CHAPTER 7

Creating a Culture of Team Accountability

At the end of the day, each team needs to determine how it will assess its performance and how it will hold itself accountable, not only to results but also to team process. Generally, when we think of accountability we focus immediately on results—quality and safety indicators, patient satisfaction scores, employee engagement surveys, and financial results. All of these measures are under intense scrutiny in today’s health care environment.

While we certainly acknowledge the importance of focusing on these key metrics, we believe it is also essential to address accountability within the team itself—to the inner workings of the team, if you will. One way to think about the relationship between results (quantitative measures) and team process is with the following diagram:

Figure 7.1 Team process

In the context of what we want to emphasize, it is really about the team’s commitment to each other and to the patients and families (or internal customers) it serves. In Chapter 5 we spent a significant amount of time discussing the concept of ownership and presenting strategies on how to further enhance ownership. When teams are operating from this position of ownership, everyone feels a responsibility to produce—produce results, yes, but also to produce for each other.

Figure 7.2 A map for leading adaptive teams

The framework we have spelled out within the chapters of this book (see Figure 7.2) can provide a road map for addressing accountability to the team process. Implementing a learning focus, creating a safe environment for dialogue, embracing adaptive behaviors, creating ownership, and awareness of how personality, biases, and beliefs impact group dynamics—all of these areas—can be addressed from the standpoint of accountability.

Before we dive more deeply into creating accountability processes and structures in these areas, we will first address, albeit briefly, accountability to results.

Accountability to Results

As discussed previously, much has been written and presented on accountability to results in health care, and we are not going to rehash all of those discussions here; rather we will highlight some of the material that is available. One of the most notable perspectives on accountability to results is Kaplan and Norton’s work on the balanced scorecard (Norton and Kaplan 1993). This work was important because it argued that a focus on measurement was just as important in business as it was in science. The notion that if you can’t measure it you can’t improve it really took flight as a result of that first Harvard Business Review article (along with the work that was occurring in the field of total quality management). The four key areas they called out as ones to systematically measure were: customer results, financial results, internal business processes, and learning and growth (Norton and Kaplan 1993).

Many health care organizations have found it useful to adopt this framework, and consulting groups such as the Studer Group have incorporated this methodology into their own consulting models—the concept of “pillars” used by the Studer Group is one example where organizations create and track measures in the areas of patient satisfaction, quality and safety, employee satisfaction/engagement, and financial performance (Studer 2003).

The benefit of using such an approach is that it helps leaders at all levels pay attention to a variety of metrics, including those that focus on internal processes such as employee engagement and morale. Additionally, since many metrics are now mandated by the federal government, or other regulating agencies (e.g., Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Leapfrog, etc.), leaders can simply plug these measures into their balanced scorecard categories.

But accountability runs deeper than just tracking performance against these quantitative measures. As addressed at the beginning of this chapter, we really want to focus on accountability to the team and team process.

Accountability to the Team

One of the problems with using the term accountability in our health care organizations is that we all have slightly different perceptions of what the word actually means. Furthermore, this interpretation is based on the social systems we live in and it also implies that our behavior is being monitored (Goodman, Evans, and Carson 2011). In fact, many of the current accountability systems in health care are doing this very thing. It’s not that this is necessarily bad; certainly, as consumers of health care we want to ensure that those with whom we entrust our care are following standard protocols and engaging in safe practices. However, there can sometimes be a negative connotation associated with the word. The reason for this is that there is often a perceived accusation that one has not performed adequately. Since (we believe) the vast majority of health care professionals are operating from the best of intentions, and often have a perfectionistic streak, it is not surprising that there can be negative reactions to the word.

The Oz Principle explains accountability as “a personal choice to rise above one’s circumstances and demonstrate the ownership necessary for achieving desired results” (Connors, Smith, and Hickman 2010). The authors approach accountability from a positive, future-focused perspective by addressing behaviors that lie either “above or below the line.” Below-the-line behaviors include finger-pointing, declarations that it is “not my job,” and giving up personal responsibility by waiting to be told what to do. Above-the-line behaviors (for which they advocate) are: “see it, own it, solve it.” Engaging in these above-the-line behaviors encourages individual ownership of the situation and an unwillingness to pass it off to someone else, or to ignore the situation entirely. We like this approach to both individual and team accountability because it links up nicely with our advocacy for creating a greater sense of ownership within teams.

Considering the diagram we presented earlier, process—content—relationship = results, we would like to focus our attention on process, content, and relationship, and examine it through four of the topic areas we addressed in earlier chapters.

