From the Blame Game to Accountability in Health Care

FROM THE BLAME GAME TO ACCOUNTABILITY IN HEALTH CARE

Bruce Harber and Ted Ball

In Canada’s $100 billion health care system, the provinces blame Ottawa for a lack of funding, Ottawa blames the provinces for mismanagement, hospitals and regional health boards blame both, while health practitioners and patients blame them all. We need to move beyond the “blame game” to an adult culture of accountability and best practices in delivering high quality health care, suggest Bruce Harber and Ted Ball. Acknowledging that this requires moving to a new mind set, they propose six principles for a new system of accountability and a transformation of corporate governance in health care. They sound a note of urgency, suggesting that the current health care system is “a burning platform” that threatens the quality of life of hard pressed front- line workers.

Dans le secteur de la santé, qui dispose d’un budget de 100 milliards de dollars, les provinces accusent Ottawa de les sous-financer, Ottawa accuse les provinces de mal gérer leurs fonds, les hôpitaux et conseils de santé régionaux accusent à la fois Ottawa et les provinces, alors que patients et praticiens accusent en bloc tout ceux qui précèdent. Il faut en finir avec cette ronde d’accusations pour adopter une culture de responsabilisation axée sur des pratiques assurant des soins de qualité, affirment Bruce Harber et Ted Ball. Ce qui exige un tout nouvel état d’esprit, conviennent-ils. Ils définissent donc six principes en appui à un nouveau système de responsabilisation et à la transformation subséquente de la gestion des soins de santé. Et le temps presse, jugent-ils, étant donné le climat délétère dans lequel travaille le personnel de première ligne, soumis à des pressions qui menacent sa qualité de vie.

ccountability is a word that is loaded with meaning political dynamics of our federal system, the issue has that strikes fear in the heart and soul of our health become: who gets the blame when funds earmarked for A care system. That’s because it has come to mean: diagnostic equipment are used to buy a lawn-mower? “Who is to blame?” And, “how should they be punished?” Accountability is very different from blaming, which So why are we surprised when the outcome of this approach means: “to find fault with, to censure, revile, reproach.” is blame-avoidance, blame-shifting, cover-ups, in-fighting, Blaming is an emotional process that seeks to discredit the defensive behaviour, antilearning dynamics and the cause blamed. But when people work in an atmosphere of blame, of even further dysfunction in a health system that has they naturally engage in defensive routines — covering up already been diagnosed as being among “the least healthy their errors and hiding the real issues that need to be dealt work environments in the country.” with if the performance of our health system is to actually Our bottom-line message in this essay is this: The improve over the next few years. concept and the process of accountability needs to be Within the health care delivery system, our existing culture fundamentally redefined within the public sector — from of blame generates fear and destroys trust. When we blame, we top to bottom. attempt to prove that others must have had bad intentions or Our first ministers chose to make Roy Romanow’s rec- lack ability. The qualities of blame are “judgment, anger, fear, ommendations to improve accountability within the health punishment and self-righteousness,” according to Marilyn Paul system mean: “Who is in charge?” Within the traditional a scholar in the field of organizational accountability.

