Building a Culture of Accountability Within Organization. Creating Individual Accountability for Performance. A Lesson Learned from Hospitality Industry.
Wednesday, July 1st, 2009ACCOUNTABILITY WITHIN ORGANIZATIONS
Building a culture of accountability within a medical practice or a hospital department involves the following elements: effective sponsorship; a shared purpose; clear performance targets, time lines, measurement, and consequences; an effective implementation team; A-players; and weekly accountability.
Effective Sponsorship
In Managing at the Speed of Change, Daryl Conner (1992) defines “sponsorship” as the willingness to sanction or sponsor organizational change. Effective sponsors have not only the authority but also the will to establish direction and performance expectations for the organization based on correct principles.
Sponsorship is the most important element in creating an accountability culture. In a hospital setting, I use Conner’s term “initiating sponsor” to describe the role of the CEO, as the board-appointed fiduciary, in sponsoring accountability for results. The initiating sponsor is a person who has “the power to break from the status quo and sanction a significant change.” This person (most likely the hospital CEO) is supported by several other “sustaining sponsors” that likely include a governing board, medical staff leaders, a hospital executive team, and service-line or department managers who actually foster the culture of accountability. In a medical practice, the initiating sponsor may be a group president or a governing body.
In organizations with a culture of accountability, all sponsors are committed to making decisions based on proven principles of success. They make their decisions based on what is right rather than who is right or most persuasive. These exceptional leaders are authorized to make the required decisions, and they have the individual and collective will (some might say the integrity) to make even difficult choices without compromise. Once decisions are made, these leaders have the ability to establish policies in support of their decisions and to accept or assign responsibility for implementation, authorize the implementers, and hold them accountable to deliver the desired results. When barriers to implementation arise (and they always do), these leaders overcome the barriers rather than settling for something less than their organization’s full potential.
A Shared Purpose
The most effective healthcare organizations possess a compelling sense of purpose that engages the physicians, management, and support staff not only in meeting the clinical needs of patients but also in identifying and meeting the nonclinical needs, wants, and priorities of their customers. Exceptional primary care practices understand that their prosperity depends on building and maintaining relationships with women, who make the majority of healthcare decisions for families. They also understand that their established female patients provide the major source of new patient referrals to the primary care practice, literally becoming the practice sales force. Exceptional specialty practices understand their need to identify and meet the needs, wants, and priorities of their customers, including Mrs. Smith and referring physicians. Exceptional hospitals and hospital-based specialists understand their shared purpose to meet the needs, wants, and priorities of patients, their families, and referring physicians.
Sponsors within these exceptional organizations not only set the service performance standards, but they also exemplify those standards and do not tolerate anything less from others within the organization. Organizational policies and procedures are built with service as a primary directive. Service issues are identified, objectively reviewed, and reported to the sponsoring body, which ensures that they receive proper management attention.
Clear Performance Targets, Time lines, Measurement, and Consequences
Successful organizations are not afraid to set significant performance targets. They strive to excel and do not leave excellence to chance, because they know chance is a poor business partner. They set performance targets and standards in the context of their common purpose to achieve both short-term and long-term objectives. These targets are documented, along with time lines for achieving them and a responsible party or parties. Lesser organizations stop at this point, satisfied that they have done all that is required for success, only to be disappointed later with their lack of achievement.
Exceptional organizations complete the process by establishing clear measurement mechanisms to assess whether progress is being made toward their objectives. Progress is reviewed frequently so barriers can be quickly identified and eliminated or managed with the help of the initiating sponsor or sponsoring body. Consequences of failure to perform are always present and consistently applied. This does not mean that an occasional mis-step or failed implementation is automatic reason for dismissal or redeployment. It does mean, however, that physicians, managers, and staff who demonstrate a pattern of missed targets or standards do not remain with the organization for long.
An Effective Implementation Team
The best plans in the world are of little value if they are not effectively implemented. In every organization—from the smallest medical practice to the largest health system–—initiating sponsors must depend on others to implement their plans. Governing bodies and senior leaders within organizations are accountable for the development of an effective implementation team.
In most situations, organizations delegate the responsibility for implementation to competent managers. Exceptional sponsors make sure that the manager (or management team) hired to direct implementation of approved plans and policies is also exceptional. They hire managers rather than caretakers. They expect their managers (even in the smallest medical practices) to contribute actively to performance improvement and to the implementation of best operating practices. These leaders authorize their managers to act on approved plans and direction, never undermining those managers by failing to publicly sponsor unpopular policies or procedure changes. They do not skimp on manager salaries. They know that if they hire, retain, and properly sponsor the best managers, the return on their investment will be many times the manager’s compensation.
Without exception, the best-performing health systems, hospitals, and medical practices hold their managers accountable for effective implementation. They do so through frequent meetings to review performance targets, time lines, and barriers to implementation and positive outcomes.
A-Players Only Need Apply
In his book Topgrading, Bradford Smart (1999) discusses the significant direct and indirect costs of employing C-players. The costs include the direct financial implications of mistakes and rework, increased customer frustration and turnover, and the costs of losing frustrated A-players who have grown weary of covering for their incompetent peers. Many organizations are far too lax in their efforts to hire A-players for each position and even more hesitant to properly document poor performance and to terminate the C-players they mistakenly hire.
Exceptional organizations, on the other hand, expect their exceptional managers to hire, train, and retain the very best support staff members for each position. As Smart suggests, A-managers are not afraid to hire other A-players and are not threatened by excellent performance and innovation in their subordinates. Exceptional organizations tend to “hire slow” to identify and better match candidates with jobs. They also tend to “fire fast” when an obvious mistake has been made. These organizations make good use of a 90-day probationary period, during which they provide proper training and assess the competence of every new employee.
Weekly Accountability
Most healthcare organizations do a good job of delegating job responsibilities and authorizing employees to fulfill those responsibilities. When it comes to holding people accountable to deliver the targeted result within the approved time line, however, even sophisticated hospitals and health systems often fall short.
We frequently ask department and office managers a few questions related to accountability. First, we ask who holds them accountable. Most managers identify their boss. We then ask what results they are expected to achieve. This question is a bit more difficult for many. In response, we usually get a list of their job duties. When pushed a bit further regarding accountability for results, many managers either cannot respond at all or discuss their responsibility to explain budget variances (what we call “storytelling”). Finally, when we ask how they are held accountable, their responses usually reference informal discussions with the boss or a monthly meeting with organizational leaders that largely consists of coming up with a better story than the one they presented the previous month.
Accountability in exceptional organizations is different. It certainly includes a report of financial and statistical outcomes, which are often driven by the availability of information on a monthly basis. However, reporting goes well beyond quantitative outcomes to measures of qualitative performance and appropriate activity. Rather than looking in a rearview mirror 12 times each year (often three or four weeks into yet another month), effective organizations hold their valuable human resources accountable for activities much more frequently. Some activities, such as the sales force discussed earlier, lend themselves to daily accountability. In many cases, a weekly accounting of activity, progress, and barriers is adequate to ensure continued progress.
Regardless of the time frame, “if not,” “why not?” and “by when?” are questions raised by sponsors in quarterly board meetings, monthly committee meetings, and senior leadership councils. They are also posed by managers to staff on a daily or weekly basis. Why weekly or more often? The answer is simple. Most of us are so busy reacting to urgent and immediate needs and demands that we fail to accomplish some of our more important tasks unless we know that we will be asked specifically about those tasks at day’s end or week’s end—that is, unless we will be held accountable for our activity and our outcomes.
