American Association for Physician Leadership

The ‘Accountability Factor’ as a Predictor of Medical Group Leadership Culture

Daniel K. Zismer, PhD

Elliot D. Zismer, MS

Gary S. Schwartz, MD, MHA

Sept 7, 2023

Volume 10, Issue 5, Pages 36-39


Physician leaders interested in approaching organizational culture from the perspective of “accountability” are encouraged to begin with quality of care and the patient experience. The “accountability factor,” an item in the CulturePulse© leadership culture evaluation tool, is a strong predictor of how providers and staff perceive the overall condition of the leadership culture of medical services organizations.

Most seasoned physician leaders and administrators agree that leadership culture influences performance in medical groups at all levels, including quality of care, the patient experience, operational efficiencies, and effectiveness of medical practices. Most would also agree that culture is multi-faceted and somewhat amorphous.

It is a challenge for leaders to know where to start with initiatives to improve and enhance the cultures of the organizations they lead. By pursuing cultural improvement based on anecdote, conjecture, or overconfidence in “knowing the people” who work in the organization, leaders risk missing the right opportunity, or worse, doing further harm to an already fragile clinical care culture.

Setting The Stage For The Evidence

Every organization has a culture by design or default, and that culture is the leaders’ responsibility. In medical services organizations, doctors are designated leaders, whether they hold a formal leadership position or not, and strongly influence leadership culture.

Medical groups rarely, if ever, have unified cultures. Instead, they are a mosaic of sub-cultures influenced by several factors, such as clinical sub-specialty composition, practice locations, types of patients served, operating financial incentives created by provider compensation designs, and even work shifts.(1,2)

A medical service organization’s culture can shift quickly and dramatically based on changes in leadership and other internal and external factors.(3,4) Any combination of factors can be more or less influential at any particular time. When leaders guess about situational factors that most influence the culture of the organizations they serve, they may be confident in their opinions, but too often guess wrong or miss the subtleties of the factors that matter most at a particular time.

Evaluation Of The Accountability Factor

CulturePulse© is a comprehensive and proprietary 21-item leadership culture evaluation tool that can be administered to a variety of organizations, including medical services organizations. One of the items (No. 16) is the “accountability factor,” expressed as “I believe all members of the organization are held to the same levels of accountability within the organization.”

A foundational assumption (hypothesis) examined here is that leaders’ abilities to manage the practicalities of the accountability factor successfully will lead to healthier, more high-performing leadership cultures in medical services organizations.

After multiple administrations of the CulturePulse across several medical services organizations, aggregated results demonstrated a common “V-shaped” response pattern for the accountability factor. Respondents tended to rate this item appreciably lower on the scale when compared with most if not all, other items.

A sample of five administrations of the CulturePulse totaling 1,015 staff and providers working in medical clinics was compared for all 21 items in the evaluation tool. The V-shaped effect for item No. 16 was comparable across all administrations, and the only difference was the average score for this item across organizations in the sample (Figure 1).

Follow-up analyses of scaled and written responses were undertaken to answer three important questions:

  1. What is the relationship between item No. 16, the accountability factor, and the instrument’s final anchor item No. 21, “I believe the organization’s culture is as good as it should be”?

  2. Are there other relationships between instrument items that help explain the relevance and importance of the accountability factor and its relationship to leadership culture and organizational performance?

  3. Is there evidence in the written comments section of the instrument that might shed light on the reasons and rationale for the characteristically lower response pattern for the accountability factor across organizations?

Based on the analysis, we find that:

  1. The accountability factor is a strong predictor of respondents’ belief that “the culture of the organization is as good as it should be” (p < .001). Leaders can be confident that how they manage the “accountability factor” will affect how staff and providers will evaluate the organization’s overall culture.

  2. Factors that affect (predict) respondents’ assessment of leaders’ abilities to create a positive culture of accountability are reflected in responses to nine of the 21 items in the instrument. Nine factors (instrument items) of significance were revealed (multiple linear regression analytics applied; adjusted R squared .771, ANOVA F value, p < .0001).

    • “I am clear on the mission of the organization.” (p < .002)

    • “Every patient will receive the experience they deserve from every team member.” (p < .003)

    • “The person I report to trusts me to use my best judgment when carrying out my responsibilities.” (p < .001)

    • “I will be treated fairly when it comes to how I am rewarded for my performance.” (p < .001)

    • “The organization (leadership) creates policies and rules for the good of all.” (p < .000)

    • “I am proud to be associated with the organization.” (p < .004)

    • “My mistakes are seen by the person I report to (my leader) as an opportunity for me to learn and move forward better prepared.” (p < .000)

    • “Leaders welcome and will genuinely listen to honest feedback on how the organization cares for its people and those we serve.” (p < .002)

    • “Leaders in the organization work and collaborate effectively for the collective good of the organization and its mission.” (p < .000)

  3. An examination of tens of thousands of words of written response to the final anchor item, ”I believe the culture of the organization is as good as it should be,” provided descriptive and specific leadership behaviors associated with the significance of the accountability factor and its relationship to the quality of the leadership culture in the participating organizations. In addition, a few of the more repeated phrases about leadership and accountability were:

    • Leadership and favoritism.

    • Leadership and perceived leader competence.

    • Leadership and how they speak about those they lead and leaders they work with.

    • Leadership and perceptions of fairness in the management of staff assignments.

    • Leadership and the application of policies and rules.

    • Leadership and leader selflessness, and lack of.

    • Leadership and the leader’s inclination and capability to teach and develop people.