POLICY OPTIONS 49 NOVEMBER 2003 Bruce Harber and Ted Ball

In contrast, accountability empha- of our own errors or shortfalls, and view- any real control over the results we are sizes keeping agreements and perform- ing them as opportunities for learning producing. In British Columbia, reduc- ing tasks in a respectful manner. It is and growth, enables us to be more suc- ing the number of health authorities all about learning, truth and continu- cessful in the future.” from 52 to 6 does not mean that the ous improvement. Is that not what we BC Ministry of Health actually has bet- really need in our health care system rrors, shortfalls and mistakes can, ter “control” over the quality and today? Are we now ready to learn from E of course, take place at any point effectiveness of health care delivery in our past mistakes? Are we really pre- in the system: how provincial public that province. pared to change? servants designed a particular policy or Across the country, public ser- It was 15 years ago when the program; how operational managers vants — few of whom have any practi- health care system flirted with tech- implemented a program; how teams of cal operating experience in complex niques and processes for Total Quality health professionals were organized service delivery organizations — are Management and Continuous Quality within systems, structures and process- being assigned the task of drafting or Improvement (TQM/CQI). We learned es to deliver the services; or, whether redrafting “performance agreements” back then about Edward Deming’s “93 or not service provider organizations that in many cases seek to “microman- percent vs. 7 percent” rule. Deming are aligned at the service delivery level. age” and “control” health care agen- taught us the wisdom of 60 years of his Paul says that “accountability cre- cies and institutions in a belief that a experience working with organizations ates conditions for ongoing construc- centralized approach will make health that were seeking to improve care provider organizations their performance. Accountability is very different from “more accountable.” Deming said that 93 per- blaming, which means: “to find fault Our intentionally provoca- cent of the time, problems in with, to censure, revile, reproach.” tive question is this: Are we the organizations and systems doomed to continue to repeat that he dealt with could be Blaming is an emotional process that the mistakes of the past, or are traced back to the design of the seeks to discredit the blamed. In we ready to fundamentally systems, structures and process- contrast, accountability emphasizes rethink how accountability is es. He said that only 7 percent keeping agreements and performing actually designed into our sys- of the time were the problems tems and processes? Are caused by people, and in half of tasks in a respectful manner. It is all provincial politicians and their those cases where there was a about learning, truth and public servants prepared to give “people problem” the root continuous improvement. up the “illusion of control”; cause was actually inadequate and are local Boards and CEOs training or skills. tive conversations in which our ready to accept their accountability for So, if we already know that most of awareness of current reality is sharp- achieving measurable and agreed- our problems flow from design flaws in ened, and in which we work to seek upon high-level outcomes? our existing systems and processes, why root causes, understand the system From the available research, and do we continue to insist on clinging to better, and identify new actions.” She from our own reflections and experi- our ingrained habit of “blaming people” lists the true qualities of accountability ence, we suggest six key principles that in our accountability processes? It may as: “respect, trust, inquiry, modera- we think should be embedded in a be too late for the premiers and the tion, curiosity and mutuality.” new accountability system. health ministers to shift from their tra- Best practices teach us that “mutu- ditional political strategy of blaming the ality” is a key success factor in ou can’t be accountable for anything federal government, but it is not too late accountability processes that work. But Y over which you have no control. A to shift course when it comes to defin- that would require a significant para- best-practice accountability agree- ing the word “accountability,” with digm shift for a health care system that ment must be a “fair business bar- respect to the relationships between is currently rooted in hierarchical com- gain.” It is a personal promise to provincial ministries of health and the mand-and-control systems, structures, achieve measurable results. But a per- agencies and institutions that they fund processes, and leadership styles. son can’t keep their promise if cir- in each province; the relationship Are we now ready for such a mind- cumstances beyond their control between boards and their CEOs; and set shift? change. That makes sense, doesn’t it? between the CEO and their managers. The truth is that our health system If a CEO is being held accountable for Experts like Marilyn Paul, advise us that is still addicted to the mental blinder improving staff/physician morale, and “a focus on accountability recognizes that Peter Senge calls “the illusion of their provincial government is that everyone may make mistakes or fall control.” Having an “illusion of con- engaged in highly emotional disputes short of commitments. Becoming aware trol” does not mean we actually have with unions and physician organiza-

50 OPTIONS POLITIQUES NOVEMBRE 2003 From the blame game to accountability in health care

The Gazette, Montreal Just another day at the office — doctors and nurses, the front-line workers of Canada’s health care system, in action at a Montreal ER.

