Affidavit of Peter M. Mowschenson, MD

Regarding General Principles of Healthcare Administration

PERSONALLY APPEARS before the undersigned authority, duly authorized to administer oaths, comes Peter M. Mowschenson, MD, who after first being duly sworn, states as follows:

Introduction

1.             This affidavit addresses general principles of healthcare administration.

2.             This affidavit does not address any specific healthcare facility. Nor does it address the care of any specific patient.

3.             The way healthcare facilities are managed is not obvious or intuitive.

4.             Even clinicians with years of experience in a facility may have limited knowledge of how that facility is administered.

5.             Because most adults will have significant experience with healthcare as patients or consumers, it is possible to have intuitions about healthcare administration — intuitions that are strong, but wrong.

6.             The purpose of this affidavit is to provide a sense of the reality of healthcare administration — a sense that is highly general but based on fact.

7.             Dan Holloway of Bell Law Firm drafted this affidavit after consulting with me. Mr. Holloway drafted a statement of general principles of healthcare administration based on his reading of the relevant literature. He shared that statement with me, we discussed it, and he drafted this affidavit based on our discussion. I reviewed the draft and edited it for substance, to make sure it correctly states my substantive views. I have not edited this affidavit for style.

8.             I understand that Mr. Holloway has asked providers from a variety of backgrounds to address these issues. Because the general principles are general, I would expect most if not all informed individuals to agree with these principles.

My Perspective on Healthcare Administration

9.             I am a surgeon at Beth Israel Deaconess Medical Center and Assistant Professor of Surgery at Harvard Medical School.

10.          I have served as:

a.    1984-1988 — Chief of Surgery, Brookline Hospital, Brookline, MA

b.    1994-1997 — Executive Board Member, Harvard Center for Minimally Invasive Surgery

c.     1995- 2019 — President, Affiliated Physicians Inc., Beth Israel Deaconess Medical Center [prior to 1996: Affiliated Physicians Inc., Beth Israel Hospital]

d.    1996-2014 — Vice President & Board Member, Beth Israel Deaconess Care Organization [prior to 2013: Beth Israel Deaconess Physicians Organization]

e.     2001-2010 — Member, Board of Trustees, Beth Israel Deaconess Medical Center

f.      2014-2019 — Board Member, Beth Israel Deaconess Care Organization

g.    1982-2000 — Staff Council Beth Israel Hospital

h.    1988-2001 — Medical Executive Committee Beth Israel Hospital [after 1996: Beth Israel Deaconess Medical Center].

11.          I have first-hand experience of some of the ways in which non-clinician healthcare administrators are responsible for systems for safe patient care.

12.          My CV is attached to this affidavit.

Bottom Line

13.          Preventable medical error is a major cause of death in the United States. It is difficult to know how many deaths are caused by medical errors, but one widely cited estimate ranks medical error as the third leading cause of death in America.

14.          Healthcare administrators consist largely of individuals who are not licensed healthcare providers. Non-clinician healthcare administrators may be highly knowledgeable about various aspects of healthcare, but they are not licensed medical professionals.

15.          Medical errors usually arise from a combination of two general factors: (a) systemic problems that create unreasonable potential for error, and (b) failings by individual clinicians within that system.

16.          A primary job of non-clinician administrators is to support clinicians by providing systems that facilitate proper medical care and actively prevent medical error — to set clinicians and patients up for success rather than failure.

17.          When non-clinician healthcare administrators do their work negligently, they can contribute to medical errors that hurt patients.

18.          Some healthcare institutions persist in attributing medical error solely to clinicians. Such institutions refuse to acknowledge any contribution to error from the work of non-clinician administrators. This mentality is dangerous: It perpetuates system-level problems that promote medical error and hurt patients.

Discussion

The Complexity of the System & the Risk of Medical Error

19.          A hospital is a large, complex system.

20.          Care of a hospital patient frequently involves multiple people in varying roles — for example, physicians, “mid-level” providers, nurses and nursing assistants, “allied health” staff such as X-ray technicians and physical therapists, and a variety of support staff including secretarial, housekeeping, food service, and other staff. 

21.          Typically, care of a multi-day hospital patient is handed off multiple times from one physician to another, and from one nurse to another. 

22.          Typically, individual physicians and nurses in a hospital have multiple patients. 

23.          The complexity of hospital care creates potential for medical errors of various kinds. 

24.          Many types of healthcare system failures are known and predictable — for example, miscommunication during patient hand-offs, silo-ing of responsibilities, cognitive biases, overwork or understaffing, organizational cultures that discourage raising concerns about patient safety, etc.

25.          Medical errors can be reduced by a culture of safety and a program of continuous improvement.

Management as a Distinct Discipline

26.          Managing or administering a healthcare organization is not the same as practicing medicine or nursing. Management or administration involves different roles, different actions, different responsibilities. 

