Are the management objectives for hospital physicians ethical?

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Some of the universally accepted hospital management indicators include hospital occupancy, bed rotation index, mean stay, number of hospital discharges, readmission rate and the productivity of external units.<a class="elsevierStyleCrossRefs" href="#bib0240">5–9</a>However, physicians ultimately provide healthcare and, thereby, manage the resources. To optimize management, the institutions set operational objectives, apart from the organization's general strategic objectives. The operational objectives provide practitioners with a number of specific management goals<a class="elsevierStyleCrossRef" href="#bib0265">10</a> to improve the efficiency and equality of management without compromising the quality of healthcare.<a class="elsevierStyleCrossRefs" href="#bib0270">11,12</a> In exchange for achieving these goals, physicians are given an incentive, usually financial. Most of the operational objectives include classical indicators of hospital management (mean stay, waiting time in consultations) and direct indicators of expenditures (pharmaceutical and others). Other objectives assess the practitioners’ research and teaching functions.<a class="elsevierStyleCrossRef" href="#bib0280">13</a>In the standard management model for Spanish hospitals, the management-directorate provides an annual proposal for the operational objectives to each department and unit. After reaching a consensus with the ward physicians, the department head or responsible clinician transmits the appropriate claims to the management, which may accept them. In all cases, the claims must be signed (and thereby accepted) beforehand by all members of the department so that the clinicians can receive compensation for achieving the objectives. This is therefore a vertical objectives planning model.<a class="elsevierStyleCrossRef" href="#bib0285">14</a>Marking objectives for clinicians is a positive step, because working with incentives improves practitioners and, hence, the healthcare system. However, the operational objectives of management, as there are typically designed, place significant conflicts of value on the table. For example, management tends to offer objectives with merely economic criteria, prioritizing management over quality care and pressuring clinicians through their collective agreement. These ethical conflicts have seldom been studied. This article analyzes the ethical issues created by the operational management objectives for physicians who work in Spanish hospitals.Bioethics and ethics of healthcare organizationsPhysicians have always had the need to ethically justify their professional actions, at the personal level, to patients and to other practitioners. Traditional medical ethics has considered that the moral obligation of physicians consists of searching for the maximum benefit for the patient, classifying any other objective as immoral. This perspective has clashed for decades against any issue related to the financial management of health,<a class="elsevierStyleCrossRef" href="#bib0235">4</a> because physicians understand that the objectives of management can interfere with the primary purpose of their profession: providing the best care for their patients.<a class="elsevierStyleCrossRefs" href="#bib0290">15,16</a> Healthcare practitioners, especially physicians, have increasingly recognized the importance of combining financial management with patient care, in such a way that they accept the need to establish objectives and measure results, to better manage resources without neglecting healthcare.<a class="elsevierStyleCrossRef" href="#bib0300">17</a>Bioethics arose in the 1970s as an update to traditional medical ethics. Bioethics can be defined as the branch of ethics that deals with promoting rational and optimal clinical decisions, accounting for clinical facts and the preferences and values of all those involved in the decisions.<a class="elsevierStyleCrossRefs" href="#bib0305">18,19</a> For the decisions to be rational and optimal, it is important to incorporate all values and principles involved, not just conduct a classical search for the patient's benefit. We need to include, for example, respect for the freedom of the involved parties and the fair distribution of resources.<a class="elsevierStyleCrossRef" href="#bib0315">20</a> We can thereby achieve a more global and realistic perspective of the problems.<a class="elsevierStyleCrossRef" href="#bib0320">21</a>Organizations also have a set of ethics, values that guide their priorities and that are expressed through their strategic objectives. Although healthcare institutions should conduct efficient management, they cannot forget the values upon which their ultimate goal is cemented: optimal patient care, which should modulate all management decisions.<a class="elsevierStyleCrossRef" href="#bib0295">16</a> Managing under the perspective of values enables us to track ethical management objectives such as ensuring equitable access and responsibly containing expenditures.<a class="elsevierStyleCrossRef" href="#bib0320">21</a>Ethics of management objectivesWhat should be incentivized and what is incentivized?Physicians are incentivized to achieve quantitative results, based on figures and percentages on healthcare management indicators: prescribing a certain percentage of antiretroviral agents, obtaining a shorter mean stay, etc. The current system of incentives has the danger of prioritizing quantity over quality. As an example of the efforts to reduce expenditures, physicians are rewarded by the system for assisting more patients in a shorter time, measured through indicators such as the bed rotation index, the number of first and successive consultations and the duration of an outpatient consultation.