Introduction
Professionalism in health services delivery typically describes the rights, duties, and obligations of certified individuals who offer their services to the public. But recent scholarship has expanded the scope of inquiry to include organizations and their rights, duties, and obligations, invoking the concept of “organizational professionalism” (OP).Reference Egener, Mason and McDonald1 One line of research, for example, has shown that an organizational framework that embodies a “Culture of Professionalism” is critical to healthcare providers’ well-being and their ability to provide excellent patient care and support public trust in healthcare entities.Reference Lee, McGlynn and Safran2
There is not yet a single, widely accepted definition of OP. A better understanding of the definition, implementation, and measurement of OP in healthcare organizations may facilitate the creation and long-term sustenance of desirable organizational cultures in the health sector. With an improved understanding of this concept, healthcare organizations that understand, measure and seek to improve their OP may develop knowledge and strategies to intentionally implement laws, policies, processes, and procedures informed by OP principles. In turn, a more robust development of OP in healthcare organizations may support leadership and modeling for sustaining organizational cultures that bolster trust and support the efforts of individual healthcare professionals as they strive to deliver healthcare services to their patients in a professional, ethical manner.
The “Charter on Professionalism for Health Care Organizations” (the Charter) defined OP with reference to four domains that encompass the organizational competencies necessary to sustain and enhance a “Culture of Professionalism”: (1) patient partnerships, (2) organizational culture, (3) community partnerships, and (4) fair business practices. These domains match concepts in professionalism which articulate that trust in professionals arises when they meet expectations in relations with patients, colleagues, community, and business associates. The application of these concepts to foster trust in organizations has intuitive appeal, but the Charter was developed by leaders in academic medicine, and it is not known whether its concepts are useful to leaders in other settings.
The “Charter on Professionalism for Health Care Organizations” (the Charter) defined OP with reference to four domains that encompass the organizational competencies necessary to sustain and enhance a “Culture of Professionalism”: (1) patient partnerships, (2) organizational culture, (3) community partnerships, and (4) fair business practices. These domains match concepts in professionalism which articulate that trust in professionals arises when they meet expectations in relations with patients, colleagues, community, and business associates.
The research study described here sought to understand whether and how leaders in high-performing healthcare organizations understand OP, how they might measure performance in its four domains, and if and how they might use the concepts in the Charter and its associated domains to build trust in their organization.
To explore the Charter’s practical applications, the authors first engaged a panel of ten experts, including individuals with clinical and academic backgrounds in medicine, health services, law, public health, organizational behavior, communication, and ethics who have contributed to the exploration and literature on professionalism in medicine. The panel considered the Charter, including its implementation (or lack thereof) and the lack of related measures and metrics, and recommended conducting a qualitative study with leaders of high-performing healthcare organizations to better understand their knowledge and use of the concept of OP. We prepared a summary of the positions/roles of healthcare leaders interviewed while also protecting the anonymity of interviewees ( Table 1).
Table 1 Positions/Roles of Interviewees
Since the proposed definition of OP needed to be reality-tested among organizational leaders, and there are no widely accepted metrics for assessing OP and therefore no resource for identifying high-performing organizations regarding OP, we elected to gather experiences of executives using in-depth qualitative interviews. We chose to interview leaders at organizations widely considered as high performers in health services delivery. For this purpose, we selected healthcare organizations that were recent recipients of the Malcolm Baldrige National Quality Award (Baldrige Award), which we considered as a proxy for a high likelihood of having embraced performance in regard to OP or OP-like themes. Since the language used in the Charter is not identical to terminology used in the Baldrige standards, we created a crosswalk of language used in the Baldrige “Core Values and Concepts” and corresponding OP domains ( Table 2 ), which we used in developing our interview guide.
Table 2 Baldrige Language to Organizational Professionalism Language Crosswalk
Note: (NIST, n.d.(b) and Egener et al., 2017).
The Baldrige Award was used as the criterion to select healthcare organizations for this project as it is the highest level of national recognition for performance excellence that a US organization can receive.3 It was established by the US Congress in 1987 to recognize and improve performance of the nation’s businesses, hospitals, schools, nonprofit organizations, and government agencies.Reference Hertz4 The Baldrige Program recipients have contributed to more than $29 billion in economic benefit and the ratio of benefits for the US economy to Baldrige Program costs is 820:1.5 The healthcare sector award was initiated in 19996 and 28 healthcare organizations have received the Baldrige Award since 2002.7 State, local, and regional Baldrige-based award programs use the Baldridge Excellence Framework to advance organizational excellence and competitiveness in states and regions. These programs help many local organizations start and continue their performance excellence journeys.