tions, how can the CEO be held equipment or technology — and must be able to hold his or her boss accountable for the results that such nobody removes the barrier, why accountable for providing the supports an atmosphere will produce? should they be expected to be account- they mutually agree are required to However, the CEO should certain- able? How can they possibly deliver on successfully achieve their outcomes. ly be accountable for demonstrating their promise if they are not given the An accountability agreement is improved outcomes with their own support they require to succeed? therefore a tool for people to mobilize organization’s unions, staff and physi- Best practice accountability agree- the support they need to make them cians that they are able to achieve ments list the “supports required” to successful. It’s a manager’s best friend, from the processes that they put in achieve the outcomes for which a per- not their worst enemy! Between the place to achieve their measurable son is willingly accountable. If they provincial governments and the agen- results locally. don’t get the support they need, they cies and institutions they fund, there If a manager is being held can’t be held accountable. It’s that sim- also needs to be an explicit and “fair accountable for an outcome that can ple. That’s where this concept of mutu- business bargain.” only be achieved if a certain barrier is al accountabilities comes into play. removed — like the lack of a skills At the operating level, a manager ccountability for outcomes means development program, or the lack of with an accountability agreement A that activities/efforts and processes

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are not enough. Think of the mindset stand what is expected of them and accountable — for the outcomes or shift required here. Our health care why, they must also have the neces- results achieved at the service delivery system is characterized by a complex sary resources, conditions and skills level of the system? set of rigid bureaucratic processes to achieve the outcomes for which At the operating level of our designed in separate silos holding dif- they are being held accountable. Is health care system, we need to ask our- ferent assumptions. Unfor- tunately, bureaucratic Best practices teach us that “mutuality” is a key success factor processes create jobs with in accountability processes that work. But that would require turf boundaries to protect at the operating level of the a significant paradigm shift for a health care system that is system and between the currently rooted in hierarchical command-and-control public servants and the systems, structures, processes, and leadership styles. organizations that receive funding. that not a reasonable and “fair busi- selves: what are we in management The real focus of the existing ness bargain?” In a best practice and governance going to do to provide system is on the rules, regulations accountability process, no one is the practical supports required to and bureaucratic processes — not on given points for “following the make our people successful? achieving outcomes. Should we not process.” The only thing that counts The leadership of the Canadian be accountable for achieving measur- is getting the results. health care system has argued very able results from the next $27 billion If the process design does not publicly over the past ten years that that our health system is expecting produce the results required, we need our sector’s root problem was “a lack of to receive from the federal govern- to change the process. Better yet, we funds.” Now that we have an addition- ment over the next five years? need to design processes that are al $49 billion in federal funding, will Best practices would suggest that focused on achieving the results that we achieve better outcomes through a holding people accountable should are required — right from the start! redesigned system, or, will we sink the only be done in the context of clearly So let’s start now, by honestly reflect- new money into the exact same sys- defined outcomes or results. These ing on the unintended consequences tem and start another campaign to outcomes must be understood and of the way we currently define and complain that we still don’t have adjusted regularly to reflect new reali- practise accountability in the health enough money? ties as they emerge in a constantly care system — and in the public sec- In our view, a system that is changing and chaotic environment. tor generally. focused on “accountability for out- Not only must everyone under- We urge public servants who are comes” would have the best chance of currently designing “performance finally shifting our traditional pattern Six Principles for Accountability agreements” or “business planning of spending more and more resources Design process” for the health agencies and to produce poorer results. institutions that receive public fund- 1. You can’t be accountable for ing to re-examine some of the core ccountability for results requires real anything over which you have assumptions behind the design of A empowerment and room for person- no control. such agreements. Is the accountabili- al discretion and judgment. This princi- 2. “Accountability for outcomes” ty process really designed to achieve ple would require another paradigm means that activities/efforts/ the outcomes that we all want to shift for the health sector: the princi- processes are not enough. achieve, or are the processes designed ple is about the reality of balancing 3. Accountability for results requires to exert “control” by the public serv- empowerment and accountability. real empowerment and room for ice, and to ensure that blame can be Not the empty rhetoric that has con- personal discretion and judgment. placed elsewhere? tributed to the growing cynicism of 4. Accountability must be dynamic: There is another wicked question: our front-line health care providers, outcomes and targets change as Is there a danger that such “agree- but real empowerment. While the circumstances change. ments” become the CEO’s real boss, health care sector is clearly part of the 5. Accountability and stewardship for rendering the board to play the role of knowledge economy, many of us con- the organization belongs to every observer and interim monitor? The tinue to live with industrial-age employee. fundamental policy question is this: Is assumptions about the “need for com- 6. Accountability is meaningless there really a system for independent mand and control.” without fair and appropriate community governance, or, is the The assumption in other modern consequences. public service in our provincial capi- knowledge-based industries that rely tals in charge — and therefore on skilled professionals is that the

