It’s less of a workplace metric and more of a culture that leaders must establish. You either have it, or you don’t … but you can get closer to achieving it.
“... An underexplored concept whose meaning remains evasive, whose boundaries are fuzzy, and whose internal structure is confusing ...”
That’s how one scholar characterizes “accountability” in a 400-page book on the topic. And yet the noun — and its adjective form, “accountable” — have become bywords in the health care vocabulary.
Indeed, in its reviews of hospital operations and performance, the Joint Commission has reclassified what it used to call “core measures” as “accountability measures.” And management training programs and professional development seminars have jumped on the concept of “creating a culture of accountability in health care,” or variations on that theme.
Accountability is kind of a supercharged word. Most executives misinterpret and misuse it. To most executives, it means, ‘If you don’t achieve what I tell you to achieve, you’re a bad person.’ And that leads to a lot of trouble.
Catalysis CEO John Toussaint, MD
Then there’s the rise of “accountable care organizations” — groups of physicians, hospitals and other providers who coordinate their services and receive payment based on measurement of quality and cost. Thus, they are complexly accountable: to their patients, for assuring safety and the best possible outcomes; to their colleagues, for collaborating toward achievement of the organization’s goals; and to the Centers for Medicare & Medicaid Services, for reporting their metrics, improving comparative performance and cutting unnecessary expenses.
Nowhere, perhaps, is the A-word more fraught with nuance than in health care.
“I once wrote a paper on accountability in Annals of Internal Medicine,” says Ezekiel Emanuel, MD, PhD, chair of the department of medical ethics and health policy at the University of Pennsylvania. With his wife, Linda Emanuel, MD, a professor of medicine, psychiatry and behavioral medicine at Northwestern University’s Feinberg School of Medicine, Ezekiel dissected the term and found “at least 11 distinct parties that can be held accountable or hold others accountable” in health care.
They include individual patients, individual physicians, non-physician health care providers such as nurses and physical therapists, hospitals, managed care plans, professional associations, employers, private payers, the government, investors and lenders of capital, and lawyers and courts.
Beyond that, they wrote, there are also six distinct “domains” of accountability in health care — that is, “activities for which a party can legitimately be held responsible.” Those are professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion and community benefit.
Finally, the Ezekiels explained, accountability entails two procedures: “evaluation of the adherence to or compliance with the criteria for specific content areas” and “dissemination of the evaluation [for] responses or justifications by the accountable party or parties.”
A Powerful and Confusing Word
On the ground, observes John Toussaint, MD, the CEO of Catalysis, a Wisconsin-based health care leadership and best-practices consultancy, “accountability is kind of a supercharged word. Most executives misinterpret and misuse it. To most executives, it means, ‘If you don’t achieve what I tell you to achieve, you’re a bad person.’ And that leads to a lot of trouble.”
By his reckoning, an accountable system “is not derived from a shame-and-blame thinking process,” he says. “Blaming and shaming is the death of thinking about how to improve performance. It shuts down people’s creativity. The person waits for a superior to tell him or her what to do. That’s why we have so many quality problems in health care. People are fearful to try anything. They fear being yelled at, being fired.”
Most health care organizations, believes Toussaint, lack formal processes and managerial behaviors that foster accountability. “So why would you expect to see it?” he asks.
In fact, he asserts, “99.9 percent of people are good actors.” So, when lapses occur, they’re “usually a function of bad management, not bad actors. Almost all medical errors are related to process problems, not people problems. And most processes in health care are horribly wasteful and perfectly designed to fail on a regular basis.”
Robert Wachter, MD, professor and chair of the department of medicine at the University of California at San Francisco, whose department is the nation’s leading recipient of National Institutes of Health grants, makes a similar observation.
“When I started learning about systems thinking, and the model of how errors occur,” he says, “I’d walk around the wards and put on my systems lens and look for bad handoffs, glitchy procedures ... and it was scary as hell. They’re absolutely constant!”
More troubling, says Wachter — who pioneered the subspecialty called hospital medicine (its practitioners are called hospitalists) — was that so many errors were occurring at UCSF, one of the world’s most prestigious academic medical centers.
“If making things better is about making people better, well … “ he reflected, trailing off with his thought. The attending physicians, residents, nurses and staff he was observing were already the crème de la crème.
“That’s when the light bulb lit,” he recalls. The only way to improve patient safety and the quality of care delivery was to “think hard and change the system so we catch errors before they cause harm.”
