This commentary presents an ethical argument and practical suggestions for holding health administrators accountable for quality improvement efforts and results. Using hockey analogies and drawing on evidence from various studies and literature in organizational ethics, it argues that health leaders must promote system performance by ensuring that there is a well-organized delivery system around patients' episodes of care and that all personnel are performing at an acceptable level. Informed by system transformation and successes in the UK, this commentary proposes four strategies to hold leaders accountable: require leaders to be familiar with front-line operations, adopt a service-line approach, evaluate organizational performance by analyzing and publicizing outcome metrics and utilize outcome-based incentives.

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