspectives of employees.

High-value, cost-conscious practice also depends on interprofessional collaboration.[38] Validated measures of team cohesion have been developed,[39] and numerous studies demonstrate that better teamwork is correlated with better patient outcomes, patient satisfaction, organizational efficiency, patient engagement, and worker satisfaction.[40] Studies are beginning to emerge that test whether interventions to improve teamwork also improve clinical outcomes, though more research is needed.[41,42]

Community partnerships

Traditional clinical services account for only 10% to 20% of a population’s health, and genetics account for 20% to 30%.[43,44] Spurred by well-articulated missions to create healthy communities, model health care organizations have sought to address the remaining 50% to 70%—the so-called social determinants of health—in rich strategic partnerships with the communities they serve.[45] The health of the U.S. population has improved significantly during the last century; however, many high-risk communities have not shared in the gains achieved by traditional health promotion strategies. There is growing recognition that promoting the health of populations requires a systems approach to understanding and addressing the social and environmental factors that can protect or undermine health.[46]

As awareness of the importance of addressing “health” as a broader construct has grown, so too has awareness of the importance of health care organizations joining together—in full partnership with each other and the communities they serve—to define barriers to health and health care, design interventions, maximize the value of investments, and implement new strategies together to improve a community’s health.[47] Partnerships of this type require skill, collaboration, and a level of trust that has not previously existed among most health care organizations and the communities they serve. Still, several notable examples have emerged.[48] The Affordable Care Act includes the requirement that nonprofit health care organizations demonstrate their “community benefit” beyond the usual charity care to include community health assessments, planning, implementation, and evaluation.[49] The expectation is that health care organizations will provide “a wide range of services and activities that focus on improving health status and quality of life in local communities.”[50]

In tandem with the mission to create healthy communities, model health care organizations recognize that shifts in public policy toward population and outcomes-based reimbursement make effectively addressing the social determinants of health mission critical to fiscal sustainability in a post-fee-for-service future.[51,52] In this way, the long-term health of model health care organizations and the communities they serve are inextricably intertwined and must be addressed in real partnerships where this reality is embraced by all.

Operations and business practices

In recent years, a vision for a health care system that continuously learns and improves has evolved.[53,54] Efforts to enhance ethical behavior in health care organizations result in best operational and business practices and in real benefits for patients.[55] Furthermore, Tsai and colleagues[56] found that hospitals that rank high on the use of effective management practices provide a higher quality of care than lower-ranking hospitals, and hospital management’s use of such practices is associated with a high-performing board of trustees.

Paine[57] argues that increasingly, companies are launching ethics programs, values initiatives, and community involvement activities premised on management’s belief that “ethics pays.” In health care, this concept goes well beyond the economic value of branding and includes efforts at cost control, service quality improvement, patient and staff safety, risk management, innovation, reputation, loyalty, and satisfaction for both patients and providers.

Bart and Tabone[58] found an important relationship between nonprofit hospital leadership satisfaction with mission statement and their organization’s performance. Their primary finding was that leaders do in fact discriminate and differentiate in the wording of mission statements, which in turn influences organizational behavior and performance. Of distinct importance is a commitment to service quality, patient welfare, and satisfaction. Components typically not included in the mission are financial goals and competitive strategies. Ethical guidance in the form of mission statements are valuable tools for health systems to use to improve organizational performance and increase employee motivation.[59]

Holy Cross Hospital System (HCHS) of South Bend, Indiana, provides an example of a successful organizational program to ensure that HCHS’s organizational structure and performance were value based and mission driven.[60] HCHS developed 11 mission standards, created opportunities for ownership, and fostered personal responsibility within the system to ensure the fulfillment of its mission. This process of mission discernment is expanded on by Gallagher and Goodstein[54] and represents an ethically grounded and practical process to ensure the moral integrity of an organization. The key operational values of the HCHS mission statement were faith, service, excellence, empowerment, and stewardship. The core values that drove the discussion and development of its mission were social justice and human dignity. Financial and legal issues were considered, but this was proportionate to core service commitments to the poor and vulnerable. As a result of sound moral grounding through its mission statement, HCHS was able to clarify choices among competing goals for the organization and find compromise for stakeholders both internal and external to the organization.

At the Harvard Vanguard Kenmore Medical Associates practice, where previous quality improvement efforts had been associated with deteriorating morale, leadership implemented specific relationship-centered practices which defused pent-up anger and frustration in the staff, decreased isolation, built teamwork, and facilitated significant quality improvement.[61] They created an environment in which each clinician and staff person was treated with dignity, involved in identifying and solving quality-of-care issues, and incorporated into a systematic approach to continuous improvement. This facilitated the adoption of process improvement techniques pioneered by Toyota Production Systems, while at the same time improving morale.

Ethics guidance that is formalized in codes and organizational mission statements promotes ethical discourse and deliberation around institutional integrity and responsibility, and influences organizational behavior in meeting those goals.

Charter Obstacles

The Charter is aspirational; it is meant to describe the behavior of a “model organization.” Many of its challenges are cultural, requiring both organizational leaders and employees to alter their historical views of their organizations and their roles within them. Traditionally, health care institutions have been hierarchical and physician focused. And despite recent financial, structural, and operational changes, health care institutions have not fundamentally altered the relationship between leadership and employees. Some individuals may be challenged by the more dynamic, open dialogue between leadership and the full spectrum of professions, employed nonprofessionals, and patients as described in the Charter. In addition, the Charter reminds all those individuals to focus on the ultimate goal of medicine, healing the patient. While the pace of work can make each task seem an end in itself, mindfulness of the larger institutional mission and each individual’s role within it can impart a sense of purpose to every job and meaning to each activity.

Another challenge is altering the social determinants of health. The ecology of these determinants is complex and not fully understood. Nor is any social structure in a position to affect all the influences on these determinants. The Charter does not suggest that health care organizations are solely responsible for improving the social determinants of health but, rather, suggests that they seek strategic partnerships with other organizations, government, and local communities, consistent with their means and their unique missions, in order to improve the health of the community.

What We Want to Accomplish

This Charter complements existing treatises on professionalism, creating a document directed at health organizations and systems rather than a group of individuals. The Charter defines the professional competencies and behaviors that organizations can leverage to create an environment that promotes professional behavior throughout the organization. Developed by administrators, physicians, nurses, and patients, the Charter is a multidisciplinary effort that melds the aspirations of all involved to provide such an outcome.

We wish to ensure that this is a living document similar to the Physician Charter on Medical Professionalism and will take lessons learned from the process employed with that charter. The task of accomplishing this will rest with a representative multidisciplinary committee. The committee will seek opportunities to publicize the document in professional and trade journals as well as opportunities to present the Charter at professional meetings. The Charter will reside on the Web site of the Foundation for Medical Excellence (www.tfme.org). A list of health care systems, professional organizations, and hospitals that endorse this Charter will be listed. A nonmonetary annual prize will be awarded to the most influential practice resulting from such commitments. We foresee a time when the Charter could be incorporated into criteria for acknowledging excellence in health care organizations by certifying organizations. Further, we will ask for feedback so that the document can be modified in the future as needed to adapt to the dynamically changing world of health care delivery.