1. 
   

   To explain how healthcare organizations influence professionalism.

   
   
2. 
   

   To identify common themes in organizations that have successfully advanced professionalism in their institutions.

   
   
3. 
   

   To identify the organizational “levers” for influencing professionalism.

   
   
4. 
   

   To provide illustrative examples of how several specific organizations have advanced professionalism.

The framework for professionalism described in this book includes consideration of the role of organizations in building a culture of professionalism. Our premise is that systems in which physicians practice influence physicians’ behaviors in positive or negative ways by shaping the practice environment. The chapters on patient-centered care, integrity and accountability, pursuit of excellence, and fair and ethical use of healthcare resources each included a section on the role of the healthcare system in contributing to professionalism. This chapter describes further the role of the healthcare system, including academic medical centers, ambulatory care centers, community hospitals, and integrated delivery systems, and provides some specific examples of organizations that have integrated some aspect of professionalism into their culture.

Egener and colleagues (2012) propose that healthcare organizations, particularly nonprofit ones, have a responsibility to uphold the values of professionalism because these organizations are perceived as the face of the profession by the public and because their tax exempt status requires them to serve the best interest of the public. We suggest that healthcare organizations should uphold the ethical values of beneficence, dignity, justice, honesty, and self-discipline, just as individual healthcare professionals should do. In order to live up to these values, they suggest that organizations need to develop competencies and demonstrate professionalism behaviors. For example, the value of beneficence means doing good and acting with generosity. For an organization, this may mean providing services not only to patients who come to the facility, but also proactively providing care for patients in the community who may not come in but need help to be healthy or to manage medical problems. Other organizational behaviors that demonstrate a commitment to this value could include caring for uninsured patients in the community or working to eliminate health risks in the community (e.g., environmental hazards, gun violence, and obesity). In other words, healthcare organizations can demonstrate professionalism by committing to a set of ethical values and acting to realize them. Table 12-1 presents a set of values, competencies, and behaviors to describe organizational professionalism. Organizations also set the internal culture that shapes the work of the physicians, nurses, and other members of the team. Healthcare organizations provide a powerful message about “how things are done around here” through formal policies and procedures, incentives, and informal and usually unwritten rules that are modeled by leaders.

In this multispecialty group example, the clinic is seeking to provide “patient-centered care” and to build a “relationship-centered environment” for staff. Patient-centered care is a component of professionalism and the culture of the clinic supports this through engaging patients in decisions and through building both physical space and processes that foster relationships. Written rules are not necessary for patients or physicians to understand what is expected in this clinic. Over time, and with consistent leadership reinforcing the message, the unspoken rules become embedded in the processes of care and become the norm for all staff. Physicians who consider working at the clinic will choose to join the practice, or choose not to do so, based on whether the culture fits their values. Successful steps in changing the culture to one of patient-centered care are celebrated by leaders and staff, and this provides positive reinforcement for the change.

It is important to note that most organizations do not use the word “professionalism” to describe the behaviors they are trying to foster. This makes sense as the goal is to foster a set of values and behaviors that are well-accepted and enacted by all the professional staff. It is much easier to describe professionalism as a set of observable behaviors than to use the term “professionalism,” which is interpreted in many different ways. Organizations may not even consider that they are working on professionalism when they develop efforts to foster these behaviors. Language used by the organizational leaders may be “plan for excellence” or “patient-centeredness.” Hence, the language these organizations uses varies but we consider them examples of fostering professionalism, since they are working to uphold the values of the Physician Charter. (see Chapter 1, A Practical Approach to “Professionalism”) and to foster the specific behaviors that demonstrate those values in action.

Cunningham et al (2011) conducted interviews with leaders of healthcare organizations about how they advance values consistent with the Physician Charter. Organizations selected were recognized by peers as successfully building cultures to support some aspect of professionalism. The common themes identified included:

1. 
   

   articulating values clearly;

   
   
2. 
   

   aligning organizational systems and structures to support the desired behaviors; and

   
   
3. 
   

   cultivating strong interpersonal relationships within the organization.

