Insights February 2013

Accountability for Performance

Hugh MacLeod and Tom Closson


Today, I am joined on the balcony of personal reflection by Tom Closson, a prominent healthcare leader. We start with the premise that, fundamentally, health system accountability for performance is about information. Every accountability strategy, whether it deals with accreditation or report cards — patients’ bills of rights or paying for performance — includes information about the expectations and realization of performance. Although performance information is necessary for accountability, it is not sufficient. Health system accountability becomes real when governors and managers in provider organizations and their staff can effectively relate their work to performance information. In order to do so, four key success factors must also be present: 

  1. Rationalized system roles
    Payers (primarily governments in Canada) and provider organizations must have a clear separation of roles. If government micro-manages, providers cannot fairly be held accountable for achieving goals. Government must have the courage to limit itself to setting goals, targets and high level strategy and then ensure appropriate supports for providers to excel.
  2. Aligned target setting
    Information about government goals — priorities, indicators and targets— must be clearly communicated by government. Reporting against these targets should be aligned between government and  providers as well as within and among provider organizations so that governors and managers and their staff are held responsible for achieving  targets that will further government goals.
  3. Aligned incentives
    All the players should have their incentives aligned. Conflicting incentives will lead to conflicting actions. Rewards for managers and staff should be based to a significant extent on their actual contribution to system goals. 
  4. Capacity to improve performance
    The capacity to improve performance should be a key characteristic of any accountability framework. This means that providers must have the necessary resources to improve performance, such as: effective leadership, information on evidence-based practices, benchmarking performance, peer support for change and process improvement capabilities.

When all these factors are in place and aligned, a new culture of accountability can emerge. This combination of factors is common in the private sector where there are performance improvement programs linked to bonus systems to provide individuals with clear information on expectations for performance, support for achieving those expectations and clear rewards for their achievement. In the private sector if performance is consistently poor an organization usually goes out of business as the market weeds out organizations that do not perform well.

But as you might suspect, not everyone agrees that this level of accountability is possible in publically funded health care. Some are sceptical. Some, like our not-so-friendly Ghost of Healthcare Despair, shouts down on us.

“You just don’t get it, a lack of political courage is why dramatic and sustained accountability for performance has not occurred in health care.  Politicians are too timid to set system goals and use effective accountability mechanisms for providers to make significant changes to the healthcare system because of perceived political risks. Even worse, the changes would take more than one term to implement, requiring sustained focus and long term commitment to new ideas. The short term political focus prevents the sustained accountability for performance that you dream about.”

The first step to instil accountability for performance into the healthcare system is to define the goals of the system and to determine specific measures and targets or metrics for assessing results.  Responsibility for measuring and ensuring accountability should not solely rest with government as it is too distant from the point of service to make effective local accountability decisions.  For true accountability to be instilled in healthcare, all stakeholders must be made accountable for their performance for achieving system goals within regional or local structures close to where the population resides. Government needs to stay out of the weeds. If government cannot resist political pressure and regularly intervenes in local health provider operations and decisions in response to negative local media stories, then they will have overstepped their appropriate role and undermined the local governance role that they have established for achieving performance improvements.

If the healthcare system is to improve its performance over the long term, it must shift from a paradigm where no one – or only a few – are accountable for achieving a particular set of results, to one where a wide range of players is accountable for achieving a broad range of results. To paraphrase Barber, when there is a problem in the system, the answers cannot come only from government, because it has the money, or from provider organization boards and management, because they are “in charge.” Rather, the answers will come when we ask, collectively, how are we going to solve the problem.  Accountability for achieving results must go beyond boards and management – and beyond a vague concept of shared responsibility – to include physicians, other healthcare providers, professional associations, regulatory bodies, government, regional networks and the public.

There is little accountability within Canadian healthcare as to who is responsible for what — and at what levels of service.  Accountability should focus on those who take on leadership roles to set service levels for the public and be responsible for services and requirements. In Canadian healthcare there is still a high degree of provider fragmentation. For example, in all provinces government has allowed doctors to operate generally outside of any regional or local networks that government has created. Given that doctors are not integrated into the leadership and operations of the regional health systems they often feel alienated from regional efforts to improve system performance and act in a manner that is not supportive of those efforts. Excellence is achieved in organizations by staff who collectively take pride in work well done. We will reach excellence in healthcare through credibility of local leadership, integrity in organization, alignment of effort and collective accountability for performance.