27.          Healthcare administrators need education, training, and skills different from those required to be a physician or nurse. Non-clinician administrators must have education or training in management, but need not have gone to medical or nursing school. Physicians or nurses need not have training in managing organizations.

The Importance of Non-Clinician Administrators’ Responsibilities for Patient Safety

28.          No clinician is in a position to prevent all risks of medical error that patients are exposed to.

29.          Clinicians work within the systems and organizational culture created and maintained by administrators — largely, non-clinician administrators. 

30.          A healthcare organization’s leadership — including non-clinician administrators — plays an essential role in protecting patients from medical error.

31.          Negligence by non-clinician administrators can promote medical error and contribute to patient harm.

What Administrators Do

System-Building & Management

32.          Most simply, the senior administrators are responsible for creating systems to promote patient safety, and then managing those systems — to oversee processes to decide what needs to be done, to make sure it gets done, and to coordinate the actions of the dozens or hundreds or thousands of personnel in a healthcare organization.

33.          The creation and management of the patient-safety function is critical, because work not assigned and managed is apt to go undone.

34.          Purely administrative patient-safety work includes creating an administrative structure to take primary responsibility for patient safety — creating an executive-level position for patient safety, and creating the number and type of patient-safety administrative staff necessary for the healthcare organization’s particular needs.

35.          Purely administrative patient-safety work includes creating and maintaining a process for continuously promoting a culture of safety throughout the organization.

36.          Purely administrative patient-safety work includes managing a process for formal, actively managed quality improvement projects.

37.          Purely administrative patient-safety work includes managing an ongoing process to ensure that personnel are trained and prepared for the roles they occupy.

38.          Purely administrative patient-safety work includes managing a process to ensure the healthcare system is implementing practices that protect patients. Just papering the file is not enough. Policies must not only be created: They must be actively promulgated, supervised, and enforced.

Interaction of Non-Clinicians & Licensed Medical Professionals Regarding Patient Safety

39.          Depending on the nature of any given patient-safety work, non-clinician administrators work in varying ways with licensed healthcare professionals:

a.    Administrator-driven action: In some tasks, administrators act essentially independently, with limited input from licensed medical professionals. For example, non-clinician administrators may independently decide to administer a survey on patient safety. Administrators may seek input from licensed healthcare professionals for certain aspects of the survey administration, but the survey primarily requires purely administrative work.

b.    Professional-driven action: Some tasks even at the administrative level consist mainly of professional work, with support from non-clinician administrators. For example, the content of protocols for stroke patients obviously resides in the domain of licensed medical professionals. But non-clinician administrators may play a facilitating role in the process of developing those protocols.

c.     Back-and-forth tasks: Non-clinicians and licensed medical professionals may work together on a project sequentially, passing the ball back and forth — an administrative task, then a medical task, then another adminstrative task, etc. In a simplistic scenario, for example, a CEO may direct the Chief Medical Officer (a physician) to assess and update policies for care of stroke patients in the Emergency Department. The CMO does the work and hands the policy to the CEO. The CEO has administrative staff promulgate the policy throughout the organization. Then the CEO directs the CMO to assess whether ED staff are properly trained on the updated policy and, if not, to create a training program. The CMO performs that work and reports back. The CEO then announces a training requirement and allocates time and resources for it. Then the CMO conducts the training.

d.    Joint collaboration: On some tasks, administrators may work jointly, simultaneously with clinicians. For example, a non-clinician administrator and a physician may work together to create a flowchart of an intubation procedure as performed in the ICU, as part of a patient-safety project.

e.     Hybrid projects: Large patient-safety projects may involve all of the different interaction types described above, in different ways, at different stages of the project.

40.          Again, the work of both non-clinicians and licensed medical professionals is integral, essential, and non-redundant. Negligence by either type of personnel will undermine or defeat the project.

Interaction of Non-Clinician Administrators & Licensed Healthcare Professionals as to Medical Policies

41.          Concerning medical policies, non-clinician administrators are responsible for:

a.    making sure need-assessments are performed to identify what policies or protocols should be created,

b.    making sure policies and protocols are communicated effectively to healthcare system staff (instead of just papering the file),

c.     making sure training is given so that healthcare system staff understand how to apply the policies and protocols in practice,

d.    making clear that the policies and protocols must be followed (that is, that they are not bureaucratic formalities which staff can disregard),

e.     monitoring compliance, and

f.      ensuring remedial actions are taken where compliance problems arise.  

Accountability for Hospital Administrators

42.          It would be wrong to hold doctors and nurses accountable for their negligence, but at the same time to exempt non-clinician administrators from accountability for their own negligence.

43.          It would be dangerous to exempt non-clinician administrators from accountability for their own negligence. That would remove an important incentive for them to work diligently to create systems that protect patients.  

                                                                                    Peter M. Mowschenson, MD

SWORN TO AND SUBSCRIBED before me

_________________, 2022

____________________________________

NOTARY PUBLIC

My Commission Expires: