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.