Far too many organizations believe that creating a corporate culture of accountability simply requires coming up with a statement of values, putting it on some posters and hanging them around the office. If only it were that easy. Nathan Rosenberg, a founding partner at Insigniam, says that (tweet this!): culture is much more powerful and pervasive than a bunch of aspirational bullet points. “It’s whatever is reinforced and it acts like an invisible force field,” he says. “Resources and strategy are important, of course, but a significant part of what people can and cannot accomplish at an organization is a product of corporate culture.”
In other words, as much as words matter — and they do — communication about values only makes an impact when it truly reflects how people in an organization act. And that means that changing culture to become more accountable and responsible demands a lot of work, especially in healthcare. Why? Rosenberg believes that the quirky and complicated business model in which patients don’t pay directly for the services they receive means providers are often insulated from the kinds of signals that motivate companies to create cultures geared around responsibility and accountability to patients. “It’s not customer satisfaction that drives success. It’s payer satisfaction,” he says. “No matter how great a job you do, the federal government or an insurer is only going to pay you X amount for a particular procedure.”
A CULTURE OF ACCOUNTABILITY
Accountability has become one of those catchphrases that is used over and over again without common understanding of what it means, says Rosenberg. “To give an account is to give a reckoning — a reckoning of results but more importantly a reckoning of the actions, and inactions that contributed to the result.”
In true accountability, there is a focus on actions. Yes, there are always circumstances one has to contend with that we cannot control. Our actions and inactions are how we have power, the ability to respond. Building cultures in which patients, physicians, nurses, and administrators each own the ultimate outcome, and their actions and inactions to bring about that outcome, takes a constant reinforcement of that mindset.
For large organizations especially, the prospect of reorienting a culture to be more accountable and responsible can be daunting. Is there a secret one-size-fits-all approach to implement systemic cultural change?
No, in fact, there isn’t. At least that was the experience Richard Buchler had when he worked with the Sutter Gould Medical Foundation (SGMF) in Modesto, California. A part of the Northern California medical group Sutter Health, SGMF utilized so-called rapid improvement events aimed at addressing hyper-specific deficiencies in how the organization functioned to establish real accountability. With Buchler as a facilitator, these improvement events brought together a task force of between nine and 12 people that always included an administrator, a physician, frontline workers, subject-matter expects, and a patient.
In one instance, Buchler worked on patient registration, looking for ways to make it faster, cheaper, and more satisfying for patients. Besides coming up with ideas for improvements, a central task was instituting accountability. “Each weeklong event always included a plan afterward to make sure that any improvements that were made were tracked and improved upon long after the event,” he says. “A central part of any improvement project was setting up accountability. New processes established were written up as standard work that all staff were expected to follow at all times.” Managers, too, were tasked with making sure any new procedures were followed, and director-level executives were also expected to do routine “rounding” tours to verify that changes were being embraced.
DEFINE EVERYONE’S ROLE
Jon Kleinman has a pretty simple way to illustrate the importance of clearly defined roles when it comes to creating a culture of accountability. Kleinman, a partner at Insigniam who specializes in leadership development and innovation, says it’s best to picture an organization as the pit crew for a Formula One racer. “That car rolls in for a stop, and you’ve got just a few seconds to change all four tires, fill the gas, and do a bunch of other things. You can imagine what would happen if you had unclear lines of accountability,” says Kleinman. While often difficult, Kleinman believes that taking the time to delineate who must answer for specific results being achieved or not is absolutely essential.
Leaders at Buffalo, New York-based Catholic Medical Partners have devoted a lot of time and effort to defining the myriad roles of numerous stakeholders in its network of 900 independent physicians. “What we have created is a culture around collaboration,” says Dennis Horrigan, CEO of Catholic Medical Partners. “They’re a diverse group of doctors and they’ve told us they want help to deliver better quality. We helped them by supporting the adoption of electronic health records so they and their staff could make better use of technology for care management. We also had success in advocating with the health plans on their behalf.”
Naturally, this is only part of the equation. Physicians who are part of the Catholic Medical Partners network must meet clearly defined standards for delivering evidence-based medicine, reducing readmission and infection rates, and other measures. Horrigan says that Catholic Medical Partners, which has garnered numerous awards for its use of technology and quality of care, has also made a significant effort to encourage patients to play an active role in their treatment. In part, that involves providing patients with web-based educational materials so that they can better understand their illnesses. But it’s also about ensuring that patients who need it have access to care coordinators, typically registered nurses, who can make sure they have the right medications, arrange follow-up appointments, and visit them in their homes to see that all their needs are adequately addressed. Not only does this approach boost patient involvement and accountability, it also reduces expensive hospital readmissions.
MEASURE AND RESPOND
An essential step toward creating a culture of accountability is some sort of objective measure of whether goals are being met. In the case of Catholic Medical Partners, Horrigan says that doctors are supplied with a vast array of data about their performance, along with resources to improve whenever necessary. “How well do you treat hypertension and diabetes? They know because we can help measure it,” he says. “We are identifying areas of improvement and giving them patient satisfaction data.”
The aim is for doctors to always improve and stay a part of the healthcare network, says Horrigan. But accountability also means taking some action when physicians don’t meet their commitments. “In some cases, we have asked doctors not to continue in our organization because we don’t think they are fulfilling their promise,” he says.
While it’s true that a few nice words from a CEO are not enough to establish a culture of accountability and responsibility, it’s also true that executive team support is critical. Buchler says little would have been accomplished during his time at Sutter Health without the backing of key leaders. (tweet this!) “The most important key to setting up accountability in healthcare is that the effort to do so is led by the CEO,” he says. “Without his or her buy-in, physicians can easily get away with doing runarounds of the new processes if they perceive them as being inconvenient.”
CRITICAL SUCCESS FACTOR
Culture of responsibility and accountability: In order to drive demonstrated value, both patients and providers will need to operate at higher levels of accountability. Organizational and clinical culture, processes, and structures must be organized to institutionalize accountability and responsibility.