Accountability in Health Care

1. Accountability in Health Care Dr. Judith Shamian April 19, 2010

2. What is accountability? At its most basic, accountability is about individuals who are responsible for a set of activities and for explaining or answering for their actions. • It is being “answerable” for something. • It should be positive and premeditated. • It emphasizes keeping agreements and performing tasks in a respectful manner. • It is about learning, truth and continuous improvement. • Accountability ranges from micro to macro… from personal to organizational to system to international. • Without accountability, organizations are incapable of achieving and sustaining high performance. (Emanuel & Emanuel, 1995; Paul 1997)

3. Levels of Complexity Level of Complexity • Simple • Complicated • Complex

4. COMPONENTS OF ACCOUNTABILITY

5. Component of Accountability The concept of accountability contains three essential components: • the loci of accountability – WHO • the domains of accountability – WHAT 3) the procedures of accountability – HOW (Emanuel & Emanuel, 1995)

6. Loci of Accountability - WHO The loci of accountability is simply the parties that can be held accountable or hold others accountable. • Health care consists of at least 11 loci of accountability. (Emanuel & Emanuel, 1995)

7. Domains of Accountability - WHAT A domain of accountability is an activity, practice, or issue for which a party can legitimately be held responsible and called on to justify or change its action. Accountability in health care consists of at least six domains. (Emanuel & Emanuel, 1995)

8. The Procedures of Accountability - HOW There are two components to the procedures of accountability. • Evaluation of the adherence to or compliance with the criteria for specific content areas. • Dissemination of the evaluation and responses or justifications by the accountable party or parties. (Emanuel & Emanuel, 1995)

9. MODELS OF ACCOUNTABILITY

10. Models of Accountability • The Professional Model • The Economic Model • The Political Model • The Organizational Model • The Governance Model

11. The Professional Model The physicians and patient participate in shared decision making and physicians are held accountable to professional colleagues and to patients. • In medicine, the traditional model of accountability has been the professional model. • In this model, health care is not a commodity but a professional service. • Two primary loci of accountability: • Physicians to their professional colleagues and organizations • Individual patients • Two primary domains of accountability: • Competence • Legal and Ethical Conduct (Emanuel & Emanuel, 1995)

12. The Economic Model • Market is brought to bear in health care and accountability is mediated through consumer choice of providers. • Patients are viewed as consumers; physicians and hospitals, as providers or economic producers; and health care, as a commodity or product. • Locus of accountability is the relationship between individual consumers and providers of health care—physicians, hospitals, and managed care plans. • Traditionally, government is seen as marketplace regulator ensuring efficient, competitive, and fair operation of the market. • The primary domains are price and quality – financial performance and professional competence. (Emanuel & Emanuel, 1995)

13. The Political Model • Physicians and patients interact as citizen-members within a community and in which physicians are accountable to a governing board elected from the members of the community. • Patient well-being is neither a commodity nor a professional service. The goal of health care remains the patient's well-being, but its precise content and the optimal mechanism for achieving it are subject to interpretation by the community of citizen-members. • Locus of accountability is the relation of providers to a governing board of representatives. In turn, this board is accountable to the members, both patients and physicians. • The primary domains of accountability are not fixed. (Emanuel & Emanuel, 1995)

14. The Organizational Model Organizational accountability exists when all members of the workforce individually and collectively act to consequentially promote the timely accomplishment of the organization’s mission. • All members of the workforce: Executives and managers are responsible for holding their subordinates accountable for the effective and efficient conduct of activities supporting mission achievement. Subordinates, through their actions, set an example by which positive pressure is applied to their peers and seniors for greater accountability. • Individually act: Enough individuals throughout the organization must act accountably in order to achieve the critical mass necessary for the existence of an accountable organization. • Collectively act: Often, groups of executives, managers, or individual contributors make and execute the organization’s decisions. • Consequentially promote: Accountability cannot exist without both positive and negative consequences. • Timely accomplishment of the organization’s mission: For accountability to exist, one must know what is to be accomplished and within what time frame.

15. The Governance Model There are several different kinds of Governance Models including: • Advisory Board Model - This model emphasizes the helping and supportive role of the Board and frequently occurs where the CEO is the founder of the organization. • Patron Model - Similar to the Advisory Board model, the board of directors in the Patron Model has even less influence over the organization than an advisory board. • Co-operative Model - In this model, all responsibility is shared and there is no Chief Executive Officer. Decision-making is normally by consensus and no individual has power over another. • Management Team Model - Boards operate by organizing their committees and activities along functional lines. In larger organizations, the structure of the board and its committees usually mirrors the structure of the organization's administration. Just as there are staff responsible for human resources, fund-raising, finance, planning, and programs, the board creates committees with responsibility for these areas. • Policy Board Model - The job of the board is: to establish the guiding principles and policies for the organization; to delegate responsibility and authority to those who are responsible for enacting the principles and policies; to monitor compliance with those guiding principles and policies; to ensure that staff, and board alike are held accountable for their performance. (Nathan Garber & Associates)

16. System Model:QMentum Program – Governance Standards Built on 5 key functions of governance: Developing the mission, vision and values; collecting and using knowledge and information; developing the organization; building relationships with stakeholders and demonstrating accountability. These standards are grouped into six subsections based on the five functions: • Developing a clear direction • Building knowledge through information • Functioning as an effective governing body • Supporting the organization to achieve its mandate • Maintaining positive relationships with stakeholders • Being accountable and achieving sustainable results

17. What model should exist in health care? • It is argued that not one model of accountability fits all of health care. • Health care is too complicated, with too many parties, with too many complex relationships for just one model. • Stratified model of accountability? (Emanuel & Emanuel, 1995)

18. Systems Accountability • All components within the system must work together towards to end result of improving patient outcomes. • If one component of the system is not functioning properly, others will suffer. • The goal is positive and productive patient and practice team interaction. • Healthy public policy, supportive environments and community action, along with delivery system design, clinical information systems, decision support and self managed support must all work in harmony • If these components are all accountable to one another then improved patients outcomes should be achieved.

19. Challenges-Next Steps - The “Canadian Stroke Strategy” needs to be treated as a complicated system • In addition to the Best Practice Recommendations there is a need for a role, responsibilities, accountabilities tool kit • There is also a need for an evaluation/accreditation tools and processes that can evaluate/monitor and provide feedback on the Strategy implementation and maintainance

20. …and the journey continues. The Journey Continues Health Starts at Home • www.von.ca