- Accountability
The requirement to account for one’s actions and outcomes to a higher authority; cannot be delegated
- Responsibility
The obligation of ensuring the required task is complete; can be delegated and/or shared; often used interchangeably with ‘accountability’
Strategic accountability
At the strategic level of the health system, ministers and department leaders may have their accountabilities legislated through parliament (National Health Act 1953 [Cth]; Public Health Act 2010 [NSW]). These accountabilities are well documented, and expectations are clear and legally binding. The parliamentary process holds to account those in power for delivering on these accountabilities, and if the community is not satisfied with their performance, those in power may not be re-elected.
Publicly available external peer review is another way in which hospitals and health services are held to account. Health service accreditation through the Australian Council on Health Care Standards (http://www.achs.org.au), the Health Round Table (http://www.healthroundtable.org.) benchmarking groups and various medical college auditing procedures (Royal Australasian College of Physicians, n.d.) are some examples. These simple but effective external reviews can motivate chief executive officers and the organisations they administer to be accountable to an external standard set by a third party that acts on behalf of the community’s interests.
Operational accountability
At the health service or departmental level, key accountabilities are often framed in an operational plan developed following a gap analysis between the current situation and the ultimate goal. In the operational plan, a list of priorities is developed and documented using the SMART format (see below) with specific individuals identified to be accountable for each element.
Individual accountability
Before accepting a task, the accountable officer should examine the accountability structure, specific expectations, allowable resources, authority to act, ability to negotiate or modify expectations (including timeframes) and consequences of success and failure.
Leadership and holding to account
Managers often try to be likeable, and they try to avoid tension, conflict and ongoing performance reviews. Accountability is particularly difficult if personal friendships cloud the professional relationships required at work. However, it is more important for managers to be respected rather than liked (Ehrler, 2005). Staff will not always respect a popular leader, but a respected leader will always be popular!
Holding an employee to account can require the manager to conduct a difficult conversation with the employee, and many managers are reluctant to approach this. Despite feeling apprehensive, by utilising the SIMPLE or SMART frameworks set out below to guide discussions (and documentation), the manager can approach such issues with confidence and competence. There is no easy way around this responsibility – it must be met head-on.
Although many leadership styles have been studied and documented, no one leadership style will be suitable in all situations. Traditional leadership styles include autocratic, bureaucratic, participative and laissez-faire; more contemporary styles include charismatic, connective, servant, transactional and transformational. In our view all styles of leadership have currency in various situations. In a disaster situation, an autocratic style may be necessary as there is no time for consultation and consensus; in a budget development process, a bureaucratic style may be useful; in an industrial relations conflict, a participative style may be warranted; and in a quality improvement brainstorming workshop, a laissez-faire approach may work best. Directing, supervising, coaching and delegating leadership styles are all appropriate in various situations and can all be used with the same employee concurrently, depending on the situation, even in performance management scenarios when holding a staff member to account.
Knowing that leadership is more about behaviour than personality (Kouzes & Posner, 2007) and that a leader–constituent relationship characterised by fear and mistrust will not produce positive outcomes, most leaders endeavour to develop relationships characterised by respect and confidence. Feedback delivered by a respected and credible authority holds the most value to the recipient.
Sally is a four-year postgraduate registered nurse working in a busy medical inpatient unit. She has worked hard to develop her nursing skills since completing her graduate nurse program and is now well regarded as a senior registered nurse. In her performance appraisal and development discussion with her nurse unit manager, Sally is given the feedback that she is performing well and that her willingness to be a preceptor and mentor to new and unskilled staff has been noted and appreciated. Sally indicates she would like to work towards becoming a clinical nurse.
The nurse unit manager takes this opportunity to discuss with Sally the requirements for clinical nurses. Together they discuss areas for Sally to focus on developing, and Sally is provided with the clinical nurse role description and the role-specific information. Sally and her nurse unit manager document a plan for Sally to follow to facilitate her development along this pathway.
Over the next six months, Sally works to complete the development plan as laid out in the performance appraisal and development and attends a workshop designed for aspiring clinical nurses. She continues to demonstrate sound clinical judgement in the workplace and fills in as a team leader on several occasions.
At the six-month review, Sally and her nurse unit manager analyse the plan and Sally’s achievements to date. Sally is then offered the opportunity to backfill in the clinical nurse role to cover a period of leave. Sally is delighted her hard work has paid off and agrees to the position.
The nurse unit manager ensures that Sally has all of the information regarding code of conduct, role description and portfolio responsibilities, and they have an in-depth discussion regarding the leadership aspects of the role. This action is recorded on the performance appraisal and development, and Sally is provided with a copy of the document. The expectations are both clear and documented.
Holding to account requires very clear communication and decisive directions so that all participants know what is expected. However, not every employee can meet every expectation all the time, and most reasonable managers will demonstrate some latitude in their expectations. When both parties share the same understanding, a failure to perform according to the manager’s reasonable expectations may be due to one of three primary factors: skill, hill or will. Firstly, the individual may not have possessed the skills required for the tasks; for example, unforeseen barriers arose that they did not know how to approach and required further training to tackle. Or, the slope of the hill may have been too steep, meaning expectations were unrealistic: timeframes, the quality of work or the resources required may not have been clear, resulting in unachievable demands. Finally, the individual may not have had the will to complete the task: perhaps it was never explicitly determined to be a priority, or the individual involved was lazy, rude or vengeful.
- Expectation
A belief that something will happen as agreed or perceived
It is often easy to find fault in the performance of others and yet fail to see our own part in failures or difficulties encountered. How illuminating would it be to see our own contributions to the outcomes achieved?
- Performance
Fulfilment of a set of obligations or expectations, usually assessed as being sufficient to be deemed satisfactory or complete
Frameworks for holding to account
In management, there are many approaches to framing accountability and holding to account. Some simple frameworks are discussed below that can assist managers to approach their responsibilities and those they delegate to allow them to consistently and predictably implement accountability processes.
Smart and Simple
Accountabilities and expectations should be SMART: specific, measurable, achievable, relevant and time-specific. They should be documented in clear and understandable language. The more important the accountability or expectation, the more important it is to document clearly using the SMART format. If not documented at the outset, specific expectations can be forgotten or confused, leading to argument, wasted time, renegotiation and ill-will. As a rule, committees, groups or multiple persons cannot be held accountable for making things happen. Too often, such group accountabilities result in everybody-somebody-anybody-nobody scenarios, whereby everybody is asked to achieve a goal, everybody thinks somebody will do it, anybody could do it, but in the end nobody actually does it. It is therefore important that only one person is held responsible and accountable for delivering each key assignment.
Miller (2006) articulates a SIMPLE approach to accountability whereby roles and tasks are easy to remember each time a new accountability is established. The approach helps guide managers and their teams in meeting these accountabilities:
Set expectations
Do not assume that employees know what is supposed to be done, when, and to what standard unless these are clearly explained at the outset. The clearer these expectations are, the less time is subsequently spent clarifying or arguing about them. To ensure complete understanding, expectations must be relevant and realistic.
- Relevant
Aligned with overarching business objectives
- Realistic
Attainable within known constraints
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