Creating a Culture of Accountability in Health Care 
Joshua O'Hagan MHA 
David Persaud PhD 

The Health Care Manager
April/June 2009 
Volume 28 Number 2
Pages 124 - 133

Abstract

Health care providers are constantly striving to improve quality and efficiency by using performance management systems and quality improvement initiatives. Creating and maintaining a culture of accountability are important for achieving this end because accountability is the reason for measuring and improving performance. The keys to creating a culture of accountability will be explicated by examining the extant literature, and from this, 6 methods will be outlined for creating such a culture.


HEALTH CARE PROVIDERS have used performance management systems and quality improvement methods in an attempt to improve the quality and outcomes of health care services. Unfortunately, although these techniques have been successful in industrial fields, they have not been nearly as successful in the health care area.1 There are a number of reasons for this. However, the main factor has been the negligible change in organizational culture to complement the tools and processes that are used to improve quality.2

If an organization wishes to continuously learn and use evidence-based practices, it must create a sense of accountability within employees. Instead of shifting from 1 flavor of the month to the next, accountability ensures the permanence of performance management and continuous improvement by holding people accountable on a daily basis. The totality of all persons being accountable for their actions serves to create accountability at the unit, department, organizational, and industry level. This article will discuss concepts of accountability and methods to facilitate the creation and sustainability of such a culture.

DEFINING A CULTURE OF ACCOUNTABILITY

Accountability encompasses the procedures and processes by which one party justifies and takes responsibility for its activities such as for achieving various organizational goals.3 In some aspects, accountability is very similar to stewardship in health administration because it demonstrates responsibility to the patient population that the organization serves. Also, as with stewardship, accountability aims to ensure careful and responsible management of human, physical, and financial resources. Essentially, these concepts are concerned with the efficient utilization of resources while providing maximum benefit to stakeholders by combining an individual's dual responsibility to self and that of others for their actions.4

It therefore becomes important to describe what a culture of accountability in health care looks like and why it is necessary to focus on culture. To answer the first part of this question, we would expect that a culture of accountability would contain a set of common elements wherein the common belief is continuous learning and improvement at the individual, unit or department, and organizational levels; wherein decisions regarding care and direction are guided by evidence-based protocols and clinical practice guidelines (CPGs) but not by individual preference; wherein performance measurement is an essential element in assessing outcomes and guiding improvement initiatives; wherein reporting errors is encouraged and not punished; and wherein there is collaboration and coordination among and between all levels of the organization and across all specialties. The second part of this question relates to the fact that any significant organizational change initiative that is to be long-lasting does not occur without changing the culture of an organization.5,6

WHY IS A CULTURE OF ACCOUNTABILITY IMPORTANT?

The primary reasons include improved quality of patient care and value for money spent on health care services.7 Increasing the accountability of employees will also reduce overuse, misuse, and underuse of resources while possibly reducing costs for payers.8 Accountability also improves the quality of patient care by increasing the use of evidence-based medicine and performance measurement with the aim of reducing inappropriate care.7 Furthermore, accountability encourages the assessment of evidence from process and outcome measures by using feedback from performance measurement to improve processes and outcomes of health care activities.9 Finally, accountability is synonymous with the utilization of evidence-based practices, such as CPGs, while enhancing learning and reducing variability.8 Intuitively, if employees and organizations are holding themselves more accountable, then the desire to learn and use evidence-based practices and performance measurement tools will be increased, thus engendering continuous assessment, learning, and change. Consequently, variability in health care will decrease as a result of a culture that emphasizes accountability.10

THE GOAL OF CULTURE CHANGE

The ultimate goal of creating a culture of accountability is to create a continuously learning organization. A continuously learning organization promotes the acquisition and use of new knowledge as a strategy for coping with change and also recognizes the critical need to empower workforces to learn and participate in continuous improvement.1 To support a culture of accountability, an organization must be able to access, create, manage, and use knowledge so as to improve organizational processes and allow organizational members to experience the benefits of accountability. In addition, when employees become more accountable for their actions and are given more responsibility, this enhances the development of a culture that reflects continuous improvement and learning.8,10

SIX STEPS IN DEVELOPING A CULTURE OF ACCOUNTABILITY

To create a culture of accountability, several factors need to be addressed. People must believe in the concept; have committed leadership; and be given the training, tools, and requisite resources to succeed. They also need performance feedback to motivate improvement. Without these resources and support, those being targeted for culture change will only become cynical and frustrated when they attempt to fulfill accountability expectations.10 With this in mind and the evidence from the literature, 6 steps are outlined that can be used to develop a culture of accountability (Table 1).