    • Leadership and the fair and equitable management of rewards, including compensation, assignments, and promotions.

A Deeper Dive Into The Findings

The evidence presented here strongly supports the connection between how leaders manage accountability and the overall state and status of the leadership culture in medical practices. However, leaders should be mindful of several other lessons learned from the data analysis before applying the findings cited above.

While the effects on the accountability factor response pattern have been reliably demonstrated in every administration of the CulturePulse, the specific instrument items that produce the pattern can differ between and within organizations. In other words, while the characteristic V-shaped pattern may be evident for the organization overall, the extent of the effect, as well as the factors that cause the effect, will most likely differ department-to-department, program-to-program, site-to-site, and leader-to-leader based on the leadership culture within each. Therefore, a one-size-fits-all approach to addressing organizational accountability is not recommended.

Medical clinics, like every organization, are collections of sub-cultures. Leadership culture varies within organizations based on leadership competencies and style. The accountability factor can be well managed in one sector of a medical practice and not so in others. Likewise, positive and negative significant shifts in the leadership culture of reporting sectors have been found with routine serial applications of the CulturePulse. The shifts occur for various reasons. Most notably with leadership change, or leaders performance, regardless of cause.

When the accountability factor is poorly managed within specific sectors of a medical practice, the culture always suffers. In the worst situations, staff and providers can feel trapped by sub-par leaders. While they may feel positive about the culture of the organization, overall, the culture where staff and providers work can be seen as lacking, stifling, problematic, and deleterious.

Members of organizations observe and are affected by how leaders do and do not cooperate, collaborate, problem-solve, and generally work together to further the mission and values of the organization. Observed problems between leaders can be taken as a sign of organizational instability and leadership incompetence. Neither the best leaders, or staff, will endure such conditions for long.

A deeper dive into the data also demonstrates that the accountability factor is a complex construct linked to several attitudinal predispositions, behavior patterns, and personal and professional competencies of leaders. These factors, along with situational factors within organizations, affect leadership culture in medical clinics, which will then affect organizational performance.

Physician Leaders’ Perspectives

Physician leaders are uniquely positioned to address the accountability factor in organizational culture. Their positions as formal leaders and experienced clinicians provide the platform and mandate for managing accountability as a key performance requirement for excellence in clinical care, the patient experience, and the organizational productivity and efficiency.

Physician leaders face several challenges in holding physicians and staff accountable to the culture and organizational performance. CulturePulse results typically identify three areas of opportunity for formal physician leaders’ attention and intervention.

  1. Providers on the front lines build close bonds with those who support them in delivering care. Physicians can become overly protective of members of “their team.” Other more ancillary staff are observant of such “special relationships.” Team members can flaunt these close relationships to the detriment of the work environment and culture. In organizations, physicians can be “captains of their own ships” (their teams). Still, they also are accountable for ensuring that all ships in the organization sail in the same direction under the same flag and that all crew members are treated with equal fairness and respect.

  2. Staff gauge non-provider leaders’ competence based on their abilities to hold those they lead accountable to expected and espoused standards of behavior and performance, those related to the patient experience, and how team members deliver on the related organizational promise, for example. Favoritism and inequitable distribution of rewards are commonly stated failures of non-physician leaders. Physician leaders who fail to recognize and act upon such perceived leadership competency problems at the staff levels, may find their leadership competency questioned.

  3. Those who take pride in the delivery of high-quality care and patient experience excellence will come to question their commitment to their organization when the leadership culture fails to hold all to account. Staff turnover can be traced to leadership’s failure to adhere to espoused missions, organizational values, related policies, standards of performance, and a supportive leadership culture.

Physician leaders who wonder where to start with efforts to approach organizational culture from the perspective of accountability should begin in the familiar waters of quality of care and the patient experience. A strong predictor of the state and status of the leadership culture of medical services organizations is: “Every patient will receive the experience they deserve from every team member.” A leadership culture journey rooted here enhances the potential for success.


  1. Zismer DK, Utecht BJ. Culture and Culture Alignment, High-Performing Healthcare Organizations and the Role of the Governing Board. Part One: Culture and Culture Alignment – The Foundation of a Board’s Culture Game Plan. The Governance Institute’s E-Briefings. 2018;15(2).

  2. Zismer DK, Utecht BJ. Culture and Culture Alignment, High-Performing Healthcare Organizations and the Role of Governing Boards. Part Two: Setting a Culture of High Performance and the Responsibility of Governing Boards. The Governance Institute’s E-Briefings. 2018:15(3).

  3. Zismer DK, Schwartz GS, Zismer ED. Ten Lessons Learned from Studying Culture Performance in Medical Groups. Journal of Medical Practice Management. 2022:37(4).

  4. Zismer DK. The Science of Culture, A Look Inside Health Systems. Minnesota Physician. 2021:34(10).

Daniel K. Zismer, PhD

Daniel K. Zismer, PhD, is co-chair and CEO of Associated Physician Partners, LLC, and endowed scholar, professor emeritus, and chair of the Division of Health Policy and Management at the University of Minnesota School of Public Health.

Elliot D. Zismer, MS

Elliot D. Zismer, MS, is Senior Vice President, Associated Physician Partners, LLC, Stillwater, Minnesota.

Gary S. Schwartz, MD, MHA

Gary S. Schwartz, MD, MHA, is a practicing ophthalmologist in Stillwater, Minnesota, and is president of Associated Eye Care, LLP, and co-chair and executive medical director of Associated Physician Partners, LLC.

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