1. Cox, Sharon MSN, RN
  2. Beeson, Ginny MSN, RN, NEA-BC

Article Content

As Mark Samuel says in his book, Creating the Accountable Organization, "The myth is that accountability is a way to blame someone for making a mistake, resulting in fear. The truth is that accountability is the key for increasing trust, reducing fear, and improving morale and performance."1 Accountability is a willingness to answer for results and behavior. It's a commitment to own, discuss, and learn from mistakes and successes in an environment where individual and shared ownership produce outstanding results. Accountability is a personal responsibility-it isn't my job to "hold you accountable," it's your job to be accountable.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Accountability is inherent in professional practice; the challenge is creating a work environment that allows staff members to take accountability and develop as high-performing professionals. It's essential to see accountability not as a means of control or faultfinding, but rather as a process supporting the belief that people want to be accountable for the work they do and develop themselves along the way. This belief in people is evidenced by coaching those who fall short of meeting performance expectations and truly appreciating those who consistently meet or exceed them.


Reflect for a moment on your basic beliefs about accountability because your assumptions will play out in what you do, consciously or unconsciously. Do you set a tone of learning from mistakes or do you focus on punishing for mistakes? Do you focus on fixing blame or fixing the system? Are you the first or last to admit your own mistakes? As a leader, you set the tone. When you handle mistakes with acknowledgment and support rather than blame and punishment, you create an environment in which accountability can flourish, replacing faultfinding with a more positive approach. The question then becomes: "What part of this is ours to own?" or "If you had this to do over again, what would you do differently?" Dealing with accountability in a constructive rather than punitive way builds trust and a sense of partnership.


In healthcare, our culture has been one that addresses accountability in a punitive fashion; however, as long as accountability is about punishment, we'll never have true accountability. In this article, we examine some of the reasons why we struggle with accountability and offer ideas, tools, and techniques to move from a negative to a positive approach to this extremely important topic.


Why do we struggle so much with accountability?

Accountability means having challenging and sometimes uncomfortable conversations. Usually, the people who need to be held accountable are the difficult people-and they've been difficult for a long time. We're afraid of losing people: "What if I hold them accountable and they leave?" Some managers don't want to be seen as a "battle axe." Often, the process for dealing with disciplinary issues is incredibly time-consuming and feels not only like jumping through hoops, but also that it seldom leads to lasting behavior change. And, of course, there's the nursing mantra, "We're too busy, too busy!"


When given the choice between challenging someone on an unmet responsibility and taking care of it ourselves, we almost always choose the latter (because it's easier). With pressures prevalent in healthcare today, we have a laser-like focus on hitting targets, often at the expense of a well thought-out process for how to reach those targets, why they're so important, or what will happen if targets aren't met. The urgency of meeting targets and deadlines overshadows the importance of understanding why we're doing what we're doing. This means we miss out on opportunities to build commitment and help people realize their full potential.


What are the primary components of accountability?

To instill accountability in our organizations, we need to clearly understand the three key building blocks of accountability. (See Figure 1.)

Figure 1:. Three key... - Click to enlarge in new windowFigure 1:. Three keys of accountability

Clear expectations

If we want people to meet job expectations, we need to clearly explain what the expectations are. It's in this vital first step that we often miss the mark. The problem can be a sender problem, such as giving unclear expectations: "We need to do better on The Joint Commission this year." "We have too many medication errors." "You aren't a good team member." Although these statements may be true, they give no indication of what should be done to improve the situation. To be successful, we need to answer all the "W" and "H" questions. For example: "What do you want me to do?" "Why's this important?" "How do you suggest we get started on this?" "What ideas do you have regarding this issue?" "When is this due?" "How does this fit in with all our other projects?" "Who else is working on this?"


We also need to be direct and convey commitment. Saying, "Does it seem loud in here this morning?" isn't direct. If we think it's too loud, we should say, "We need to quiet down. It's very loud this morning." Saying, "The boss says we need to do this, so I guess we need to do it" doesn't convey commitment. When you say this to your staff, you've just told them you aren't excited or in agreement. If I'm a clinical nurse and my boss isn't committed, then neither am I. Similarly, our nonverbal and verbal cues must match. Rolling your eyes or an insincere tone also tells me you aren't that committed.