Table 1 - Click to enlarge in new window Table 1. Six steps to facilitate the creation of a culture of accountability in health care

Table. No caption av... - Click to enlarge in new window Table. No caption available.

Culture change requires committed leadership. Inadequate or inappropriate leadership has been identified as a key factor when attempts to change culture fail.6 Within the context of leadership, there are also 2 management philosophies that are pervasive. They are commitment-based management and control-based management. The first view postulates that people are capable of self-discipline and, given the opportunity and developmental experiences, they will seek responsibility in exercising initiative.11 The consequences of such commitment-based management are that employees take initiative and seek out responsibility. They also become actively engaged and committed to their work and have high morale and cooperation and trust for one another. Furthermore, there is low employee turnover, utilization of human capacity is high, and employees take pride in the organization and its mission-they are intrinsically motivated to be accountable.11

In contrast, control-based management assumes that people are incapable of self-discipline and cannot be trusted. Consequently, they need to be monitored and controlled closely to ensure that they behave consistently. There is also a pervasive belief that without proper surveillance, people will lose motivation.11 The consequence of such control-based management is that employees follow instructions and do just what they are told. There is no organizational citizenship behavior.11 A sense of indifference toward work occurs, and this creates an environment where there are low morale, mistrust, feelings of helplessness and frustration, high employee turnover and absenteeism, and low utilization of human capacities and where employees show symptoms of deviance and aggressive behavior11 Currently, most health care organizations use variations of control-based management philosophy, and this inhibits intrinsic motivation.11

What is required under these situations in which control-based management pervades is the utilization of transformational leadership principles that also incorporate fair practices (procedural justice) to reduce pervasive organizational barriers that are present in the health care industry.5,11 This is unlike transactional leadership, which works by trying to engender organizational compliance and control by using mostly material motivational factors such as reward systems.6 Transformational leadership by contrast is based on inducing culture change for the long term by mapping onto employee-shared values such as stewardship for the health care system and by creating a compelling vision that communicates urgency for change. It also creates an environment of psychological safety that fosters open reporting, active listening, and frequent sharing of insights and concerns and by empowering and supporting team learning throughout the organization.11 An emphasis on fair procedures can then lead to organizational citizenship behavior.11 This behavior includes being helpful and conscientious, performing job duties to levels well beyond those normally expected, becoming involved in the governance of the organization, and taking steps to improve all aspects of a job even when it is not mandatory.12 Essentially, it is a reflection of being a good steward (an effective and ethical agent) of the organization, which ultimately is the key to accountability.

Leadership that exemplifies accountability must also be pervasive at all levels of the organization.10 It is a mistake to think that leadership is primarily an administrative function because in a health care setting, most protocols are a combination of both administrative and clinical processes. The implication of this is that, in addition to having a chief executive officer, the change process must involve a team of leaders and individual managers to help inspire change within each portfolio, department, and unit. For example, to gain physician buy-in, a physician champion must help to motivate others. This can help to reduce resistance from other physicians, especially given the fact that they are the gatekeepers of the health care system.13 It should also be noted that this argument does not only apply to physicians but to other health care professionals as well. Therefore, the consequence of using transformational leadership principles is to engender commitment-based management. This serves to enhance employee responsibility, morale, cooperation, and trust; reduced employee turnover; and increased utilization of human capacity-thereby helping to maintain accountability within the organization.11

To create a culture of accountability, it is important to reinforce that not only the quality of patient care will improve but also the quality of work will improve organization-wide. If employees associate the development of a culture of accountability with being reprimanded, it is unlikely that they will accept the new direction. Instead, what is required is a complete and total focus on emphasizing that this change will improve health care quality and employee satisfaction. For example, a method for increasing accountability within the organization could be the implementation of an error-reporting systems.14 However, the key is to emphasize that the system is being used to fulfill 2 goals. The first is to correctly identify deficiencies in care processes, information technology, and medical equipment and supplies. The second goal is to learn from these adjustments to continuously make further improvements that will produce better outcomes for patients and improved working conditions for employees. Reinforcing quality and learning in this way provides an important impetus for worker input to improve organizational activities.5,11