<a class="elsevierStyleCrossRef" href="#bib0325">22</a> This management therefore has a predominantly financial perspective.If there is one thing we can say for certain, it is that an activity cannot be incentivized that goes against good medical practice.<a class="elsevierStyleCrossRefs" href="#bib0330">23,24</a> We should therefore be careful when designing objectives and signing off on them. If by meeting the objectives we end up with poor clinical practice, we are going against the aims of our profession for which we, and not the center's managers, are responsible. We cannot issue unjustified early discharges from hospital wards, cease prescribing indicated and recommended drugs for a specific indication or quickly assess patients in consultations by the mere fact of having met the agreed-upon objectives. Ethical objectives incentivize good practice, without forgetting that resource management should be efficient. For example, if 2antibiotics have a similar effect, ethics would dictate that we should prescribe the less inexpensive one. However, if the more expensive one is better for treating the infection, we should give priority to efficacy.<a class="elsevierStyleCrossRef" href="#bib0340">25</a>We should therefore ensure that good clinical practices and actions are incentivized. This approach is both ethical and efficient, because if patients are treated properly, they will require fewer consultations, there will be fewer readmissions, and the mean stay will be shorter. The process cannot however be inverted: incentivizing exclusively with quantitative indicators (such as mean stay) and trusting in the practitioner's goodwill to properly treat patients. If good clinical practices are incentivized, the physician and patient will benefit simultaneously. To this end, we need to search for indicators of good clinical practice, which can be quantitative or not.How should objectives be designed and how are they designed?Typically, the management creates a proposal for each department with the annual objectives. These objectives are communicated to clinicians through the department head. The system is therefore hierarchical, with barely any participation and where clinicians lack decision-making capacity.The centers’ management should work in conjunction and directly with healthcare physicians in preparing the management objectives. Modern healthcare management seeks to replace the pyramidal structure with a more horizontal one, with the participation of all healthcare practitioners who work in the organization, thereby promoting the institution's human capital. The objectives should therefore be discussed and agreed upon between the hospital's management, the intermediate directors (unit, department and section heads) and the ward physicians.Another important issue regarding the method of designing objectives is to whom they are directed. If the objectives are designed for a department or unit as a whole, then they indirectly pressure each physician, because if one of the physicians does not meet the objectives, the entire department or unit is affected. Moreover, objectives that are solely individual are also not appropriate, because a large part of the clinical activity is collective, not to mention the fact that the pressure on the physician would be even greater if the objectives were exclusively individual. The objectives should therefore be mixed. There needs to be a collective part (for those activities that depend on the group) and an individual part (based on the specific tasks of each physician). Otherwise, the objectives will lose moral value and be inefficient.If clinicians are granted a leading role in designing the objectives, a threefold result is achieved: the clinicians are more involved in the management, the health care is improved (clinicians know best the needs for care), and efficiency is optimized. All of this has a positive effect on the organization.<a class="elsevierStyleCrossRef" href="#bib0345">26</a>What objectives are truly important for improving clinical practice?Objectives are often focused on activities that are out-of-phase with the current reality of the healthcare system. It is therefore important that the objectives are in keeping with the core aspects of our healthcare system. A number of examples are given below on how to update the management objectives in the current healthcare system.Currently, the objectives that are agreed upon in Spanish hospitals are focused almost exclusively on the classical indicators of hospital management, related to the care of acutely ill patients. However, care for chronically ill patients consumes 80% of healthcare expenditures in Spain.<a class="elsevierStyleCrossRef" href="#bib0350">27</a> The general care regimen for patients in Spanish hospitals is anchored in the past, excessively focusing on the care of acute disorders. It is essential that we redirect certain objectives toward the care of chronically ill, polypathological and highly complex patients. Applying the classical hospital management objectives (e.g., mean stay) to these patients is inadequate. An example of the objectives for this type of patient is the design of care continuity maps to prevent hospitalization and improve the interaction between primary care (PC) and specialized care (SC).The continuity of care and healthcare services includes coordination between PC and SC. Lack of communication and coordination between PC and SC causes, among other problems, congestion of patients in hospitals, which negatively affects the entire system.