A Different Sense
To begin with, declares Toussaint, “many health care organizations haven’t defined what the heck it is that people are supposed to be accountable for. What are we trying to achieve? Better quality? Lower cost? Better patient satisfaction?”
One hospital he advised listed 235 strategic initiatives. He calls that “ridiculous.”
The first step toward creating a system of realistic accountability, he counsels, is to “decide what exactly it is we want to achieve. Most executives don’t have a clue. What we suggest people do is put all their initiatives through a filter, a yes/no set of questions, asking, ‘Is this absolutely critical to achieving our mission?’ ”
The judgment, he notes, can be “wait.” Or, “put this one on hold.” Or, “Never gonna do it.”
“I don’t care how you say it,” he says. “If I can get at least half of them off the initial plate, get down close to the mid-100s, that would be a good start. [Even] 115 is too many still, so you’ve got to keep at it. And you can’t just put 20 into one bucket. That doesn’t count. But now we can start to assign the resources necessary to achieve our goals. A senior executive should be in charge.”
Toussaint is an advocate of the Plan-Do-Study-Act methodology for quality improvement — and, ultimately, accountability.
“In health care, we do Plan-Do,” he observes. “We never study to see if we’ve made any difference. An accountable system is one that’s in a process of constant PDSA. In meetings, we say, ‘This is what we have found.’ If something didn’t work, we say, ‘What are we going to do about it?’ We’re trying to get at root problems and we’re actually learning something along the way.
“If we have a system like that in place, accountability means a process for learning how work flows and adjusting to what happened to improve in the next PDSA cycle. Now failure takes on a different sense. It’s ‘OK, what are we going to do next?’ not ‘Who’s to blame?’ ”
In 2015, Vice Adm. Adam Robinson, MD, MBA, CPE, the 36th Surgeon General of the U.S. Navy, became CEO of the Veterans Affairs Maryland Health Care System. He took over an organization whose Baltimore teaching hospital (a primary training site for the University of Maryland Medical School), mental health facilities, nursing homes and outpatient clinics were among the VA’s worst performers. Budget cuts had reduced staffing by 13 percent. Patient satisfaction scores were chronically low. So was morale among the 3,500 employees, who often cited a lack of higher-level accountability when polled about their dissatisfactions.
“ ‘Accountability’ was almost a code word,” Robinson recalls, “for ‘certain people in supervisory or managerial roles seem to be able to do whatever they want to do, with no repercussions.’ “
He tackled the situation “in a very Navy way,” he declares. (Details of the transformative process were described in the November/December 2017 issue of the Physician Leadership Journal.) After meriting only one star in 2014, the Baltimore VA Medical Center held three (on a five-star scale) in the 2017 ranking.
“The first thing that has to occur,” Robinson says, “is that, as commanding officer, you have to set a course. You issue a set of orders — here’s your mission, here’s your vision. Here’s the guiding course.”
Notwithstanding the highly publicized mistakes and misdeeds at some of its facilities around the country — including the months-long waits for veterans seeking health care at the installation in Phoenix, Arizona, that surfaced in 2014 — the VA summarizes its ideals in an acronym: ICARE, standing for Integrity, Commitment, Advocacy, Respect and Excellence. For his system, Robinson introduced a second layer of values: Innovation, Compassion, Accountability, Research and Education. “We called it ICARE-square,” he says.
He then launched a series of ongoing education programs for all VAMHCS physicians, nurses and frontline staff, designed to impart “an understanding of the responsibilities and competencies of leadership, with ethical and integrity principles embedded, and to give them the management and supervisory skills they need as a basis for professional growth.”
Robinson likened VA Maryland’s mission of delivering patient- and family-centered care to a three-legged stool. The patient, the patient’s family and the staff are the legs. “Which is the most important leg?” he asked at his first assemblies.
“Usually, they said ‘the patient,’ ” he recalls. “But it was a trick question. It’s a three-legged stool! They all have to be the same length and the same strength. That was an eye-opener — the staff had never been included in the model. You have to resource these dedicated people with educational experience, and remuneration, and the respect of leadership. Stop looking at the budget and start managing to the needs of your staff and your patients. You have to break down walls and create a care model in which there is free and open communication.”
Foregrounding accountability as an organizational value made a few people nervous. There were retirements, transfers and resignations, Robinson acknowledges. But he wasn’t unhappy about that.
