Question: How do I get my clinicians to be accountable?
Answer: Rethink accountability and blame.
The Mantra of Accountability
When I was a clinical leader, nothing got the hairs on the back of my neck standing faster than hearing the phrase, “You need to hold your teams accountable.”
Repeated like a mantra in many of the meetings I attended, the phrase was code for, “If you (i.e., frontline leaders) would just crack down on your people, the objective (e.g., hand washing, bedside rounds, specimen labeling, fill in the blank…) would be met.”
There seemed to be a belief that the only way to get team members to be accountable was by administering a negative consequence to the “blame-worthy”.
No one explicitly said, “Your team members are to blame and you need to punish them.” Such statements wouldn’t be politically correct, but that was often the underlying sentiment.
Accountability and the “Blame Culture”
I found this belief echoed by the clinical leaders who participated in my research on barriers to error reporting.
The interviews clearly revealed they understood that a “blame culture” was detrimental to error reporting and optimal patient care. For them, the difficulty lay in understanding how to hold clinicians accountable for their errors without using blame and punishment.
In their minds, accountability and “no-blame” could not go hand in hand.
Accountable or “No-Blame” – Does It Have to be One or the Other?
What seems like a conflict between accountability and “no-blame” is likely the result of an ongoing debate in healthcare about finding an appropriate balance between a systems approach or an individual approach to preventing errors.
On one side is the system-focused approach (also known as the “no-blame” approach) that takes the stance that errors reflect predictable human failings in the context of poorly designed organizational systems, and on the other side is the individual-focused approach (also known as the “accountable” or “blame” approach) that treats errors as failings on the part of individuals due to negligence or inadequate knowledge or skill (1).
This juxtaposition of “no-blame” and “accountability” creates a confused perception that we can’t have both: an approach that fosters accountability and doesn’t blame the individuals.
However, we know that the alternative (accountability with blame) doesn’t lead us to our ultimate goal of transparent error reporting and optimal patient care because it leads to defensiveness, fear, and cover-ups.
Unfortunately this leaves us entrapped by the limitations of our own thinking causing us to swing from one extreme to the other.
Human factors expert, Dr. Rollin Fairbanks, believes that we’re now on the blame side with the recent “culture of accountability movement”. He states that there is a “misconception that the appropriate answer is a more punitive approach to frontline human error” (2).
It doesn’t have to be this way. It just so happens we CAN have both – accountability AND “no blame”.
Rethink Accountability by Removing Blame
To break out of our current dilemma, we first need to uncouple blame from accountability, because they are completely different concepts.
Accountability emphasizes engaging in critical conversations, maintaining agreements, continuous improvement, and mutual respect. And, blaming is an emotional process that discredits the blamed (3).
Once we understand the difference between the two, we need to envision how we can foster accountability without blame.
Building Blocks of “No-Blame Accountability”
So how DO we foster accountability for errors without giving harmful reprimands?
It starts with these basic tenants:
- A fundamental belief and understanding that in complex systems, such as healthcare, individual and system level factors affect each other – neither domain operates independently. Therefore, generally, it is counterproductive to assign individual blame for errors.
- Learning to have skillful “accountability conversations” with team members who make errors that validate their worth, acknowledge their good intent and explores with them ways they can take responsibility for the error.* These types of actions build trust between the leader and the team member and foster ownership for the error.
- Follow-up conversations with the team member to check in on their well-being and closing the loop with the error resolution process.
* These will vary depending on the error and the person and could include doing an investigation that reveals vulnerabilities in the system, redesigning a work process, or having the team member share what they learned from the error with their colleagues so the error isn’t repeated.
True Accountability Lies in Shifting Toward Meaningful Conversations that Build Trust
Organizations that have fostered a healthy dose of “no-blame accountability” among its members have successfully shifted the focus from the debilitating effects of blame to the promotion of meaningful conversations that build trust so that transparency can be fully realized.
Although full transparency has been a goal for healthcare for over a decade, as an industry we are still at the beginning stages of understanding what it will take to get us there. Transparency won’t come without trust, and trust won’t come as long as well-meaning clinicians believe they will be blamed for errors.
“No blame accountability” is possible but it’s not simple. It takes skill and practice, and a belief that there is a better way. By taking the approach outlined above you’ll start to pave a path toward true and safe transparency. The benefits to your clinicians and to your patients will be well worth your efforts.
Learn about other deeply ingrained beliefs we have in healthcare that prevent clinicians from reporting their errors by reading my article Effects of Shame and Guilt on Error Reporting Among Obstetric Clinicians.
- Wachter, R. M., & Pronovost, P. J. (2009). Balancing “no blame” with accountability in patient safety. New England Journal of Medicine, 361(14), 1401–1406. https://doi.org/10.1056/NEJMsb0903885
- Perry, S. J., Mosher, H. J., Persoon, T. J., Bass, E. J., & Fairbanks, R. J. (2013). Healthcare systems design at a crossroads. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 57(1), 713–717. https://doi.org/10.1177/1541931213571155
- Paul, M. (1997). Moving from blame to accountability. Systems Thinker, 8(1), 1–5.