There is one concept in the corporate universe that is loaded with so much unspoken subtext as to make its meaning, and therefore its use, impossible. That concept is “accountability.” While it is an important idea, its importance is part of what has clouded its use and meaning. Most of this confusion stems from the fact that it rests on the belief that cause/effect relationships can be clearly understood. If a bad thing happens—we lose market-share, a patient dies unexpectedly, or our patient experience scores drop—we can isolate the pattern and draw a throughline from a failure back to a specific decision or behavior, usually made by one person. We can then hold that person accountable for the effect of that decision. This allows the rest of the engine to run uninterrupted without requiring broader reflection once a scapegoat has been selected and dealt with. While an important idea in reducing errors and improving outcomes, a hypervigilance on accountability actually makes improvement in patient experience more difficult.
Again, before beginning, let me address the comment that some of you have. I strongly believe that we should not hold people accountable. In a broad sense, every employee should be able to explain how their work improves the overall performance of an organization. Not in an “every minute must be a valuable productive minute” kind of way, but simply that their performance aligned with their job description is a net positive to the organization. In a more granular level, if individuals make decisions that make an organization less successful, they should be called to answer for those decisions. My thesis here is not to absolve everyone of all sin, but to explore how the ability to improve as an organization can, at times, be threatened by a focus on accountability.
Accountability is Vague
Part of the impetus for writing this essay comes from looking at the fallout from Target’s troubling Halloween costume and Callaway’s disturbing ad for a new golf club.1 I will not delve into politics surrounding these decisions. I will let you determine if the outrage was overblown or under-blown. My only point here is that these are both sizable companies and the decision to move forward with what ended up causing them grief was not the product of ONE person. It was the product of decisions made by multiple people, heck, multiple committees in the organization. Seeing this as an single person’s failure is to not understand how decisions and processes are made in a large organization.
Likewise, work to improve patient experience gets vetted by a number of different groups before it is operationalized. I have never worked on a PX initiative that didn’t have nursing, doctors, and other health professionals at the table, not to mention the various PX champions who would be training this work. Usually that table also included marketing, organizational development and education, and other interested parties. If it was a significant piece of work, it also likely worked up the organizational structure to the various senior leaders who would oversee this work. If that work does not bear fruit, or worse, doesn’t even take root, I would certainly take accountability for that failure as the primary instigator of the work. Just as I expect that my accountability would be filtered through the dozens of eyes who saw the plan and agreed with it. This becomes the crux of the challenge here. As the subject matter expert, I need to own my failure in this situation. But to turn around and say the failure is exclusively mine fails to appreciate that the approval of and the work to execute the vision was not exclusively mine. Or, quoting a phrase popularized by JFK, “success has many fathers, failure is an orphan.”
Accountability Ignores Externalities
In 2020, patient experience scores nationally were continuing to improve. Indeed, over the course of measurement, while individual hospitals and systems may ebb and flow, overall scores continued to improve for decades, so the national benchmarks crept up and up. But starting in 2020, the national scores started to tumble. Over the course of the next eighteen months, over eight years of improvement vanished. PX scores were in a free-fall. This was not because the universe suddenly forgot how to be nice to patients. It was because of the impact COVID had on how healthcare was delivered. When someone needed to don personal protective equipment (PPE) to enter every patient room, there was no longer a way to casually round on patients. The decision to enter every room was weighed against the availability of PPE and the time to do so. Wearing masks and visors and engaging in personal distancing meant that many of the nonverbal cues in communication got lost. So, as the number of contacts dropped and as the value of any individual contact was muted, patient experience scores dropped.
This is a clear example of how scores can be impacted by things that are not easily controlled. My favorite economics professor that I have referenced before, Sal-Val, taught me the importance of externalities. Those forces that can impact an individual who was not involved with the creation of those forces. General Hospital located in AnyTown, USA did not create the COVID crisis, but they certainly suffered the impact of the crisis. Their PX scores, much like their balance sheet, were hit hard by things that were outside of their control.
While COVID is an obvious and extreme example, hospitals are always buffeted with headwinds. Health systems need to successfully navigate these waters, just as every business does. The point here, though, is not that these externalities are an excuse for the struggle, but simply that they can explain the struggle. The link between COVID and profitability can be an easy set of dots to connect. Explaining that link when it comes to employee turnover, community reputation, or patient experience can be a bit more complex. The point here is that blaming the head of HR, the marketing team, or the PX champion without factoring in other causes is disrespectfully simplistic.