When setting expectations, make sure they're understood. Frequently, the sender is clear, but the receiver doesn't "receive." How often has this happened to you? Your boss calls the managers into his or her office to explain a new policy. At the end, he or she asks if anyone has a question and no one asks a question. (This can be for many reasons: you don't want to appear stupid, you have a million things to do before going home, you don't want to seem like you aren't a team player, and so on.) You all leave the office and say to each other: "What in the world are we supposed to do?"


If people don't understand the expectations, at best, they'll interpret what you say in a way that makes sense to them, which may or may not be what you want; at worst, they'll ignore you. Either way, outcomes, results, and quality are at risk.



Once we've set the expectations, the next step is follow-through. Do people have what they need to do the job? What are some necessary first steps? Is follow-up needed? If so, how often? When? Who'll do it? Follow-through can involve mentoring, coaching, guiding, feedback, encouragement, and support. Staff members may need motivation or inspiration as they strive to meet expectations. Often, as people get involved in the work, it's discovered that additional time or resources are needed. Sometimes, expectations need to be altered or changed. All follow-through actions should focus on goals, behaviors, and actions; always refer back to the expectations (which is why it's helpful if they're written down). Follow-through does take time, patience, and persistence. Asking how staff members are doing with the new policy, how their project is coming along, or how the new orientation is going can be part of your daily routine; put it on your to-do list. (See Table 1.)

Table 1: Tips for fo... - Click to enlarge in new windowTable 1: Tips for follow-through

Without follow-through, accountability falters. If you ask me to do something, give me a special assignment, and then never ask me about it again, what's my incentive to complete it? Taking the time to agree on what follow-through looks like-time frames negotiated, check-in points delineated, and resources identified-is time well spent. When follow-through is done well, a sense of partnership develops, adjustments can be made before an issue escalates, and engagement is strengthened.


Rewards and consequences

If we want people to meet the expectations, there needs to be rewards when they do and consequences when they don't; we struggle with both.


Looking at rewards first: What are the challenges regarding rewarding people? One is simply remembering to do it! We take for granted that most of our staff members are meeting expectations and we miss out on the power of a well-timed word of thanks. Other challenges are keeping rewards sincere and timely. It isn't helpful to be told how good you are when the boss is about to ask you to take on something else. Rewarding staff doesn't take time; it takes effort, memory, and practice. It doesn't cost anything, it isn't hard, and it requires no training. It's one of the cheapest, easiest, and best ways to improve accountability.


Don't make rewards complicated; it's the simple things that matter. Make sure there's a clear connection between the reward and the behavior. Research indicates that the frequency of praise significantly improves performance and retention, especially for new hires.2 In his book, Discipline Without Punishment, Dick Grote writes, "The more that the manager provides positive consequences for good performance, the more likely it is that good performance will be delivered."3 Patterson et al. in Crucial Confrontations remind us to "praise more than you think you should, then double it."4


Addressing consequences is the most challenging piece of this three-part process and a key reason we struggle with accountability. It involves conflict, and we don't like conflict. Usually, the people we need to have conversations with are the "difficult" people who frustrate us so much that we move into a parent/child style, which is often punitive. We can also vacillate to the other extreme and make excuses for marginal performance: "Bless her heart, she tries hard" or "Clinically she's really good, but no one wants to work with her." Then we complain about "bless her heart" in the parking lot and hope she'll transfer to another unit.


Finding the balance between these polarities and taking a more positive approach to accountability involves progressing from coaching to counseling and then, if all else fails, to a nonpunitive disciplinary process. Effectiveness in this phase takes time, thoughtful intention, and an ability to be both firm and compassionate. Organizational support is also necessary, particularly from human resources (HR).


Knowing your efforts will ultimately impact quality, safety, teamwork, morale, retention, productivity, and workflow will hopefully motivate you to take the time and be intentional when dealing with the consequences of marginal performance. It also reinforces fairness for those who meet expectations day after day, and increases your credibility as a leader. Setting limits with a manipulative person or refusing to rescue someone with a victim mentality is challenging; we've provided a pocket card with several useful phrases and acronyms to guide your conversations at (click on the Online Exclusives tab).


Even the best managers have difficulty with the consequences piece. Tips and conversation starters are provided in Table 2. However, the best way to foster accountability in your staff is to model it yourself. Each time you deal with consequences, you have an opportunity to practice accountability in a positive or negative build commitment or just compliance.