“Having one outlier on staff, someone who gets away with murder and is not dealt with in a definitive way, can kill an organization,” he warns. “Fast. That negative influence can drag the whole group down.”
At the same time, he says, “I’m not going around firing people. I’m setting a tone and an expectation. If you don’t show respect, commitment and compassion to our patients, you cannot work here. And they’re policing themselves. The most important piece, the catalyst, is to have involved, engaged leadership, who’re right there with them. At all levels. That’s what sets the tone.”
A Moral Dimension
“Once an organization establishes certain rules and standards,” Wachter observes, “accountability means you adhere to them.” But there’s also a moral dimension, he says: “What do you do when no one’s looking?”
In the case of handwashing, for example, despite its importance to infection control, some doctors and nurses frequently neglect it. The same dynamic applies to the formal list of safety precautions before a surgical procedure.
“Errors are part of the human condition; it will never be possible for an individual to avoid all errors,” Wachter asserts in “Accountability in Patient Safety,” a 2015 article he co-wrote for the Agency for Healthcare Research and Quality. He proposed organizations should “aim to create environments where opportunities for workers to ‘be good’ are logistically feasible [say, with a sink or a germicide dispenser inside the door of every patient room] and culturally reinforced [say, with every scrub nurse empowered to speak up to the eminent surgeon who shortcuts a checklist].”
In the aviation industry, he points out, “the pilot and co-pilot are allocated 15 to 20 minutes to go through their preflight checklist, and there’s just an assumption they’ll do it. It’s built into the planning and the salary structure. Medicine hasn’t built time for that into our economic model.”
But it’s starting to. Around the country, hospitals and health systems are adopting the Lean methodology that Japanese automakers popularized, in which teams of workers and managers critique their own performance and each member is entrusted to flip the switch on the assembly line if something looks amiss.
At Johns Hopkins Hospital in Baltimore, every unit has adopted a set of performance metrics for which it is held accountable, says Michael Rosen, PhD, an associate professor of anesthesiology and critical care medicine. Repetitive failure to hit a target generates attention up the line, ultimately reaching the system level — but not to be punitive, Rosen emphasizes. “The idea is to fix it,” he says, and these “escalating review sessions are relatively new for us, and very powerful.”
At UCSF, Wachter notes, every outpatient clinic has a board showing measures in four or five domains. “And there’s an absolute expectation that the leader of the unit will do weekly rounds and everyone will sit down and talk about what’s on the board, how they’re doing well or how they could do better,” he says. “There’s a much more rigorous systems approach to management accountability. The seriousness with which people take this is like night and day.”
Walking the Walk
Like rainwater percolating into the subsoil to nourish crops at the roots, a culture of accountability filters down from the top, industry literature universally emphasizes. So what does it say about accountability in U.S. health care that only 52 percent of the nation’s hospital leaders have agreed to report clinical performance data to the Leapfrog Group?
Leapfrog is a nonprofit watchdog organization established by major health care purchasers in 2000 to collect, analyze and disseminate hospital data. The aim was to “trigger giant leaps forward in the safety, quality and affordability of U.S. health care by using transparency to support informed health care decisions and promote high-value care,” according to the organization’s mission statement.
“It’s disappointing,” says Erica Mobley, Leapfrog’s operations director, “that almost half the hospitals in the country are unwilling to make that commitment [to transparency]. Hospitals are very willing to make excuses for why they decline to report, but I think they owe it to their patients and their purchasers. Those that do report recognize it as a very valuable performance tool for benchmarking and identifying areas where they have gaps.”
About 100 new hospitals sign on to Leapfrog each year, she says. “And we’ve started to see more and more frequently that those that do poorly own up to their mistakes. They tell their community, ‘Here are all the things we’re going to do to get better.’ They’re not shying away, they’re being accountable.”
“The whole public accountability piece in health care is new,” observes Johns Hopkins’ Rosen. “People are intimidated by it. Transparency is a cultural change.”
But it’s seeping in. “All arrows point to more measurement and more accountability,” Wachter says. “And for all the bumpiness in the road, medicine is better today than it was 20 years ago.”
Adds Toussaint: “The more deeply leaders, managers and associates understand the principles of operational excellence, the greater the probability of creating a sustainable culture where achieving ideal results is the norm rather than the aspiration.”
David Ollier Weber is a freelance health care and business writer based in California.