Understanding accountability begins with defining the term.
by Shaun Frost, MD, SFHM
In my last column, I outlined the “accountability imperative” facing the specialty of hospital medicine, and I discussed the need to hold ourselves accountable for delivering true, high-value healthcare. However, this is easier said than done; being accountable in the complex environments in which we work is difficult. The key to simplifying accountability rests in deconstructing the concept in a manner that allows us to consistently appeal to its fundamental tenets, so that applying these tenets in our everyday lives is easy. Understanding accountability begins with defining the term.
To be truly accountable, one must first appreciate what accountability is, and what it is not. This is beautifully articulated in a well-written book by Connors, Smith, and Hickman titled “The Oz Principle: Getting Results Through Individual and Organizational Accountability.”1 Connors and colleagues advise that we must conceive of accountability as forward-looking versus backward-looking judgment. All too often, society thinks of accountability as a historical or retrospective concept, that accountability is something to invoke when an individual has failed to meet expectations. Defining accountability in this manner casts the concept in a negative light by invoking fear and anxiety; accountability becomes synonymous with punishment, retribution, blame, humiliation, and scrutiny.
“The Oz Principle” suggests that “accountability is more than a confession,” and warns that people who narrowly define accountability in this manner become “obsessed with the past, and blissfully ignorant of the future.” This is sage advice for the profession of medicine. All too often, clinicians and healthcare professionals yearn for a past era in which it was supposedly easier to practice medicine because of independence from rules, regulations, protocols, pathways, performance measurement, and performance reporting. In lamenting the loss of a past era, people risk ignoring the present and thus fail to embrace healthcare reform initiatives that will soon establish new expectations. These new expectations must be met to ensure future success.
It behooves us─hospitalists─to define accountability in a more constructive and future-oriented manner. To this end, Connors and colleagues propose that accountability be conceived of as “a personal choice to rise above one’s circumstances and demonstrate ownership necessary for achieving results.” Such a definition empowers us to anticipate the future by acting proactively to avoid problems, rather than reactively, which forces us to explain why problems occurred. In so doing, we embrace our current situation, actively seek to understand new initiatives compelling us to alter our behavior, recognize the dangers in maintaining outdated status quos, and become actively engaged participants in obligatory change initiatives.
If this is our perspective, genuine, patient-centered care will become the norm, and we will avoid the temptation to dismiss problems as beyond the scope of our responsibility or control. If rising above our circumstances is the motivation, we will not blame poor patient satisfaction survey results on bad hospital food, avoidable hospital readmissions on unavailable post-discharge follow-up appointments, and unnecessary testing on the risk of malpractice litigation.
Furthermore, we must appreciate that our spheres of responsibility overlap those of others in healthcare. As such, success in meeting our expectations directly influences the ability of others to successfully meet theirs, which directly affects our collective ability to achieve healthcare improvement goals. For example, if hospitalists do not effectively communicate patient-care-plan information to nurses, nurses will not be best prepared to respond to patient questions, and patients will potentially be dissatisfied with their hospital experience. In such circumstances, it would be unfair for the hospitalist to blame poor patient satisfaction scores on nursing, because patient dissatisfaction could have been avoided had the hospitalist been accountable for sufficient communication of care-planning information.
Examples such as this turn the spotlight on healthcare professionals. We are jointly accountable for the delivery of high-value healthcare, and are interdependent on each other in this regard. According to “The Oz Principle,” “when people view their accountability for results as something larger than doing their own jobs, they find themselves feeling accountable for things beyond what a literal interpretation of their job description may suggest.”
The key to maintaining a future-oriented and proactive view of accountability (pushing us to consistently rise above our circumstances) is to not fall trap to becoming a victim. Connors and colleagues caution that when confronted with poor results and suboptimal performance, there is a natural temptation to make excuses, point fingers at others, create arguments for why we are not to blame, and otherwise rationalize why we are not accountable. Unfortunately, this attitude only perpetuates the myopically negative view of accountability “as a confession,” to be invoked to scrutinize, blame, or punish. A victimization mentality leads to the creation of cultures in which “saving face” is more important than solving problems, and, according to “The Oz Principle,” “quick fixes are favored over long-term solutions, immediate gains are favored over enduring progress, and process is favored over results.”
The danger of favoring process over results seems particularly germane to healthcare quality improvement (QI). In the complex, fast-moving, and pressurized environment of the hospital, it is easy to become satisfied with creating and deploying processes to address such issues as glycemic control, VTE prevention, or safe transitions of care. These processes are surely necessary, but they are certainly not sufficient.
Results are what we are aiming to achieve—not processes. In order to achieve results, the process must be actively managed, and the participants engaged in the processes must hold themselves─and each other─accountable for achieving the results that the processes are designed to effect.
Connors and colleagues write that “accountability for results rests at the very core of continuous improvement....The essence of these programs boils down to getting people to rise above their circumstances to do whatever it takes to get the results they want.” In order for HM to rise above current healthcare circumstances, we must never play the victim role. Blaming others will only keep us mired in current dysfunctional situations, preventing us from breaking free of untenable status quos that prohibit the delivery of high-quality and cost-effective patient care.
Accountability is difficult, especially for hospitalists. The time, though, is now for each of us to embrace accountability, because we will be expected to perform at increasingly higher levels of sophistication in the future. The first step to embracing accountability is to understand the concept, and in my next column, I will further describe concepts that demystify accountability by making it easier to apply in our everyday experiences.
Dr. Frost is president of SHM.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.