1. Section Editor(s): Raso, Rosanne MS, RN, NEA-BC

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The word accountable is everywhere: accountable care, Accountable Care Organizations (ACOs), shared accountability, accountable care units, "crucial accountability." It represents a high level in the performance hierarchy and we seem to continuously be looking for ways to improve it-individually, system-wide, and nationally. Nursing responsibility and accountability for our practice have always been fundamental to our professional code. So what's different? Are we more accountable now?

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First, you may be wondering about accountability versus responsibility because these words are often used interchangeably. They're related but different; after all, we don't have "Responsible Care Organizations." In terms of our roles, responsibilities are the requirements, the job description. Accountability comes after-did you get it done? It's being answerable for the responsibilities and the results. This is personal for individuals, and the concept translates easily to teams and organizations.


Why do we fail at accountability? Maybe the expectations are unclear or unrealistic. Perhaps we don't believe that we're accountable because we don't agree or the responsibilities seem arbitrary. It's harder to get buy-in for something that's opinion-based rather than evidence-based. We may also fail if we don't think anyone really cares if we do it or not. This reminds me of the factors we look at when using just culture principles.


In a culture of accountability, there are no more excuses for failed results. You do what you commit to doing. "Almost" isn't good enough. We "hold each other accountable," a phrase used frequently, which, unfortunately, connotes requisite supervision but really means that no one accepts excuses at any level. Leaders call out failures at the individual, unit, and organizational levels. The culture is that it isn't okay to ignore responsibilities and if they're ignored, it's dealt with effectively. By effectively, I mean respectfully and with a process for validation and follow-up.


The volume-to-value reimbursement evolution has pushed accountability for clinical outcomes into the finance department. Why did it take our payers and forced governmental transparency to push us into accountable care? We spent many years hiding our results and making excuses-a healthcare culture that wasn't accountable or truly patient-centered. We now have pioneer ACOs, groups of hospitals and providers responsible for managing and improving the healthcare for a group of patients while decreasing costs. This takes accountability to a macrosystem level with many moving parts. Some of these ACOs have worked, whereas others haven't for various reasons. This definition of accountability is a work in progress.


What do you think about the accountable care unit concept? Focused on strong collaborative leadership and interprofessional teams, it takes the ACO to the unit level with defined unit-level performance indicators, such as length of stay, patient experience, discharge time, and incidence of hospital-acquired conditions. Established goals, clearly defined responsibilities, shared accountability, and true physician-nurse coleadership-all contribute to its effectiveness.


Transparency, value-based revenue risk, and healthcare reform have changed the landscape. The pressure on us to be responsible and accountable for processes and outcomes is more omnipresent, as it should be. It's our professional responsibility to ourselves, our patients, and each other to create and nurture quality healthcare. No excuses.



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