Questions & Answers: Sustaining Accountability
IN = Interviewer MA = Matthew Anderson LH = Lewis Hooper
MA: We faced many challenges. The greatest challenge was creating a new culture of transparency, reporting and accountability in the health care system. There are components of healthcare spending for which there is minimal clear accountability. This happens in all sectors of healthcare and there is significant complexity to changing this. It is important to note that, in most cases, organizations and individuals have acted prudently with the funds despite the informal accountability structures. But this same advantageous flexibility in our health care system can also be contributed greatly to the substantial gaps in the available care.
LH: Collectively, healthcare is accountable to many masters: the patients we serve, the funders, the various professional regulatory bodies, the organizations providing services, professional standards of ethics and behaviour, and so on. However, with the exception of some financial matters and an eye on volumes, there is little direct accountability for results, particularly between the funders/stewards and healthcare providers. In my opinion, the major challenge was that the funder could not hold the healthcare provider publicly accountable for a standard that was neither financial nor professional, but rather focused on performance. The success of the WTIS project was that the field accepted this accountability willingly, and concerns tended to focus more on the mechanics of the changes, as opposed to the principle. This was certainly aided by the initial financial incentive for incremental volumes in some areas.
IN: Now that the transition has been made from government to LHINs, what factor(s) in achieving accountability were/are most important for you in managing your own accountabilities?
MA: One of the main challenges that the WTIS project overcame was setting the tone for accountability at a provincial level. We can now build on that at the LHIN level. Without the implementation of the WTIS project, it is doubtful the LHINs could have driven forward with a performance management agenda. With 14 networks moving at different rates, the push back from the field could have been overwhelming.
LH: There are several components of the success that must continue onward to make LHINs effective. The strong mandate that came with the WTIS initiative must be maintained. Government and the LHINs must continue to focus on accountability as one of the key driving forces, and they must ensure that accountability is placed on results, not process. Another key success factor is in ensuring transparency is maintained as it was during the WTIS project. Participants in the process knew what was happening, when it was happening and why. Finally, there was a sense conveyed in part through the Hospital Accountability Agreements signed by the participants that accountability would be real and performance would be monitored, and that the results of that performance would be used in meaningful ways as feedback to the accountability.
IN: How can the accountability achieved be sustained? What can others learn from this experience?
MA: For the accountability to be sustained in the long run, it is important that it be kept public, transparent and timely. The WTIS operations team needs to work with the LHINs to embed this approach into their work and goals. It must permeate all levels of planning, and there must be a consistent thread connecting targets and goals from province to LHINs, and from LHINs to healthcare providers. Without that thread, the agenda becomes too diffused, and substantial gains will not be realized.
LH: There are several key factors in sustaining the accountability that started with the WTIS project. They include the ongoing maintenance and continued development of tools. As these tools become less intrusive and more a part of the ongoing workflow, and as clinical management systems become more predominant in physicians' offices, reporting difficulties will become non-issues. There are two other related issues that I think will drive the sustainability of accountability: Ongoing, meaningful attention will need to be paid to the Hospital Accountability Agreements from the LHIN/government in a way that gives incentives to healthcare providers to be accountable. Failures and successes must be dealt with in a fair, transparent way. Poor performance must not be accepted, but must be dealt with in a fair and not necessarily punitive way. Success, if not rewarded, must be recognized in meaningful way. The system as a whole must know that accountability will continue to be taken seriously and valued by all parties.
Finally, the accountability will be sustained by the ongoing expansion of accountability to other areas. This expansion must be based on accountability for results and meaningful outcomes, not process. Healthcare as a whole and funders in particular are quite good at substituting process measures for outcome measures, and for accountability to be a transformational activity in healthcare we must move from measuring process, such as cases or volume of patients in diabetic education, to accountability for outcomes such as wait times, Hospital Standardized Mortality Ratio or the rate of amputations due to diabetes.
About the Author
Matthew Anderson is the Toronto Central LHIN CEO. Prior to this appointment, Matthew was the Senior Vice-President, Performance and Technology of the University Health Network.
Lewis Hooper is the eHealth LHIN Lead for the Central East LHIN and co-chair of the Ontario Provincial Council of eHealth LHIN leads.
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