Methods
After initial consultation with Baldrige program leadership, we identified healthcare organizations that had received the national Baldrige Award between 2018 and 2022. Ten of these organizations were purposively selected to achieve a sample with diversity in geographic location, ownership, academic affiliation, faith-based or secular, urban/rural, organizational structure, and size; leaders from six of these organizations agreed to participate. Four organizations were unable to participate due to limited resources available at the time of invitation and the ongoing effects of the COVID-19 pandemic. To supplement this sample, we invited selected award recipients of state Baldrige-based programs which yielded two additional organizations as participants. Each participating organization was invited to identify two or three senior leaders who had broad perspectives on the organization; one of the senior leaders interviewed at each organization was their lead for the Baldrige application. Study protocols were approved by the Stony Brook University Institutional Review Board (IRB #IRB2021-00167).
We developed a semi-structured interview guide, organized around the OP domains as modified to reflect Baldridge terminology (Table 2). The interviews included three main sections: (1) exploring the interviewee’s familiarity with the concept of OP; (2) describing how the organization approaches each of the proposed domains of OP, focusing on measurement strategies; and (3) exploring additional possible domains that these executives thought could be related to OP. In the second section, for each domain we first asked how the organization worked to ensure high performance in the domain, and then we asked in what ways, if any, the organization measured its performance in that domain. The third section comprised an open discussion of any additional domains that the interviewee saw as conceptually related to OP. We pilot tested the interview guide with four healthcare leaders not included in the study and made minor revisions to ensure understandability of the questions. Subsequently, pairs of researchers from our team conducted virtual, individual, semi-structured key informant interviews with twenty-three leaders from the eight selected healthcare organizations. Each interviewee signed a consent form and agreed to have their interview recorded.
The interviews were transcribed verbatim, checked for accuracy, and all personal identifiers were removed before they were uploaded to Atlas.ti™8 for analysis. Interviews were then analyzed using immersion/crystallization to identify provisional themes.Reference Borkan, Crabtree and Miller9 Iterative consensus-building among multiple reviewers and double coding of transcripts were used to identify emergent themes, resolve differences, and agree upon final coding categories.
Initial coding guidelines and protocols were developed prior to coding, utilizing a constructivist grounded theory approach.Reference Charmaz10 The initial codebook was developed through open coding with preliminary codes and subcodes, using one transcribed interview. An additional nine interviews were coded to refine the initial codebook, to reflect consistent and accurate representations of themes across interviews. The refined codebook was inputted into Atlas.ti™ where the remaining interviews were subsequently coded by one of three coders, who had regular discussions to resolve/reconcile any inconsistencies, make necessary modifications to the coding categories in the codebook, and discuss emerging themes of particular importance. Iterative consensus-building among the three coders facilitated agreement on domains and coding categories, and the codebook was modified throughout the data analysis process to reflect this consensus, based upon iterative comparisons between the previously coded and newly analyzed data.Reference Strauss and Corbin11
Upon completion of initial coding, the coded interviews were merged into one combined project file in the Atlas.ti™ program. From this merged file, each coder was assigned different interviews to double-code to optimize consistency and reliability of results. Following double-coding, the three coders jointly reconciled any noted discrepancies, reviewed/clarified any changes to the codebook, and compared reflections. They also identified primary themes that emerged, based upon the coding results, such as factors that were consistently cited or noted as relevant to OP by the interviewees. These themes were then utilized for interpretation of findings.
Results
Several themes arose across all three sections of the interviews, such as the importance of building and sustaining patient and community trust, but in general each proposed domain of OP elicited a set of unique themes. We present these below in the order in which they were discussed in the interviews.
Healthcare Leaders’ Conceptualization of OP
We anticipated that some leaders from Baldrige recipient organizations might be unfamiliar with the concepts and domains of OP. Therefore, the first part of the interview explored OP and allowed the interviewee to provide their own definition of OP.
Few interviewees had read or heard about the specific concept of OP prior to our interviews, yet all rapidly recognized connections between OP principles and their organization’s activities, performance metrics, and goals. It was also notable how easily most interviewees adopted the language of OP and used this throughout the interviews. Several described the potential for OP to help frame a more expansive and useful understanding of professionalism for themselves and their organizations. For example, one interviewee stated:
…previously, I thought [of] professionalism as our image, or maybe even certifications or education. But just thinking… some of the questions that you’re asking about, some of our partnerships, and the community influence…and I think, really, what I’m zeroing in on is how… are we specifically measuring some of these things, and are we able to improve?