52 OPTIONS POLITIQUES NOVEMBRE 2003 From the blame game to accountability in health care solutions to their most complex and rooted in the old industrial model. synergistically together within our perplexing problems are within the Systems thinking, chaos theory and organizations and with all parts of the hearts and minds of the people who quantum physics have all contributed system. work in the system. greatly to our emerging understanding Smart organizations that are thriv- of the health care sector as a complex ccountability is meaningless without ing in the knowledge economy invest adaptive system. A fair and appropriate consequences. between 1 percent and 5 percent of Each part of the system impacts For all the fear and anxiety that our their payroll budgets on developing on the performance of the other parts existing hierarchical, command-and- the skills of their people to work in of the system. We know that. When control accountability processes pro- high performance teams solving orga- there ar insufficient home care services duce in people, the truth is that there nizational problems and dilemmas by within a community, elderly people really isn’t much of a focus on the con- tapping into the collective intelligence get trapped in acute care beds, and sequences — but just the “threat” that of the people in their system. then we get back-ups in our emergency maybe something bad could happen. Is our health care system now pre- departments. A province could theoretically face pared to invest in our own IQ? Could When that happens, the resulting a tiny reduction in their federal trans- we even get to investing 1 percent of headlines seem to compel many of our fer payment; a provincial ministry of our budgets on developing the inter- politicians to invest even more money health might experience a few days of nal capacity of our people in manage- in emergency services, rather than on bad press; the members of a community ment and on the front line to board of governors might have work synergistically together to There is confusion: is it the role of some discomfort explaining to achieve the outcomes that we the board to simply monitor what their neighbours how a decision all ought to be accountable for someone in the provincial capital they made in the interests of achieving? their silo resulted in harm to the has decided is important? How do rest of the community; or a ccountability must be we integrate the high-level manager at the service delivery A dynamic: outcomes and tar- outcomes required by the level might experience some gets change as circumstances provincial government with the embarrassment over the results change. While most people they produced. would agree that this seems per- outcomes that reflect the board’s In a best practice account- fectly reasonable, the existing understanding of the unique needs ability development process, rigid bureaucratic culture of of their community? managers throughout an health care — from the premiers organization think through on down to the front-line nurse — is the root cause of the key system design the outcomes in their organization’s about inflexibility. In the existing sys- problem: an underinvestment in com- balanced scorecard that they should tem, we are given every incentive to munity care. Despite the fact that all be accountable for; the supports they focus on the process, rather than the parts of the health care system are need to be successful; and what the outcomes. interconnected, we’ve organized our- consequences will be on their organi- Deming told us: “first, drive out selves into rigid silos and departments zation, their unit and themselves if fear.” Yet fear and anxiety are the that we attempt to “manage” through they fail — or if they surpass the tar- dominant emotions that are driving traditional bureaucrat control mecha- gets agreed to. our health care system today. Best nisms, where we solve issues within When these processes are truly practice accountability agreements are each silo, often without any apparent designed with a learning and continu- flexible. When circumstances change, concern about its impact on the other ous improvement focus, they work. accountabilities change. The focus is parts of the system. They don’t work in antilearning envi- on what needs to be done to ensure The recent SARS crisis certainly ronments. that a person is successful. demonstrated the truth about the At the top of our health care sys- extent to which system fragmentation tem hierarchy, there is very little ccountability and stewardship for contributes to system dysfunction. understanding of the “lessons” we A the organization belongs to every Best practice accountability have already learned over the past 10 employee. Management guru Tom processes include integrating the agree- years of downsizing, mergers, restruc- Peters has said that health care sys- ments cross-functionally — across the turing and reengineering — the lifes- tems, structures and processes are the organization and across the system. pan of ministers of health, and their most complex organizational designs That way people truly understand how deputies is about 18 to 24 months in ever conceived by humans. But most their actions impact on others and why many provinces. So there is little or no of our core design assumptions are we need to ensure that we are working historical memory.

