In my early blog entries, I’ve been expanding on my first priorities for St. Luke’s: creating alignment within and across the System; optimizing the leadership team; and instilling accountability throughout the organization. I’ve looked at alignment and introduced some of our new leaders, and now want to focus on accountability.
When I think about accountability, I think of it in these stages: individual, team, cross-functional, and organizational.
Individual: This is the foundation, the level at which people know what is expected of them, have the tools to be able to meet expectations, and are held accountable for meeting those expectations.
Things may come up that make hitting a deadline difficult. But when we exercise individual accountability, we alert others to these changed circumstances, develop a recovery plan, and carry through.
My assessment in my first year was that while there were different levels of accountability, as there are in any organization, we did not consistently demonstrate individual accountability.
Team: This is the next step up. Team accountability occurs when accountable individuals realize that there are things that can only be accomplished through teamwork, and that everyone has additional responsibilities and accountabilities as part of the team.
A great example occurs daily in our nursing units. The individual nurse will usually understand what is expected of her in caring for patients, will ordinarily have the equipment and supplies to carry out the expected care, and will ordinarily fulfill those responsibilities on the appropriate schedule. This is individual accountability.
At some point, that nurse may go off the unit. This is where team accountability comes in. The team fills in so that patients assigned to that nurse are still cared for in the nurse’s absence. The other nurses know that their responsibilities increase when a nurse is absent, but also know that when they are gone, team members will step up.
Team accountability is a step up from individual accountability, but it’s a bad place for an organization to get stuck.
Here's an example. Suppose that the director of the cath lab has developed individual and team accountability in her staff, but stops there. The director is only interested in optimizing the department for which she is accountable. She manages the budget carefully, controls the worked hours carefully, and doesn’t care how other units are performing as long as all her areas are meeting or beating their targets.
Have you ever known a person like this? What happens if you need help from the cath lab with some quality initiative? What happens when the ER is focusing on door-to-balloon times, but the cath lab is not, or vice versa?
Team accountability, like adolescence, is a key developmental stage, but no one in their right mind would want to get stuck there. For organizations, it results in silos and the optimization of some areas at the expense of other areas and the greater organization’s goals.
Cross-functional: Cross-functional accountability occurs when we understand our relationship to and impact on other areas, and view ours as a service department and other areas as our customers. Teams that operate at the cross-functional accountability level understand that they exist for some greater purpose, and that by working together across departments, the organization can accomplish goals that could not be met by individuals or teams.
Again, let’s use some examples to illustrate. When the manager of the imaging department is rounding in the ED to make sure that there is no backlog of patients requiring imaging, that’s cross-functional accountability.
When the head of pharmacy is tracking to make sure that all necessary medications are stocked and replenished promptly in the nursing units, and that there are no expired medications in the patient bins or dispensing machines, that’s cross-functional accountability.
When the manager over supply chain is rounding in the OR to make sure the OR has all the supplies needed for the day, and checked the quality of the OR packs (all the correct instruments are in the pack, no other instruments are in the pack, and all the instruments are properly sharpened), that’s cross-functional accountability.
And when these same managers have implemented Lean principles, our TEAMwork methodology, to ensure that they are continuing to make improvements that optimize quality, safety, and service to the departments they serve, that’s cross-functional accountability. We have many more examples of cross-functional accountability, and our TEAMwork implementation will increase our success at this level.
When you think of another area that helps you do your job better, easier, on time, and more reliably, it is probably a department or team that strives to be accountable in this cross-functional manner. Write that area, department, or manager a note. Thank them for achieving this level of accountability, and point out what a difference they make in your ability to do your job!
Organizational: This is what we strive for. As a general rule, it can’t occur until we go through the other stages, yet you have probably seen a glimmer of it.
Ever been through an emergency or other crisis? I have on several occasions, and I have seen it in action. It is when no one says, “That’s not my job.” It’s when everyone pitches in, titles disappear, clock-watching stops, and people jump in to help. Unfortunately, if an organization hasn’t moved through all the other levels, those same people revert to wherever they were once the crisis is resolved.
Organizational accountability as a developmental achievement (as opposed to response to a crisis or emergency) occurs when everyone realizes their role in the organization’s goals.
It’s when the person in registration understands that patient satisfaction is a goal of the organization, knows the ways that they can help delight patients and their families, and sees how that will help the organization be successful.
It occurs when any staff member, security guard, or volunteer sees a patient outside the entrance who is complaining of chest pain, realizes that we have a quality goal related to timely evaluation of patients who may be having a heart attack, and hustles to get the patient into a wheelchair and into the ED.
It is believed that it ordinarily takes at least five years of concerted effort to get to organizational accountability. We are two years into our journey, and already we are making great progress. I am so proud of all of you who have looked to see how you can increase your own or your department’s level of accountability.
Those organizations that achieve organizational accountability will enjoy financial, quality, safety, patient satisfaction, employee satisfaction, and physician satisfaction success that other organizations can only dream of. We’re on our way. Keep up the good work!
I’d also like to wish each of you a happy and rewarding 2012. I appreciate your thoughtful input and comments, and look forward to a rich exchange of ideas and information in the coming year!
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.