Accounting for Accountability

Sit in any meeting of health care executives and you are bound to hear the term “accountability” thrown around. This is especially true today. Under health reform, so many of the needed changes depend on leaders, physicians and frontline staff delivering measurable results. We are told that hospitals and physician groups are being held accountable for patient outcomes and nurses are being held accountable for exceeding patient expectations. In reality, however, accountability is exactly what seems to be what is lacking in many organizations. It’s worth examining why this is so hard to achieve.

Accountability is often used synonymously with such concepts as responsibility, answerability, blameworthiness, liability and other terms. Loosely translated, it means the buck stops with everyone.

Every organization’s bottom line depends on all executives and employees feeling responsibility to their jobs, colleagues and patients. When is accountability an issue that needs to be addressed? One hint might be when an organization finds itself dealing with the same issues in the same manner, again and again. For example, putting hourly rounding into practice includes meeting specific objectives, but often rounding is taken for granted, as something to be done if no other needs arise. When an organization fails to achieve objectives and cannot identify why a practice such as hourly rounding is not succeeding as planned, it has an accountability problem.

The following are a few ideas on how to ensure that each employee has a sense of ownership that extends beyond a paycheck:

  • Start at the top. Creating a culture of accountability is a job that starts with the highest level of leaders. One of the biggest failures is to begin a process and not follow through with it. This causes the employee to lose respect for the process and to question a leader’s commitment, which can undermine any initiative. When I was a nursing director, I would drop everything to answer a call light or assist a visitor. No matter how busy I was, I was cognizant that I needed to send the message to my staff that these behaviors were always expected.
  • Define success. The employees must understand what the initiative is trying to achieve. Employees need to know what they are being held accountable for. How do they know when they have succeeded or fallen short? Setting clear standards and goals gives them something to target.
  • Seek feedback and listen. If you want accountability from employees, you have to be willing to listen to their advice – and then take it. Service excellence initiative decisions are often made without asking those frontline workers who probably know their customers best. Provide formal channels for employee feedback on implementation, and be sure to communicate your actions back down the chain.
  • Evaluate the results. How do you know if employees are actually being accountable to the new practice, and how do they know? Spend time sharing objective criteria such as call light volumes and patient satisfaction data. Also use input from patients and employees to find a balance between productivity and customer satisfaction.


Holding employees accountable to clear and high standards is a benefit to everyone. When you expect more from your employees, they perform better and feel good about their jobs. When employees have tools to identify and track their performance, they know exactly where and how to improve, which boosts productivity. All of these factors lead to higher staff satisfaction and patient satisfaction, which for managers and executives is the ultimate accountability metric.