Health care providers are sometimes not as cognizant of the nonmedical aspects of care such as the physical and visual aspects of the care environment and perceived courtesy and availability of staff.15 However, patients value such characteristics of service.16 There are important reasons for striving to provide quality customer service. An environment that provides exceptional quality care not only improves the patient's experience but also leads to more satisfied staff, fewer preventable medical errors, fewer malpractice lawsuits, and improved revenues-therefore helping to reinforce a culture of accountability.17 For example, studies have shown that satisfied patients trust and engage with their caregivers, have fewer complications than those who are not satisfied, are more compliant with their prescribed treatments, and are less likely to experience a preventable medical error.17

To ensure that customer service is a priority for the organization, it must be evidenced through the mission, vision, and values and also linked to the strategy of the organization in the form of a customer service plan. Moreover, to engender good customer service behavior in all employees, training sessions must be provided to all current staff on how to deliver good customer service, as well as orientation training for new employees. This should be accompanied by regular performance appraisals to hold employees accountable for higher levels of customer service.18 Moreover, the organization must ensure that employees are satisfied and empowered by having fair and equitable organizational processes, rewarding them when applicable, and using simplified forms and procedures.5,19,20 Finally, feedback from both internal and external stakeholders ought to be collected as part of a performance management program by using employee and patient surveys.9

Performance management is a demonstrated tool that improves quality21 and has a positive influence on employee performance and managerial effectiveness.12 There are 3 broad aspects to performance management-measuring, reporting, and management and assessment of outcomes relative to quality improvement plans.9 Performance measurement is an important process in creating a culture of accountability because measurement informs on quality and you cannot manage what you do not measure.7 The measurement of outcomes includes monitoring the performance of the organization against service standards and organizational goals.19 However, it is also important to collect feedback from patients and other stakeholders (ie, community health boards). In combination with quantitative information obtained through measurement tracking, assessment of stakeholder feedback affords the organization the opportunity to assess all aspects of organizational functioning. Once information has been collected, it must be reported, which can be achieved by ensuring that specific individuals or teams are held accountable to guarantee the transfer of information to the correct lines of authority.

Finally, assessment of reported data must ensue to ensure the translation of feedback from measures into strategies for action that can be used to improve health care provision; this is an important aspect of performance management.9 It is not enough to simply collect information. It must be acted upon. Consequently, the organization ought to have policies pertaining to the assessment of collected data, developing follow-up recommendations, and creating plans of action for improvement (ie, root-cause analysis). This increases accountability. One of the reasons why hospitals do not learn from their mistakes is that workers are aware of the problems when they encounter them, oftentimes solving the problems; however, organizational learning does not occur because the solutions are not transferred organization-wide.22 This is known as first-order problem solving, and it keeps problems and solutions localized so that they do not surface as organizational learning opportunities.22 What is required is second-order problem solving where the initial problem is resolved and management is also notified so that action can be taken to address the underlying causes.22 Consequently, although we attempt to develop a culture of accountability, we need the culture to be inclusive and accepting of reporting errors. This type of atmosphere provides for psychological safety and allows employees to feel secure about reporting errors.22

Change will often cause fear, anxiety, and resistance in employees.5 However, supporting the human dimension can help to minimize these feelings.19 This process begins by increasing the self-efficacy of employees, which positively enhances their beliefs about their capabilities. This is done by giving employees training, responsibility, and involvement in decision-making processes. However, one of the reasons that improvement initiatives have not always been successful in health care is that, although supporting structures have been provided, other aspects of the human dimension were not reinforced. A way to improve this is by ensuring that performance expectations at the individual, patient care team, and management levels are known-essentially clarifying accountability expectations at all levels within the organization. Examples of such expectations include precise job descriptions, the utilization of evidence-based treatment protocols, benchmarking, and the specification of expected health care outcomes.23

It has been shown that goal setting is an important predictor of success.24 Consequently, an organization should invest in mentorship programs and the development of systems that support and document individual and team progress on long-range goals.2 The roles of performance appraisals at the individual and team level are also applicable in these situations because they help individuals and teams to set goals, evaluate their progress toward success, and provide direction for the future. In developing a culture of accountability, it is important to link individual and team performance to the strategic plan of the organization, thereby emphasizing the accountability of individuals and teams.25

Another aspect of supporting the human dimension is to ensure that employees are rewarded for engaging in behavior congruent to predetermined goals. Rewarding employees can be done by using a recognition program that celebrates both small and large successes formally and informally.20 For example, employees can be recognized informally by printing their achievements in a monthly newsletter or formally with a certificate or plaque. Also, exceptional service or efforts at increasing accountability on the individual, team, organizational, or system level could be rewarded with inexpensive incentives such as gift certificates.20 The purpose of rewarding employees is to foster a culture that recognizes and accepts achievements that reflect accountability. Having such programs helps to publicize the concept to employees and makes them aware of the type of culture that is being reinforced. The organization also needs to support the existing workforce by hiring the right people. In any organization, there are those who welcome change and those who may not. It is counterproductive to employ people who are wedded to the old ways of doing business.2 Ensuring that hiring practices select people who are willing to be held accountable will help to create and maintain an organization that exemplifies a culture of accountability.