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> A desirable objective for continuity of care would be the creation of multidisciplinary teams, with SC and PC physicians, nurses, physiotherapists and social workers, who plan a coordinated care program. Teamwork with practitioners of various healthcare levels is essential for properly caring for chronically ill and polypathological patients.<a class="elsevierStyleCrossRef" href="#bib0355">28</a> Through the coordination of these teams, measures can be conducted such as early treatment of exacerbations and personalized preventive plans for this type of patient, thereby avoiding hospitalizations and decreasing costs.<a class="elsevierStyleCrossRef" href="#bib0360">29</a> Similarly, objectives can be established to boost the development and assessment of home care and home hospitalization units. These units can be effective and efficient healthcare alternatives for ensuring proper care for patients who need active and complex health care; however, by performing it at home, hospital iatrogenesis is avoided.<a class="elsevierStyleCrossRef" href="#bib0365">30</a> Telemedicine and telecare are other healthcare modalities that facilitate interaction between patients, relatives, caregivers and PC and SC teams.<a class="elsevierStyleCrossRef" href="#bib0370">31</a> Management objectives can promote the implementation and proper operation of all these interdisciplinary care models.Another key aspect includes the objectives of research and teaching, which have little weight in the set of objectives and where practitioners are not given sufficient time or means to conduct these particular objectives. As a result, incorporating teaching and research into the clinical setting is a highly complicated task.<a class="elsevierStyleCrossRef" href="#bib0375">32</a> These activities are therefore poorly developed and often underappreciated. However, these activities are essential for our profession and should be a part of our job. It is therefore important to include individualized and, above all, realistic research and teaching objectives (a specific schedule for each clinician should be created). These objectives have 2 aspects, the practitioner's involvement and the managers’ recognition. Examples of research and teaching objectives include developing and conducted clinical research projects (especially in lines of research that improve the quality of care), participating in research teams or research methodology advisory teams, publishing scientific research and presenting at congresses, participating in scientific meetings and teaching undergraduate and graduate courses. If a practitioner commits to meeting research and teaching objectives, management should respond by establishing specific schedules to provide time to meet these objectives. Countries such as the United States and Canada use half-day models, which provide practitioners with half a day to conduct the preestablished teaching or research activities. Managers should provide the necessary individual means to achieve these specific objectives; otherwise, it makes no sense establishing the objectives.Care for the physician, in its broadest sense (occupational and personal), should be another objective. An objective cannot be reached if the physician is physically or emotionally overloaded. The United States is beginning to replace patient-focused care programs with patient and practitioner-focused care programs. This is logical because although the patient gives the system its direction, the practitioner is the one who directly provides the care.<a class="elsevierStyleCrossRef" href="#bib0380">33</a>Marckmann and Maschmann indicated that central ethical values in hospital care should be integrated in the hospital management plans and, therefore, in the objectives.<a class="elsevierStyleCrossRef" href="#bib0385">34</a> The authors supported conducting repeated surveys of the hospital staff to ensure the centers’ “internal quality”. If values are incorporated and the internal quality is improved, practitioners’ physical and mental health will simultaneously improve, achieving better satisfaction and, ultimately, better external quality. According to Marckmann and Maschmann, a greater use of ethics in hospital management could also help to improve the institutions’ economy.<a class="elsevierStyleCrossRef" href="#bib0385">34</a>Conclusion: excellence, the meeting point between medical ethics and healthcare managementIn this article, we analyzed the ethical issues created by the operational objectives of management for physicians who work in Spanish hospitals. These issues are as follows: (1) the current incentive system places quantity above quality, which represents a predominantly economist management perspective; (2) the system is hierarchical, lacks participation and deprives clinicians of decision-making authority. Moreover, with a group design of objectives, we run the risk of improperly pressuring clinicians; (3) the objectives are focused on outdated activities in terms of the current reality of the healthcare system and should therefore be updated considering, for example, chronicity and the continuity of care.After analyzing these issues, we created a proposal for developing management objectives based on prioritizing quality care (which ultimately results in efficient management, given that ethical management is also economic), developing objectives in a participatory and mixed manner (with group and individual objectives) and with new objectives in keeping with the current reality of the healthcare system. Putting this proposal into practice is not complicated because the final goal of clinicians and management is the same: to provide the best health care possible, i.e., to be excellent.The goal of healthcare institutions is not savings but rather to provide optimal patient care, by considering maximum effectiveness and efficiency.