A key commonality was that these leaders were very clear about the articulated goal and that this goal was communicated broadly through the organization. Second, the values were not only written and communicated but, more importantly, were reinforced through numerous mechanisms—hiring, training, evaluation, remediation, and so on. They described building structures like payment models, physical design of space, and technology to support the goals. Recognition of employees who exemplified the values was frequently reported by these leaders as a mechanism to reward and reinforce the values publically. Although financial incentives were used, it was rarely seen as the key motivator. Third, these organizations had a common theme related to the cultivation of strong relationships to realize professional behaviors. Some leaders cultivated these relationships by adopting frameworks such as “relationship-centered care” (see Indiana University example below), whereas others emphasized being accessible to providers and staff, engaging in ongoing conversations with all organizational stakeholders, soliciting and acting on workforce feedback to improve the organization, and encouraging provider and staff “champions” to role model desired behaviors. Table12-2 provides an overview of the organizational themes.

In summary, there are a variety of levers that organizations can use to foster the values and behaviors of professionalism. For example, organizations’ physical designs, hiring procedures, payment models, performance feedback efforts, training programs, policies on unprofessional behavior, and leadership engagement with providers and staff can all help to ensure that an organization’s values are supported and sustained. The development of strong interpersonal relationships between leaders and healthcare providers and among team members appears to be a critically important element in all the examples. What follows are several detailed examples of how organizations have promoted a component of professionalism and the behaviors that demonstrate it in action. Each example includes a rationale for the approach taken, the key elements of the initiative, its outcomes, and lessons learned.

Rationale

Indiana University School of Medicine is the second largest allopathic medical school in the United States. In 1999, the school’s leaders completed an 8-year self-study and redesign of the undergraduate medical curriculum. As a result of that process, the school instituted changes in both the formal and informal curriculum. The school implemented a new formal curriculum requiring students to demonstrate proficiency in nine core competencies. In addition, its leaders committed to changing the culture of the institution to one that promoted caring, respect, and collaboration. This initiative was spurred by survey data from medical students that showed that despite a formal professionalism curriculum, the informal or hidden curriculum did not support these same professionalism values (Cottingham et al, 2008).

How They Did It—Key Elements

As part of the formal curriculum, school leaders identified professionalism as a core competency for all students. Their primary goal was for students to translate the sometimes abstract principles of professionalism into everyday practice. Students participated in reflective writing and small group discussions on professionalism issues encountered during their education. They were also required to demonstrate specific professionalism competencies by the end of their second, third, and fourth years. Key competencies for the second year include an understanding of basic professionalism principles and demonstration of respectful interactions with peers and professors. Third-year competencies include professional interactions with patients, families, and members of the healthcare team, whereas fourth-year students are expected to better understand the challenges and conflicts they face as physicians. In addition, third- and fourth-year students received peer professionalism assessments (Litzelman & Cottingham, 2007).

To address the hidden curriculum, the school used the framework of relationship-centered care, which is characterized by respectful collaborative relationships between patients and clinicians, among members of interdisciplinary healthcare teams, and between a healthcare system and its community. In addition, relationship-centered care includes a commitment to self-reflection and self-care. The initiative’s leaders advanced relationship-centered care by utilizing appreciative inquiry, a technique focused on discovering what is working well within an organization rather than identifying deficits. The initiative’s leaders formed a task force comprising students and faculty, who conducted 80 appreciative inquiry interviews with students, residents, faculty, and staff about the school’s informal curriculum. The task force then shared themes from these appreciative inquiry interviews at a school-wide meeting.

In addition, the initiative’s leaders used a process of emergent design, by letting many of their projects emerge through conversations with community members. For example, the presentation of themes from the initial round of appreciative inquiry interviews inspired a group of medical students to conduct appreciative inquiry interviews with classmates. Results from these student interviews were compiled and shared at a white-coat ceremony for the incoming medical students.

Third, the leaders based their work on the view that small, local changes in behavior can lead to larger organizational change. Therefore, they instituted a number of “local” activities around the institution, such as redesigning the admissions process to select students with a “relational orientation”; implementing executive and leadership coaching on relationship-centered approaches to administrative activities such as faculty evaluations; and developing a Change Agent Program to train interested community members in relationship-centered care (Cottingham et al, 2008).

Outcomes They Measured