(Quality/Safety/Performance Improvement/Patient Experience Interviewee)All interviewees also recognized relationships between OP principles and their organization’s core values. Quotations related to this finding are presented in Table 3 as “Acknowledgment of OP Principles Shifts Thinking About OP.”
Table 3 Sample Quotations Representing Charter Domains, Additional Emerging Themes, and Additional Observations from Healthcare Organizations
* Transcripts have been lightly edited for ease of readability.
Healthcare Leaders’ Reflections on OP Charter Domains and Measurement Tools
The interview then explored the four Charter domains of OP ((1) patient partnerships, (2) organizational culture, (3) community partnerships, and (4) operations and business practices), and asked the interviewee how their organization measured its performance in each domain. Representative quotes from the interviews are presented in Table 3 and examples of measurement tools are listed in Table 4 .
Table 4 Potential Existing Tools for Measuring OP Identified by Interviewees
1. Patient Partnerships
While the Charter does not rank order the four domains, the concept of patient partnerships was most frequently cited across all interviews. Specifically, leaders often returned to speaking about patient partnerships even when asked about other domains, especially community partnerships. Every leader expressed the belief that there is a strong connection between building trust at the level of individual patients and at the community level (see patient partnership and community partnership quotes in Table 3 ).
We asked interviewees to describe how the organization fosters partnerships with individual patients, such as in making care decisions. Interviewees often used this prompt to speak about how individual- and community-level trust were linked, which initially was surprising since we had anticipated hearing more about topics such as encouraging clinician use of tools to support shared decision-making. The fact that interviewees used this prompt to discuss community relations rather than to talk about decision-making at the individual level may reflect the senior positions these leaders held. These leaders are responsible for their organization’s reputation in the local community in various ways, and they viewed the concept of “patient partnerships” through this lens, while frequently noting that the organization’s relationship with the community depends upon the personal relationships formed between clinicians and patients. Many leaders also described trust flowing in both directions, with patient-level trust in the organization enhanced by efforts to build community trust and vice versa. Specific examples of trust-building activities at the individual patient level were not abundant in interviewee responses, although leaders often described the relationship between community- and individual-level trust, with each benefiting when the other is strengthened. One interviewee stated:
I think that … systematizing professionalism across an organization allows the organization to be more highly reliable. And the more highly reliable you can be, the more you will gain the trust of the people you are serving.
(Executive/Operations/Strategy Interviewee)When asked about organizational structures to support the quality of patient partnerships, participants most often described patients serving on internal committees, such as Patient and Family Advisory Councils, remarking on how such inclusion can counter a tradition of paternalism in healthcare. One interviewee stated:
It’s not the way that we’ve always thought about providing care, right? It’s always been this top-down approach. “We know better.”
(Medical/Nursing/Other Clinical Interviewee)In a further reflection of the relationship between community and individual trust, several leaders also referred to building partnerships with community organizations when asked to describe how the organization supports patient partnerships ( Table 3 ).
2. Organizational Culture
Interviewees were next asked about organizational culture. To open the conversation, we provided examples of “having a culture of mutual trust among people within the organization” or a “just culture.”
The Baldrige framework includes a set of core values;12 given how the interviewees were selected, it is unsurprising that all reported using these values in their performance excellence journey. Interviewees referred to their organization’s core values, often reflecting the Baldrige core values, and described how they were embedded in their organization. For example, one interviewee stated:
I think when I hear that “organizational professionalism” idea, it’s probably taking these concepts that we talk about all the time — in this case, our organization’s mission, vision, values, of course — but it’s also this role of an anchor institution. And then, how to respond to the changing needs of people.
(Executive/Operations/Strategy Interviewee)Organizational culture was seen as especially related to OP in creating a culture of accountability. Interviewees mentioned ensuring consistent standards, equity, and transparency, and creating an environment where challenging the status quo is encouraged. They frequently spoke about accountability, support, and mutual respect at work. One interviewee stated:
We show up in the morning with our hearts open, and we walk in relationship with each other and with community. We’re responsible for that concept of shared responsibility, relationship, and noticing and valuing dignity in the way that we’re all walking every day.
(Executive/Operations/Strategy Interviewee)Some healthcare leaders also sought to connect organizational culture to achieving and sustaining public trust, a consistent theme across all of the domains ( Table 3 ).