<a class="elsevierStyleCrossRef" href="#bib0390">35</a> Clinicians should assume responsibility for their role as resource managers as part of their healthcare tasks. Management objectives cannot be achieved without their involvement, because healthcare physicians are directly responsible for three-quarters of healthcare expenditures.<a class="elsevierStyleCrossRef" href="#bib0395">36</a> This represents an enormous commitment, because medical ethics impel us to provide the best patient care at all times; however, we also have the obligation to be efficient. Wasting available technical means is an attack against medical ethics. Poor resource management can result in patients not receiving the treatments they need due to the limited resources. Being a good physician means being involved in management objectives, so that the objectives can be efficient and ethical.<a class="elsevierStyleCrossRef" href="#bib0290">15</a>We need to create lines of work in bioethics and clinical management.<a class="elsevierStyleCrossRefs" href="#bib0400">37,38</a> The United States and other countries of the European Union have clinical consultants in bioethics with training in management who can help resolve the previously mentioned problems.<a class="elsevierStyleCrossRefs" href="#bib0410">39–41</a> However, Spain lacks practitioners trained in clinical, management and bioethical aspects.<a class="elsevierStyleCrossRefs" href="#bib0425">42,43</a> There are also very few research studies on ethics and healthcare management, which is therefore an area of emerging interest, both for clinicians and managers.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1156254" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1083496" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1156255" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1083495" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Bioethics and ethics of healthcare organizations" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethics of management objectives" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "What should be incentivized and what is incentivized?" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "How should objectives be designed and how are they designed?" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "What objectives are truly important for improving clinical practice?" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion: excellence, the meeting point between medical ethics and healthcare management" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-14" "fechaAceptado" => "2018-06-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1083496" "palabras" => array:4 [ 0 => "Healthcare management" 1 => "Ethical conflicts" 2 => "Management objectives" 3 => "Bioethics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1083495" "palabras" => array:4 [ 0 => "Gestión sanitaria" 1 => "Conflictos éticos" 2 => "Objetivos de gestión" 3 => "Bioética" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Management objectives at times create significant value conflicts that have so far been seldom studied. This article analyses the ethical issues created by the operational objectives of management for physicians who work in Spanish hospitals. These issues are as follows: (1) the current system places quantity above quality, which represents a predominantly economist management perspective; (2) the system is hierarchical, lacks participation and deprives clinicians of decision-making authority; (3) the objectives are focused on outdated activities in terms of the current reality of the healthcare system and should therefore be updated considering, for example, chronicity and the continuity of care. After analysing these issues, we created a proposal for developing management objectives based on prioritizing quality care (which ultimately results in efficient management), developing objectives in a participatory and mixed manner (with group and individual objectives) and designing new objectives in keeping with the current reality of the healthcare system. Putting this proposal into practice is not complicated because the final goal of clinicians and management is to provide optimal health care." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los objetivos de gestión, en ocasiones, plantean importantes conflictos de valor, hasta el momento poco estudiados. En el presente artículo se analiza qué cuestiones éticas plantean los objetivos operativos de gestión a los médicos que trabajan en hospitales españoles. Estas cuestiones son las siguientes: 1) en el sistema actual se prima la cantidad sobre la calidad, lo que supone una perspectiva de gestión predominantemente economicista; 2) se trata de un sistema jerarquizado, en el que apenas hay participación y en el que los clínicos carecen de capacidad decisoria y 3) los objetivos se centran en actividades desfasadas respecto a la realidad del sistema sanitario actual, por lo que deben ser actualizados considerando, por ejemplo, la cronicidad o la continuidad asistencial. 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