When we hold our team accountable, are we empowering or patronising them?

Accountability is the obligation to explain, justify, and take responsibility for one’s actions. From a healthcare perspective, our colleagues and practitioners should be accountable for the services they provide, the results they achieve, and the essential deliverables of quality and safety.

I have always found the notion of Clinical Accountability interesting and, at times, confronting. When I have put a framework around clinical interventions and asked practitioners to justify their professional judgments and clinical reasoning, I’ve often wondered whether I am empowering my team or patronising them with these approaches.

Please consider these somewhat familiar scenarios:

• I recently referred a very good friend to one of my colleagues in the practice. I had a reasonable understanding of my friend’s provisional diagnosis after an initial screening assessment over the phone. As such, it was hard to resist interrogating my colleague to get into their clinical mind. I wanted to understand his working diagnosis and wondered what they would do to treat it. I wanted to follow the actions of this person’s clinical journey because I care deeply about my friend. I thought of how and what questions I could ask that were, in essence, bringing accountability around what they are doing in the consultation room, without making them feel defensive.
• What about the routine clinical case conference? For example, when your colleague is reporting on advancements in ACL rehab and you want to challenge or critique some of their thinking. We must learn ways and language that bring accountability but does not patronize them.
• This is true also when you are supervising a new staff member. You observe their behaviours and try to explore their clinical reasoning by starting appropriate conversations about their rationalized intentions but are conscious of not causing performance anxiety.
• Lastly, a common scenario might be when a patient complains to you that they are not getting better and as an owner or leader, you want to work this through with the treating practitioner to understand what is it they are doing (or not doing) that relates to the patient’s dissatisfaction.

These are classic scenarios where you face the double-edged tool of accountability. The challenge in these situations is to keep people accountable without diminishing them. I want to help my team members improve clinical performance but not micro-manage them. This can sometimes feel like a mutually exclusive objective.

There are lots of reasons for this dilemma, some of which include:

1. Depending on the delivery, accountability can be synonymous with the loathed micro-management. We all know the bad stigma of what feels like ‘nitpicking’ – which implies mistrust and lack of confidence in someone’s capability. It breeds an environment where people feel like they cannot be left to their own professional judgment.
2. Physios are naturally averse to Key Performance Indicators. Sometimes when you mention patient visit averages, patient satisfaction scores, objective clinical outcomes, it can come off as being overly commercial, when on the contrary these metrics typically have a direct correlation to clinical effectiveness.
3. We do not always get the same results the same way in healthcare. Some clinicians can get very excellent outcomes and sustainable results even with unconventional methods. We must wonder sometimes whether the ‘means justify the end’.

So, how do we proceed? How do you foster clinical accountability without patronizing your people? What are some key strategies?

Clinical accountability is complex, so it helps to break it down into principles. I like to remember:

• We are all accountable to someone. We should submit to multiple parties: Clients, employers, regulating bodies, health legislation, ourselves, the moral standards set by our peers, and the higher power, God. This is the first principle we must help our people to understand and accept. The sooner we do, the better.
• We must be purposeful, and goal-focused. When we start uncovering the motivations behind what the practitioner is trying to achieve, our inquiries can help them succeed rather than come off as interrogations. Then, we can determine how we can help them.
• We must dispel the idea that accountability is about mistrust. The one does not infer the other.
• We must understand how our people like to be held to account. We can learn to use different approaches to make it more relational and suited to their preferences, lowering their defenses, and increasing their awareness of the purpose in our questions. When they can perceive the engagement as one favouring continuous improvement, performance coaching, and professional development, their levels of receptivity improve. Often “mentoring” is a more comfortable word for the same dynamic we are discussing here.

Here is a simple chart showing the 5 levels of escalation I tend to follow when stepping up accountability around clinical conversations. It is called the Accountability Dial. This helps our people take ownership of their roles individually and as a team.

Keep in mind the goal is to promote personal and peer accountability. Work hard as the leader to establish a trusting environment and encourage your team to give insights and feedback regularly and ensure a culture of accountability becomes your “new normal”. Try and avoid letting fear and ego get in the way.  Remind people you are also still learning. And ultimately, set clear framework to outline performance expectations to guide your people in providing excellent patient care and effective clinical outcomes.