3. Community Partnerships
Interviewees were next asked about their organizations’ relationships to the community, including concepts such as community benefit and engagement, and how they consider or measure professionalism in their community relations. Interviewees acknowledged that community relationships and OP intersect conceptually and practically. They referenced robust organizational collaborations with the communities they serve and other interested parties. Specific strategies mentioned were: appointing senior leaders to be responsible for community relations; being visible in the community; tracking patient experience; establishing patient and family advisory councils (PFACs); working with city, county and state organizations; initiating programs to reduce health disparities; offering scholarships to bring underrepresented minorities into the health professions; and tracking patient and workforce engagement. As noted, community partnerships and patient partnerships were often raised together with similar language. As one interviewee explained:
…The words that I’m using are really challenging the traditional hierarchy in healthcare, where sometimes, as healthcare professionals, we see ourselves as experts. And we think that we know what’s best about how healthcare should be delivered. And, in our minds, we want to break that hierarchy, and instead realize the idea of a partnership where, as healthcare systems … healthcare professionals, we bring our expertise to the table. So, we value what we bring, and equally value what the community brings, and try to put those things together on the table.
(Executive/Operations/Strategy Interviewee)One unexpected theme that emerged was shared accountability with external organizations. Multiple interviewees spoke about being part of a larger environment than their organization, with examples such as working with city officials to reduce health disparities or working with other organizations on local priorities.
In regard to measurement, the theme of accountability often arose and was seen as related to other themes such as transparency, participation, and being in and of the community, each of which were cited as organizational commitments and responsibilities. Specific measurement tools used included various types of patient engagement surveys and direct patient feedback (both negative and positive), tracking social media traffic, and staff participation levels in community outreach programs such as food drives ( Table 3 ).
4. Operations and Business Practices
The fourth domain was fair business practices, which are intended to build relationships of trust with vendors and other business partners as well as with patients. In the Charter, this domain focuses on discussion and decision-making grounded in institutional integrity,Reference Egener, Mason and McDonald1 and it encompasses attention to core values while also acknowledging financial and legal considerations.
Most interviewees easily connected the concept of fair business practices and OP; when asked for examples they identified various issues including attention to fair pricing, price transparency, billing practices, and tracking their organization’s impact on the environment. One interviewee stated:
I think the buzz right now around billing and being transparent, and people understanding what they’re paying for in terms of … operating as a business, making sure that our bills are able to be read and understood by patients. They’re itemized, so they understand what went into that charge. And we’ve done a lot of work around that over the last two years, to say: “Okay, this is us being transparent and showing them what these billing practices mean.” So, I think that was a huge step for us in terms of our professionalism to the community.
(Quality/Safety/Performance Improvement/Patient Experience Interviewee)When asked about ways to measure fair business practices, several leaders cited corporate compliance reporting as a key means of tracking organizational performance in this domain. They also identified comparative benchmarking as a way to ensure their organizations were not outliers in the marketplace. Of note, the Baldrige assessment requires that organizations identify relevant comparators and benchmark their performance on multiple metrics over time against these benchmark organizations as well as industry standards. Since the Baldrige assessment is data-driven, all interviewees reported extensively documenting performance and use of sophisticated, organization-wide data systems.
Interviewees also often identified specific examples of interactions in the community as measures of their organization’s fair business practices, as well as their organization’s role in the community as employer, revenue generator, and promoter of diversity, equity, and inclusion. These examples suggest a potential overlap and opportunity for coordination with organizational activities in the community partnership domain (Table 3).
Additional Themes Identified
Beyond the four proposed domains, six additional themes related to OP emerged: (1) patient safety and experience; (2) performance improvement; (3) staff development; (4) organizational core values; (5) clear and transparent communication; and (6) ethical leadership. While all of these might be considered to fall under the “Organizational Culture” domain of OP, their identification as distinct themes by these leaders points to the need for further work on how to describe and define OP in ways useful to healthcare delivery organizations.
Discussion
Very few healthcare executives we interviewed had heard the term “organizational professionalism” prior to being interviewed, yet all readily connected their operating processes and strategic decisions to it and could readily summon examples of how their organization attended to all four of the domains of OP, including ways in which they measured performance in each domain. This suggests that principles of OP may be embedded within the leadership and culture of these high-performing healthcare organizations, albeit with variations in how the concept is described and where related principles and practices are applied and measured. It is also remarkable that all leaders interviewed readily adopted the term during interviews, and several reported that further exploration of this concept could be useful to them as leaders developing cross-cutting initiatives around OP concepts.