Finally, whether it is training employees on a new error reporting system or a benchmarking program aimed at increasing accountability, it is important to give employees the opportunity to attend didactic sessions and learn through mentorship programs. Generally, training yields the best results when it is followed by immediate use, as opposed to several months in the future when the information has been forgotten.13

In parallel with supporting the human dimension, it is critical to ensure that a supporting infrastructure is in place to enhance the actions of employees and enable them to use their skills and resources effectively.8 Essentially, it is important to provide people with the means and competencies necessary to be successful.26 As outlined earlier, it is important to measure performance and hold people accountable for performance goals. To do this, information systems are needed that provide information on a timely basis from which to make decisions. Also, effective communication systems are needed that allow the distribution of information and knowledge to the rest of the organization. Finally, a human resource management system that ensures that individual performance is monitored and compared to accepted standards is a necessity.8 Some lessons to be learned regarding such systems include the following:

1. Many information systems are inadequate and technologically out of date (ie, DOS versions of information systems) and incompatible across different units. For example, Adler et al8 found 4 clinical databases and more than 28 systems in use across different units of one hospital, most of which were incompatible. This severely limits the ability of performance management systems since they are reliant on data from information systems. Consequently, in these situations, it is difficult to assess performance or to determine whether improvement initiatives have been successful and have had the desired impact.8 This must be overcome by ensuring integration of clinical and administrative systems. An example of this is the HealtheVet system in Virginia, which integrates a health data repository with registration systems, provider systems, management and financial systems, and information and education systems.21 This creates a health care record that supports research and population analyses, improves data quality and security, and facilitates patient access to data and health information.21

2. Communication systems often fail to provide for sufficient downward or lateral information dissemination.8 This can be overcome by having meetings between management and frontline staff regarding organizational activities and by having executive walkabouts that allow staff the opportunity for questions and to provide feedback.

3. Human resource systems often do not provide enough incentive for physicians or other staff to commit time and effort to improvement projects, such as error reporting.8 This is why it is critical to map onto those values of these professional groups and demonstrate the benefits to them. For example, if we want physicians to report adverse events, then it must be demonstrated that such reporting will not result in punitive action, and management must ensure that the benefits of reduced error rates and improved patient care are obvious.

CONCLUSION

Health care providers are constantly looking for ways to improve the quality of service they provide to meet the demands of the public and close the quality gaps in health care systems.8 The key to providing high-quality care is starting with a culture of accountability. A culture of accountability can help to reduce the overuse, misuse, and underuse of resources8; increase utilization of CPGs and evidence-based medicine; improve patient care outcomes; and ultimately create a continuous learning organization.10

Transformational leadership at all managerial levels, along with the support of key personnel from physician and other health professional groups, can help to overcome pervasive barriers to enhancing accountability embedded in health care. The emphasis on quality is important not only for patient care but also for all organizational processes. The benefits of emphasizing quality and providing good customer service to patients include improvements in patient outcomes, as well as higher employee morale and satisfaction. Performance measurement is necessary because it informs on the gaps between current and desired outcomes.21 However, action on closing these gaps is the key to improvement and visibly reinforces the benefits of being accountable. Consequently, emphasizing improvements in quality and taking the time to measure, translate, and report both quantitative and qualitative information will make culture change possible. Moreover, supporting the human dimension by providing training, clarifying roles and responsibilities, and performing expectations will help to reduce feelings of fear and anxiety that impede culture change.5 In addition, rewarding people for their efforts and hiring people who are willing to be held accountable will reinforce a culture of accountability. This must all be done in consort with the appropriate supporting infrastructure, such as information systems, communication mechanisms, human resource management systems, and performance management systems.8,19 Finally, using the 6 facilitators discussed here will help to create and maintain a culture of accountability. This will allow performance management and continuous learning and change to become enduring traits of health care organizations.

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