How Leaders Create a Culture of Accountability in Health Care

Post-it note saying "Let's Talk"

By Ted A James, MD, MHCM
August 15, 2019

– Organizational culture is shaped by leadership. What the leader permits, the leader promotes.

A local hospital has been experiencing a years-long drop in quality ratings. There have been ongoing issues with adherence to patient safety protocols, and the hospital currently ranks below the national average for surgical complications, healthcare-associated infections, and unplanned readmission. Furthermore, the hospital has experienced repeated reports of unprofessional behavior among the clinical team, including disparaging comments and angry outbursts. Leadership has been reluctant to address the professional behavior complaints directly with the individuals involved due to their status within the organization. Several well-respected members of the institution have left, and many suspect others will follow.

Sound familiar? As a leader, you are ultimately responsible for your team’s results. Unfortunately, when leaders fail to address performance and behavioral issues, this undermines the entire team; leading to lower quality and weak organizational culture. It sets a dangerous precedent as people start to learn that there are no real consequences for poor behavior or performance. Without accountability, engagement wanes and resentment can build in members of the team who are negatively impacted. Leaders lose their credibility, and top performers leave.

Creating a culture of accountability is necessary for advancing an organization and sustaining your change efforts. You improve engagement and strengthen performance when there is a sense of mutual responsibility within the team. A culture of accountability also provides greater professional satisfaction by improving the work environment.

The truth is, you cannot build a high-performing team without this leadership skill. However, in my experience working with leaders in health care, I have found that many find it challenging to hold others accountable for performance and professional standards. There may be uncertainty about how to effectively address accountability issues or discomfort with the process. You may also be pressured to ‘turn a blind eye’ when problems arise in highly-productive (i.e., major revenue generators) or highly-influential individuals in the organization. Ironically, the cost of ignoring these issues almost always outweighs any perceived benefit of tolerating the negative behavior.

 Leading with Accountability

The good news is that leaders can take a proactive stance in creating accountability in individuals and their teams. Leading with accountability is about helping people assume responsibility for their role in achieving a shared goal. This process can be a valuable experience that provides opportunities for learning and improvement. Accountability works best in the context of support and development. Also, keep in mind, you cannot hold people accountable for results they have no control over. Leaders can, however, orient people toward expectations, connect with them at regular intervals to review progress, and help team members develop the skills and resources necessary to be successful.

A physician leader’s role in holding people accountable is really about helping colleagues to succeed in areas where they struggle.

Here are 3 steps to leading with greater accountability:

1. Be Intentional:

The first step in creating a culture of accountability is to set clear expectations. You should not assume that everyone knows what is expected of them in terms of quality and performance. It is your role to communicate the mission and explain how each member of the team contributes to the goal. It helps to define roles and responsibilities together with team members to achieve clarity and buy-in. Some groups develop a team charter, a set of performance metrics, or a professional code of conduct. These are essential for building peer-accountability, especially when the leader may not have direct authority over the entire team.

2. Monitor Progress:

Monitoring the progress of individuals and teams allows the leader to provide timely feedback, identify and remove any roadblocks hindering performance, and ensure that people have what they need to accomplish the goal. Simply checking in to see how people are doing and how you can be of help is powerful. Ideally, specific performance metrics are established collaboratively with team members. Using objective and transparent data (e.g., clinical outcomes, use of safety protocols, patient experience scores, O.R. start-times, meeting attendance, deficiency reports, etc.), helps avoid ambiguity when providing feedback and benchmarking performance. Agreed-upon elements of professional behavior (e.g., communication, punctuality, respect) can be observed directly or assessed through formal feedback mechanisms and shared with individuals.

3. Have Accountability Conversations:

Almost every leader inevitably faces a situation where a team member displays behavior that jeopardizes the quality of patient care or causes the team to underperform. Examples may include repeated commitment failures, productivity issues, poor clinical outcomes, lapses in professionalism, and overt disruptive behavior. It is critical to address these issues up-front and have accountability conversations. Don’t wait too long, or try to avoid it. The problem only gets worse, and it sends the wrong message when ignored. Having a framework for handling difficult situations in accountability is crucial. You can implement this simple yet effective approach to addressing accountability:

Cup-of-Coffee Conversation:

For a moderate, single incident or small recurring issues, you can adapt the “cup-of-coffee conversation.” This step is a private, informal conversation where the aim is not to pass a verdict, but rather to raise awareness of the issue and gain a better understanding from their perspective. Be curious and don’t assume to have the whole picture already. Start with, “I was surprised to hear…”, or “Perhaps you can help me understand this better…” After listening, you can then share your feedback in the appropriate context and remind them how their actions play into the bigger picture.

‘DESC’ Discussion:  

If patterns persist, or for severe problems, you may require a more formal, authoritative intervention. When having these discussions, it helps to have a system to get your message across, anticipate reactions, and keep from getting sidetracked. One example is a modification of the DESC model used for conflict resolution and giving feedback.

  • Describe: describe the behavior or performance issue as objectively as possible. Avoid drawing conclusions. Instead, focus on the specific behavior or performance, and use data if possible.
  • Explain: explain the results of their actions, including the impact on the team and the broader organizational implications.
  • Specify: specify the desired change and work together to come up with solutions. This is an opportunity to help build personal accountability. Depending on the circumstances, however, an action plan developed by the leader may be warranted.
  • Commitment: get a commitment to abide by the action plan or solution. Ensure that there is a mutual understanding. Express the consequences (both positive and negative) of future results.

Additional Pointers:

Mastering these conversations and becoming comfortable holding people accountable doesn’t happen overnight; it takes time and practice. When you conduct accountability conversations, it helps to have your talking points prepared. Acknowledge the purpose of the meeting (e.g., “I’m telling you this because…”). Do not beat around the bush or hedge your comments. Avoid inflammatory terminology (i.e., “You always…”, or “You never…”), and refrain from accusing (i.e., state the data objectively, free from additional inference). Brace for an emotional reaction and stand firm. Don’t allow the conversation to get derailed – stay on point. If the conversation starts to get sidetracked, calmly bring it back to the situation at hand.

A signed performance improvement plan can be incorporated. These plans outline the expectations, provision of resources, milestones, frequency of future accountability meetings, measurements of results, and the disciplinary processes taken if the plan fails. This document allows the individual to know precisely where they stand and to understand the steps in remediation. Overtly egregious actions may automatically accelerate to disciplinary measures and should include human resources and legal.

Leaders must also recognize when individuals need additional help through coaching or by addressing personal issues that influence behavior and performance. Be sensitive to burnout and be sure to support colleagues. Most importantly, when positive results are achieved, be sure to celebrate success.

Leaders Set the Tone

Finally, we should understand that accountability ultimately flows from the top. If you want your team to be accountable, you need to be accountable to your team.Model the desired behavior by always demonstrating the highest level of professionalism, accepting full responsibility for your actions, and showing humility. You will garner the respect of those you lead and inspire them to follow you.

ADDITIONAL READING

Head shot of Dr. Ted James.Dr. Ted James is a medical director and vice chair at BIDMC/Harvard Medical School. He is an alumnus of the Harvard Health Care Management program and is involved internationally in leadership development and health care transformation. He also teaches through the HMS Office of Executive Education.

Follow Dr. James: LinkedIn / Twitter

Dr. James blogs about health care transformation. To see more of his posts, click on his name in the tags below.

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

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