We were especially interested in how organizations measured performance in each of the four domains of OP (patient partnerships, organizational culture, relationships with the community, and fair business practices). We heard a number of potentially useful ideas for each. In general, reported organizational measurement and tracking strategies included using surveys, various community engagement metrics, organizational business and compliance metrics, and in-person observations to identify and reward employee actions that directly exemplify professionalism. The fact that these measures already exist and are being used raises the potential for creating an OP “dashboard,” with a common set of recommended metrics for tracking ( Table 4 ).
The additional themes offered by these leaders, which were sometimes seen as distinct from the four Charter domains, suggest that the concept of OP still needs greater clarity or breadth, or both, to fully encompass the ways in which healthcare leaders interpret, implement, and measure OP within their organizations (Table 3). At the same time, the frequent references to trust and its relationship to OP across all four domains also suggest a potential unifying strategy for promoting attention to OP by focusing on its presumed impacts on patient and community trust in healthcare systems.
Limitations and Future Research
While this study is notable for being the first formal exploration of the concept of OP among health system leaders, it has several limitations, and it provides important fodder for future research. First, there is a preexisting definition of OP which we adopted, but the utility of this definition was, itself, a subject for this study. Examining a concept that does not yet have a well-accepted definition creates obvious challenges, which is why we used qualitative methods for this initial investigation. Future work should seek to further define OP, including consideration of the additional themes raised by these leaders and realistic measurement strategies for each proposed domain.
Second, there is no list of organizations that have sought to or do excel in OP, so we used the proxy measure of being a recent recipient of a Baldridge award. The Baldridge award examines concepts that are intuitively similar to those in the OP definition we used (Table 2), but they are not the same. It is likely that we found more similarities between Baldridge language and OP language and concepts than we might have if we had not selected these organizations. Future work might benefit from examining views of leaders in organizations that use other frameworks for performance improvement, such as Anchor Institution status13 or Lean management.Reference Lawal, Rotter and Kinsman14
Third, this study was descriptive, not normative. We explored how current leaders think about and use the concept of OP, but not what they would recommend for themselves or others. This will be especially important for future work on developing an OP measurement dashboard, and future research should carefully examine any proposed set of metrics for their relationship to important outcomes such as clinical outcomes or patient and community trust.
Conclusion
Enhancing the understanding of OP in healthcare organizations has the potential to establish and sustain professional and ethical organizational cultures that bolster trust through the sound implementation of laws, policies, and procedures to support the delivery of high-quality patient care. We therefore undertook this qualitative study to explore how the concept of “organizational professionalism,” as described in the OP Charter, is understood and potentially measured by leaders of high-performing healthcare organizations. The four OP domains identified in the Charter guided our interviews and data analysis, but we found very few leaders were already familiar with the concept of OP. Nonetheless, the concept resonated as important to their organizations, and they easily provided various examples of how their organizations attended to and measured performance in each of the four OP domains. These examples arose in myriad organizational contexts, which is not surprising since there is, at present, no overall set of policies and practices that fall under the rubric of OP. Further, our findings suggest both conceptual overlap across Charter domains — at least from the point of view of organizational leaders, who often returned conversations to the goal of enhancing community trust — as well as some new areas that might be included as aspects of OP. This is a formative descriptive study, which raises more questions than it answers. Many future opportunities exist to better define and align Charter domains to enhance the practical application of OP concepts in healthcare delivery organizations.
Note
The authors are indebted to the senior leaders of the eight study organizations who generously gave their time for interviews. The authors also appreciate the advice provided by leaders of the Baldrige Performance Excellence Program. The authors offer their gratitude to the Professionalism Grant Project Group Executive Committee (PGPG EC) members for their invaluable guidance, direction, and support throughout this project. Members of the Professionalism Grant Project Group (PGPG) Executive Committee (EC) include: Julie L. Agris, Ph.D., J.D., LL.M., FACHE (Chair) of the Shepard Broad College of Law, Nova Southeastern University; Barry E. Egener, M.D., of Asante Health; Dennis H. Novack, M.D. of Drexel University College of Medicine; Sherril B. Gelmon, Dr.P.H., of the OHSU-PSU School of Public Health; Matthew Wynia, M.D., M.P.H., of the University of Colorado, Anschutz Medical Campus; Richard M. Frankel, Ph.D., of the Indiana University School of Medicine; William Nelson, Ph.D., M.Div., of the Geisel School of Medicine at Dartmouth College; and Fred Hafferty, Ph.D., of the Mayo Clinic.
Disclosures
The authors acknowledge funding received from the American Board of Family Medicine Foundation, American Board of Internal Medicine (ABIM) Foundation, and The Foundation for Medical Excellence. The authors have no conflicts of interest to declare.
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