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Today, at the system delivery Here are our suggestions: Fourth, senior management teams level, we have confused board mem- First, ministers of health need to and their CEOs also need to think bers — uncertain what their role is or reflect upon how we currently practice about how they currently define and how they are supposed to hold their accountability and acknowledge that practise “accountability” in their CEO and chief-of-staff accountable for their officials are in no position to organizations. the outcomes/results that the board wants to achieve At the front-line of the health care delivery system we have on behalf of their commu- created working conditions that are, by any measure, nity and in the broader public interest. intolerable — and yet we must continue to coax our front- There is confusion: is it line people for every ounce of compassion, care, commitment the role of the board to sim- and love that they have left. We need to think about how we ply monitor what someone are going to finally start providing some “care” to our care- in the provincial capital has decided is important? How givers. This is our real burning platform: the collapsing do we integrate the high- quality-of-work life of our front-line workers. level outcomes required by the provincial government with the “assume control” by holding senior Health care managers need to outcomes that reflect the board’s managers of health care organizations learn how to tap into the collective understanding of the unique needs of accountable to them. intelligence of their organization so their community? It would make much more sense that they benefit from the knowledge If our health care system is to to develop high level outcomes for and commitment of front-line workers. improve, managers need to have some each sector — hospitals, home care Fifth, health system leaders in clarity on what is expected from the services, public health departments, government, management and local system funders and from their direct etc — and hold the governing boards governance need to be much more boss: their board. At the managerial accountable. open to learning, much better pre- level, we often have blame-avoidance Second, governing boards need to pared to be innovative, and much behaviour in a constantly changing, think deeply about the needs of their more collaborative. Because every chaotic environment paradoxically communities — and the broader pub- organization is different, health care charged with copious amounts of lic interest — and work in partnership leaders must resist simply adopting “a absolute certainty and complete ambi- with their CEOs and their senior model,” or “a template.” We must be guity. Is it any wonder that all this is a managers on the vision for the organ- prepared to innovate and customize. bit “crazy-making”? ization within their local system and We all need to keep in mind the the outcomes they are seeking to burning platform we are on. Let’s ask t the front-line of the health care achieve within their local health care ourselves: if we absorb another $27 bil- A delivery system we have created delivery system. lion in federal funding over the next working conditions that are, by any Boards need to understand how few years, will the new money put the measure, intolerable — and yet we they can hold their CEO and chief-of- fire out or make it hotter? We believe must continue to coax our front-line staff accountable for agreed-upon out- that it will be hotter if we don’t rede- people for every ounce of compassion, comes — with policy governance fine “accountability” and design our- care, commitment and love that they monitoring processes that enable them selves to be successful. have left. We need to think about how to add value. we are going to finally start providing Third, CEOs and their senior Bruce Harber is CEO of York Central some “care” to our care-givers. This is management teams need to spend at Hospital. He was most recently the chief our real burning platform: the collaps- least a year with their middle man- operating officer at Vancouver Acute. He ing quality-of-work life of our front- agers and supervisors getting aligned holds a masters degree in health admin- line workers. on their strategy. From our experi- istration and is a member of the clinical Clearly we cannot stay on this ence of leading and facilitating sev- faculty at the University of British burning platform any longer, which eral balanced scorecard strategy Columbia. means that status quo on accountabil- development processes in Ontario, [email protected] ity cannot survive if we intend to be British Columbia and the United Ted Ball is a partner in Quantum successful. States, we recommend this best prac- Learning Systems, a Toronto-based com- So how are we going to change the tice approach to getting an organiza- pany specializing in building the capacity way in which we define and practise tion aligned and focused on their of organizations to transform themselves. “accountability?” strategy. [email protected]

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