The ability of a team to create a safe environment where all team members feel safe to speak up, share observations, offer feedback, and ask questions is absolutely critical to achieving successful quality and safety outcomes. The health care industry has spent years working on this issue, and yet we still struggle mightily with it. In Chapter 3 we introduced four concepts that leaders can emphasize to create a safer environment for dialogue:

From an accountability standpoint, leaders should make it a habit to routinely conduct an assessment of how the team is performing in these four areas to reinforce the behaviors. A simple way to do this is to dedicate time in one of the standing meetings to conduct the assessment (at the end of a debrief would be one way), in order to assess adherence to the behaviors from two perspectives: (1) how each individual believes they are doing with practicing the behaviors and (2) how the team as a whole is doing. Using a Likert rating scale of 1 to 5 (1 low, 5 high) ask each team member to personally assess how well they are doing in practicing the six behaviors listed previously. Alternatively, the following three open-ended questions can be asked:

It is not necessary that team members share these results with the rest of the group—it can be quite effective to just do the self-reflection. As trust and the comfort level of doing this activity increase, the leader may choose to ask team members to share their results, along with a short explanation of why they answered the way they did.

Likewise, a similar process can be used to assess the team’s performance. The use of a Likert scale or asking open-ended questions is an effective way to engage the team in a conversation about how the team is actually doing in practicing these dialogue skills. Using the LS 1-2-4-all can also be a useful way to engage the team in a conversation about how it is doing in using the four dialogue skills.

Another strategy that can be employed is to use Patrick Lencioni’s Five Dysfunctions of a Team assessment (Lencioni 2002). Lencioni’s assessment addresses team functioning through five specific categories:

Asking team members to complete this assessment provides the group with data relative to how they believe they are conducting themselves in these five areas. The team can then decide which areas it needs to focus on and what strategies it will employ to make improvements.

It should also be pointed out that in all of these cases, the leaders need to model the reflective practice and be willing to self-disclose their own answers to the questions posed. This may not be an easy step for all leaders, but it is essential if the goal is to have the team fully engage in the process. For leaders who find it difficult to disclose their own responses, one strategy that can be employed is to first journal about their own responses and identify one to two specific examples they would feel comfortable sharing. This can be a way to ease into sharing the results of the reflective activity. It is not necessary to disclose everything that comes up for the leader—start slow, see how it goes, and build from there.

In Chapter 2 we focused on the strategies for creating a learning environment, and at the end of the chapter we provided some reflective questions for leaders to consider; those questions are also relevant from an accountability standpoint. Since leaders play such a critical role in creating an environment where learning can thrive, they need to pay particular attention to personally assessing what they are doing to create the learning environment, and how it translates to actual performance results (e.g., reviewing the balanced scorecard or pillar goals). Beginning with the five elements listed in the chapter provides a good starting place:

In Chapter 4 we identified strategies to help teams become more adaptive, such as assessing and understanding the environment, understanding if they are facing technical or adaptive challenges, and fostering a culture of learning and development.

To this end, leaders can hold themselves and their teams accountable to conducting environmental scans—put it on the calendar for twice a year and make sure you execute. Determining the nature of your challenges (technical or adaptive) is different and requires a different approach. First, it requires gaining knowledge that there is in fact a distinction between technical and adaptive challenges, followed by ongoing education to help people diagnose the nature of these problems. Early on in this effort leaders need to own the responsibility for helping the team with these practices. They need to continually ask the questions of their team and then provide the coaching to help team members with this diagnosis process. The act of being more adaptive fundamentally requires a learning mindset. So this is really about culture change and tracking long-term how behaviors are changing (or not changing).

The idea of accountability to the team provides another lens through which leaders can view accountability. As previously mentioned, accountability to results is certainly important, but so is accountability to team processes and relationships. While there is much focus today on the results side of the equation, we believe there is value in a both/and approach, with an expanded view of accountability, which we also believe benefits long-term performance and strengthens a team’s adaptive culture.

Conclusion

A key belief of ours is that leaders own culture. If, as a health care leader, your intention is to help your team (or teams) become more adaptive so that they are better prepared to respond to a rapidly changing and evolving environment, then this represents a culture change.

The intent of this book is to provide health care leaders with new frameworks and skills that will help their teams excel in this era of complexity and uncertainty. By no means do we believe what is written here captures everything a leader needs to know to be successful. Our hope is simply that leaders are able to relate to the examples that are shared, and are able to put into practice some of the concepts and skills that have been highlighted, with the goal of creating teams that are more adaptive. At the end of the day, we all have the shared goal of improving the health care experience for the patients and families we serve, and to simultaneously ensure our teams are engaged and fulfilled in their work.

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