Table 2: Tips for re... - Click to enlarge in new windowTable 2: Tips for rewards and consequences

Nonpunitive discipline

When you've been unsuccessful in getting someone's attention for needed behavior changes, a last resort is the disciplinary process. In healthcare, our approach to discipline has long been progressive negative discipline (verbal, written, suspension, termination) or treating people increasingly worse in hopes their behavior will get better. The underlying belief with this approach is that discipline and punishment are interwoven as a means of enforcing the rules; people need to be punished until they're compliant and the punishment should fit the crime. The issues with this approach are: a) it's adversarial in nature and managers have a reluctance to go there, b) it fosters compliance rather than commitment, c) it puts managers in a policing mode, d) employees learn to play the game and behave only as long as they're being monitored, and e) it rarely results in ownership for real change that's sustained over time.


Fortunately, healthcare organizations are adopting a nonpunitive approach to discipline commonly used in the business sector. In keeping with a positive perspective on accountability, nonpunitive discipline is based on the belief that changing behavior is a personal responsibility and it's possible to get someone's attention without punishing them. It's about creating a commitment to self-discipline rather than punishing someone into compliance. Fostering self-discipline inherently means the locus of control for sustaining change rests with the employee, not the manager.3


The nonpunitive disciplinary process involves a discussion of needed changes, a written outline of these changes, and, if necessary, a self-assessment decision-making leave, which is a paid day off for employees to decide whether they want to continue employment. If they opt to return and take accountability for the needed changes, they write a letter of recommitment to the organization outlining the changes they intend to make. If at any point in the future they fail to live up to their commitment, they've terminated themselves. This approach emphasizes the future rather than the past, creates ownership for change rather than being given an action plan, and allows the manager to move from cop to coach or from parent/child to partnership. In addition, nonpunitive discipline is the preferred approach in unionized environments because it's transparent and fair.5


Using this process, managers often report that the behavior changes outlined in the letter of recommitment go beyond anything they expected as employees take ownership for self-improvement and better managing their behavior. An employee relations manager reported that HR received thank-you notes from managers and staff when implementing a nonpunitive approach because it felt fair and affirming. This management practice allows us to see accountability in an entirely different light based on a belief in people rather than a need to control and coerce compliance.6


Methods for dealing with difficult behaviors, such as handling "crucial conversations," just culture training, and TeamSTEPPS, are examples of the support that's becoming more common as organizations rethink accountability. Systems and structures that move decision-making where it belongs, such as shared governance, process improvement teams, and Lean daily management, are essential for creating an environment of healthy accountability. A system for peer review is useful because peer-to-peer accountability is the ultimate goal in high-performing teams.


Figure 2 summarizes the shifts in perspectives around accountability; you may want to consider where you and your leadership team fall on the continuum between conventional wisdom and a more progressive view. The more you put systems or structures in place to move decisions where they belong, the greater the chances of creating a culture of accountability.

Figure 2:. Conventio... - Click to enlarge in new windowFigure 2:. Conventional vs. progressive

Creating a culture of accountability

The current healthcare environment is challenging us to see things in an entirely different light. As we shift our focus from volume to value, from illness to wellness, from patient as consumer to patient as partner, and from competition to collaboration, we must similarly rethink how we deal with accountability. Organizational efforts to improve the patient experience, get traction on strategic initiatives, or increase staff engagement hinge on the degree to which we can let go of outdated management practices and replace them with those that view accountability in a new light. When we get these new practices right, the ripple effect will be transformational, and that's what leadership is all about.


Bonus content

For a pocket card on accountability and nonpunitive discipline strategies, including a flow chart, sample policy, and letter of recommitment guidelines, visit and click on the Online Exclusives tab.


INSTRUCTIONS Getting accountability right



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1. Samuel M. Creating the Accountable Organization: A Practical Guide to Improve Performance Execution. Katonah, NY: Xephor Press; 2006. [Context Link]


2. Achor S. Big Potential: How Transforming the Pursuit of Success Raises Our Achievement, Happiness, and Well-Being. New York, NY: Crown Publishing; 2018. [Context Link]


3. Grote D. Discipline Without Punishment: The Proven Strategy That Turns Problem Employees into Superior Performers. New York, NY: American Management Association; 2006. [Context Link]


4. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Confrontations: Tools for Resolving Broken Promises, Violated Expectations, and Bad Behavior. New York, NY: McGraw-Hill; 2005. [Context Link]


5. Harvey E. Discipline vs Punishment. Dallas, TX: Walk the Talk Co.; 1987. [Context Link]


6. Cox S. Enough Already...Start Doing What Works at Work! Philadelphia, PA: Lippincott Williams & Wilkins; 2015. [Context Link]