Alignment of incentives offers a significant opportunity for improvement in Canadian healthcare. Governments as payers have traditionally established mechanisms for determining funding levels and features for various healthcare sectors separately from each other. As a result, hospitals, home care, long term care and doctors may have conflicting funding incentives which when taken as a whole may not be supportive of achieving collective performance goals. With physicians, for example, governments generally have a separate and distinct set of negotiations and arrive at contracts that establish the accountability that they have at a provincial level rather than a regional or local level. These contracts may or may not align well with the funding system incentives established for other sectors. A solution here is to establish some sort of funding commission in each province that has the authority and analytical capacity to set funding rates and incentives for all sectors to ensure that they are in alignment and focused on achieving provincial healthcare goals.

A further requirement which will ensure that the alignment of incentives permeates down to the local level is to have pay for performance or pay at risk systems for managers that are linked to supporting the achievement of provincial goals. Some provinces have attempted pay for performance and have subsequently aborted or minimized these efforts as a result of negative public perceptions regarding managers receiving significant rewards at a time when there are severe provincial financial constraints. Of course, challenging times are when we need the effective leadership of managers the most. Therefore, government needs to strengthen management reward systems to ensure that they encourage those managers that will lead the way in ensuring healthcare system performance improvement. 

Attempts at strengthening accountability are all for nought unless there is capacity in the system to improve performance. McMaster University’s Health Systems Evidence Service has reported on the systemic review conducted by Boaz, Bueza and Fraser (June 2011) that shows that to move evidence into practice requires a multi-faceted intervention. This includes information technology support to individuals that provide care, education materials, local opinion leaders, audit and feedback and reminders and prompts.

In conclusion, implementing effective accountability for performance in the Canadian public healthcare system is certainly possible. Nevertheless, effective accountability systems “do not come easy.” Beyond the obvious need for performance information, success will be more likely achieved if the accountability framework is established with rationalized system roles for government and providers, aligned target setting, aligned incentives and the use of a multi-faceted intervention for each performance target to move evidence into practice.

Next Week’s Guest on the Balcony of Personal Reflection: R. Alvarez in a conversation titled “Four Mindset Shifts”  

Click here to see the First Series of Ghost Busting essays.


Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Hugh Macleod is CEO Canadian Patient Safety Institute. Tom Closson is a Healthcare Consultant and former CEO of Ontario Hospital Association.


Barber M. Instructions to Deliver. Methuen & Co, Ltd. 2007
Boaz, Bueza, Fraser (June 2011).  McMaster University Health Systems Evidence Service Review.



Charles Low wrote:

Posted 2013/07/02 at 06:35 AM EDT

As a front-line provider, all of these essays puzzle me a bit.

All we need is a leadership structure which is wise, altruistic, and able to balance dynamically the greater public good all the way through the system with what an individual patient needs (or wants).

"Find someone without a vested interest," the ghost might say (but there is no such person).

But "accountability" is a sticky point here. I know of one place - ask Dr. Kitts (previous article in this series) - where it's bi-directional. "Shared" or "multi-directional" might be better. Anecdotally, that seems to be working much better.

Because, frankly, it's also somewhat offensive to hear that there is no system. (That might not be what you said, but that's what I heard.) I work hard for patients every day in a system which - yes - does need better coordination, but where many, many people function in high-performing teams to look after the often distinctly-individual circumstances of a particular patient.

As Dr. Ted Boadway of the OMA said years ago, he could come down with appendicitis, go to an ER, be evaluated, be seen by surgery, anesthesia, and internal medicine, have surgery and be resting comfortably (and safely) in his bed recovering all before the day was out - without any "central" system at all. Don't ignore the tremendous system which has been carefully crafted over many years in response to health-care needs. The people on the ground often know very well what they're doing!

Would that benefit from more of an overview? Certainly!

Would that overview benefit from a sincere, pervasive, multi-directional engagement with all levels of the system, most definitely including the workers? Most definitely!

Be careful with the concept of "accountability"! As one patient-safety expert I know says, "The standard concept of 'accountability' probably does more harm than good!" (And he's a fervent accountability-promoter!)


Jennifer Jilks wrote:

Posted 2013/07/02 at 09:06 AM EDT

Where does the patient fit into all of this accountability?


Will Sawyer wrote:

Posted 2013/08/02 at 08:03 AM EDT

Offering a pilot model to allow HCWs see "how easy" it can be, will help to move these systems forward. My proposal is to use "Hand Awareness" as a pilot that integrates all 4 of the key success factors mentioned, wrapped into a simple initiative that would greatly benefit patients and reduce costs, by encouraging ALL staff to comment on the lack of compliance reporting to a "centralized data repository"by clinical category. Hand Awareness is hand hygiene, respiratory etiquette and cross contamination awareness(T Zone) which are critical behaviors in infection prevention that would benefit Patient Safety and cost reduction immensely..


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