Again, this is not meant to absolve HR, marketing, or PX champions, but understanding the broader picture can actually help track solutions. Things like adjusting staffing ratios, or moving from 8-hour to 12-hour shifts, or leaning heavily on locum staffing, or moving to a hub-and-spoke model for delivering care all may be made to improve a hospital’s ability to efficiently deliver care and manage their bottom line. But not asking the question of how these may impact a staff member’s, community’s, or patient’s perceptions means not proactively engaging to prevent them from being problems. By treating turnover, community perception, and patient experience as distinct from these decisions means failing to identify them as products of these decisions.
Accountability Obscures Solutions
An effort to blame someone often overshadows an exploration of why things went sideways. This undercurrent of blame is often baked into a definition of accountability. I have had numerous conversations about why something did not work out as planned or did not have the impact that was expected. It seems that these sorts of postmortem meetings start with everyone in a defensive posture. The audience is less interested in why the scores declined and more interested in making sure it wasn’t seen as their fault. This response is so predictable that I now start these reviews by explicitly stating that this is not about shame-and-blame, but to simply find out what worked and what didn’t work, so we can highlight the former and address the latter. When relieved of this fear, the conversation usually is quite fruitful. This definition of accountability, then, hinders the ability to improve.
Accountability Rewards Timidity
My love of math and baseball means that it is not surprising that I liked the book Moneyball and the movie that it inspired. One of the tensions in the book involved the general manager and the manager of the team. The GM was bringing in players that fit his (at the time) revolutionary approach to baseball, but the team’s manager was not using the players as the GM envisioned. When pushed, the manager of the team essentially said that he would rather follow the old model that was leading to failure because it was easy to defend. Doing the new outside-the-box approach, if it led to failure, would tarnish his reputation. In essence, his argument was that the team would fail, regardless of strategy, and if he stuck to the dominant paradigm, he would at least be able to find another job.
Business is awash in examples of decisions being made because they are easily defensible rather than because they were more likely to produce results. This is why organizations are slow to change. Succeeding at PX often means availing oneself of new technologies or approaches. The problem is that these new approaches often ruffle feathers of the old-guard. Some concerns are certainly justified, but some concerns are simply from those who would rather fail at something that won’t get traced back to them, rather than sticking their necks out trying something new.
I remember fifteen years ago how hard healthcare2 fought against letting patients have access to their own medical records, including physician notes. Even five years after the 21st Century Cares Act (which, among other things, forced healthcare to allow more patient access to their medical information) was passed and signed into law; there was significant pearl-clutching by clinicians over what would happen when the unwashed masses would see all the highfaluting jargon in their medical record. And there were horror stories about how the failure of healthcare to catch up to the technology left patients at times poorly-served. Like the woman who learned of her miscarriage via the online portal and was left sitting alone in an emergency department room ninety minutes before a clinician came in to talk with her.
But the response in healthcare was one of timidity. It was easier to blame the technology or the possible legal exposure rather than to be the first person to stick their head above the barricade and risk getting shot. It took a long time before we stopped allowing the timid to justify their timidity by pointing at some boogeyman. Patients can now email their provider, check on test results, request refills, or schedule appointments. This was made possible because of the law but also because of the bravery of some to try and in trying slowing forcing the giant ocean liner that is healthcare to change direction. Of course, we need to evaluate the ramifications that decisions will have on other areas in healthcare. I just made that point above. But accepting inertia and the protection it provides also stimies improvement.
In the end, improvement requires a series of risks. While a detailed postmortem on any success or failure should include identifying those accountable, it also needs to appropriately place that accountability within the context of the big picture. Further, when organizations are more focused on punishing failure than punishing missed opportunities, the organization is telling its staff that doing nothing is preferable to potentially doing the wrong thing. Worse, is that when an organization holds someone responsible for something that is not really their fault, they make it easier for them to not care about things that they are in control of. When staff are often blamed before any of the other considerations, the organization’s real problem with fostering improvement is hyper-accountability, not lack of accountability.
1I will yet you Google these things, if you are not aware of them, but briefly, I will summarize. Target got grief for a Halloween costume many thought was historically tone-deaf. Calloway got in trouble for an advertisement that showed a golfer forcibly push a woman to the ground to prevent her from touching his new driver.
2Forgive me for talking about healthcare as some monolith. In my opinion, healthcare’s biggest challenge is not that it has one hive-mind head, but because it actually has ten thousand heads, each with their own perspective on fears and expectations. But that is a rant for another day.
PX Matters with Joseph Snipp 
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