Today, I'm spending the day with a health system and their quarterly management retreat, which includes about 200 managers from from the C-level on down.

One of our topics, prompted by some feedback from a management survey, is accountability. This is a really rich and interesting topic and I will barely scratch the surface on it in this post, but I wanted to share some thoughts from my preparation for the discussion and to get your comments, as well.

When I hear leaders say, “We need to hold our employees accountable!,” I usually have to ask, “So, what, specifically do you mean by that? Give me an example and a scenario.”

Far too often, “accountability” means “blame” and finger pointing – and I don't think that's really accountability in a Lean management system context.

One dictionary definition of accountability talks about the obligation or willingness to accept responsibility:

Accountability is something you take on voluntarily… it can't be forced on you. You can choose to be accountable. How can leaders create an environment where people CAN be accountable?

A dictionary definition of responsibility talks about “the person who caused something to happen.”

There are many cases where people are “held accountable” (having this accountability forced on them) when it's unfair because they aren't at all responsible for what happened.

Let's say a senior leader sees a nurse go into a patient room without using foam cleanser on their hands. “Let's hold them accountable!”

As Dr. Deming said, this is “ridiculous!”

Dr. Deming said, “Fix the processes, not the people.” Great advice.

Deming wrote (in The Essential Deming, a great read):

“The boost in morale, and in production as well, of the production worker in America, if he were to perceive a genuine attempt on the part of management to improve the system and to hold the production worker responsible for only what the production worker is responsible and can govern, and not for handicaps placed on him by the system, would be hard to overestimate.”

This statement applies to healthcare professionals, not just “production workers.”

Can we hold nurses and other staff accountable for not always following proper hand hygiene procedures when coming in and out of patient rooms?

Let's say the foam canisters are empty outside a few rooms in a row (something I've seen recently). We can't hold the nurses accountable. This is a system problem. “Writing up” or punishing the nurses would be counterproductive. We need to ask why the canisters are empty? Is there somebody to hold accountable for not restocking the canisters? Maybe not – what if it's a bad process, where there's no “standardized work” and no clear cut assignment of who refills the canisters (“everybody?”).

Are we more willing to “hold accountable” a surgeon who chooses to not follow the supposed “universal protocol” timeout procedures before a case? This might be a CHOICE on the surgeon's part… they are probably more solely responsible than the nurse who didn't disinfect their hands. But, there might be extenuating circumstances for the surgeon even. Before we jump to blame, we have to ask, “Why wasn't the protocol followed?”

We can ask:

Is it a case where the person CAN'T do the work properly? Do they not know how? This might be a systemic training problem. The individual can't be held accountable for that. Does the person not have the right resources? Maybe they WANT to do it right, but they just can't. Leadership needs to help eliminate those barriers.

Is it a case where the person WON'T do the work properly? Is the situation one where the person truly has a choice and they made a bad choice?



As Dr. Robert Wachter has written about so well, not leaping to blame and punishment doesn't mean we NEVER hold people accountable.

David Marx writes, in the context of the “Just Culture” methodology:

“No one can afford to offer a ‘blame-free system' in which any conduct can be reported with impunityâ€”as society rightly requires that some actions warrant disciplinary or enforcement action. It is the balancing of the need to learn from our mistakes and the need to take disciplinary action (that must be addressed).”

As Wachter says, we have to find balance.

This “Incident Decision Tree” flowchart (PDF), developed in the NHS, provides some good guidelines, I think. It very often leads to a conclusion the the accountability rests with the system (the responsibility of management) not the individual.

One other thought that comes up in these discussions of accountability is that senior leaders are often trying to leap to hold front-line staff accountable for their actions. But, front-line leaders are pretty far removed from the actual work and their actions might just be tampering or interference.

I'd suggest that senior leaders should focus on creating a culture of accountability through their own actions:

C-level executives demonstrate the right behaviors (always, and I mean ALWAYS, following hand hygiene protocols when entering a unit or a room) C-level executives can hold VPs accountable for behaviors (which includes learning how to remove barriers and look at systemic factors) VPs can hold Directors accountable Directors can hold Managers accountable Managers can hold Staff accountable (working together to solve systemic problems, not just blaming and punishing)

And the accountability goes both ways… leaders have to be accountable (choosing to be accountable) to their employees. There's “mutual accountability” and “tiered accountability” in a Lean culture.

From The Toyota Way Fieldbook:

“I learned you need to keep the [employees] accountable to the plant manager who is accountable for the implementation of the culture shift that we're trying to achieve.”

Without mutual accountability that starts at the top, a CNO might complain that nurses are not doing hourly rounding. Instead of just saying, “Hold them accountable!,” leaders need to work together. Instead of just assuming the rounding will be done, front-line managers can VERIFY that rounding is happening by being out in the workplace and doing checks (and sometimes rounding with a staff member). This can be done in a supportive and collaborative way.

Directors can go and verify as well… and all the way up the chain, as they did in the NHS. Represented in this drawing I made, there's tiered checking of standardized work by all levels in the organization (or there's supposed to be):

In the example, the CEO had visited the unit on the 22nd. She could see from the check boxes that other leaders weren't doing all of the rounding checks (or it wasn't documented). The CEO can go round with others… and ask questions about the rounding checks. Asking questions emphasizes the importance without having to “come down on people.” When managers and directors realize, “This is important enough for the CEO to come ask about it,” then they're more likely to be accountable, if they are able to.

The CEO is demonstrating accountability by being there once a month as the visual plan indicates.

If the CEO isn't doing her monthly checks, the message is loud and clear to the others – that the rounding checks are optional.

When my wife, as a leader, wants her managers to be accountable for not screwing around on their Blackberries during meetings, she leads by setting an example. She leaves her Blackberry in her office. She can then rightfully ask others to be accountable to cultural norms that they pay attention and be present (and I'd admit I'm not always good at that… I need to leave my iPhone in my bag more often).

What does “holding people accountable?” mean in your organization? Is that definition changing over time? What are you learning from your study of Lean principles and Lean management? What else would you add to this discussion?

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