Accountability in Healthcare Organizations and Systems

All debates about the way to improve the quality and safety of care, the control of costs or the health of the population, raise the issue of accountability. Behind this notion, there is the idea that healthcare systems have an unexploited margin for improvement if they better align the utilization of resources with what is known about the appropriateness and effectiveness of care (Maynard 2013). The common understanding of accountability is one in which a governing body (e.g., government, regional health authority, healthcare board, professional association) is in a position to mandate providers or organizations to meet certain goals or objectives. Because of the authority or legitimacy of these governing bodies, providers or organizations believe they must account for their achievements in relation to such goals or objectives. The relationship between these two sides of the accountability equation is not necessarily hierarchical – at least in principle (Saltman and Ferroussier-Davis 2000). An accountability relationship can be based on a dialogue where providers or organizations argue with governing bodies about their relative achievement of predefined goals. Even the definition of goals and objectives can be made through a collaborative process between governing bodies and concerned providers or organizations. That is, in brief, the notion of accountability does not have to be reduced to the application of formal controls on one's own activities or behaviours.

Despite variations in approaches to accountability, an accountability regime will always be based on three elements: a clear definition of desirable goals or objectives (the object of accountability), the ability to measure and monitor goal achievement and a set of consequences for providers or organizations if achievements regarding goals or objectives are not satisfactory. Defining goals and objectives in healthcare is not easy, and is contested terrain. Quantitative targets for volume of care say nothing about quality of care or patient experience. Targets around the delivery of care may have only tenuous or very indirect linkage with the improvement of the health and well-being of a population. Monitoring the process or the outcomes of care requires proper, adequate and on-time information if the objective is to provide useful feedback to providers of care and services. The consequences of performance failure by providers can be more or less coercive. An organization can face budgetary cutbacks following poor performance, but may also receive support to develop capacities to improve. While accountability is a key element in improving the governance and management of healthcare organizations and systems, an accountability relationship can be developed with a concern for learning and improvement beyond control and sanctions.

Accountability regimes in healthcare systems thus face numerous challenges relating to the definition of a clear mandate in the form of specific goals and objectives, to the attribution of these mandates to skillful providers or organizations and to the design of incentives to support the accountability relationship and improvement. The goals are related to the complex function of production (integration of care, caring for multi-morbidity chronic diseases, improving the health of the population), and they will command a broad set of competencies and knowledge on the part of governing bodies and providers, plus an ability to collaborate for the improvement of care and services.

While accountability is challenging and critical to the improvement of health systems (at least within the context of the Canadian healthcare system), we do not have much systematic research dealing with this issue. In this special issue of Healthcare Policy/Politiques de Santé, a research program under the leadership of Professor Raisa B. Deber (University of Toronto) has documented how accountability is structured within various sectors and organizations in the Ontario healthcare system. This collection of papers is very valuable because it is the first one that provides a detailed description of how accountability regimes are developed and structured across the system (e.g., the hospital sector, the long-term care sector and public health). Beyond the richness of the description of the accountability landscape in the Ontario healthcare system, this set of papers raises important issues around the theme of accountability. First, it shows that accountability is still in its infancy – not because providers or organizations do not want to be accountable or that governing bodies do not want to make them accountable, but because identifying the right targets and establishing the right mechanisms to account for the utilization of healthcare resources is a complex task. Second, these papers deal mostly with accountability regimes within the current boundaries of the system with its silos. It says almost nothing about the challenges and promises of developing accountability regimes within the context of networks or programs that transcend current professional or organizational boundaries. Finally, this collection of papers refers only marginally to the question of financial incentives, which seem to be a key lever that governing bodies use to influence the behaviours of healthcare providers and their propensity to take some goals or objectives more seriously.

Having said this, the research team has done a great job based on a single research grant to produce an exhaustive mapping of how the notion of accountability is deployed across the Ontario healthcare system. This is of interest for researchers, but also for any observers of the healthcare scene across Canada, where each system faces the challenge of better aligning the utilization of resources with broad system goals commonly defined now as the Triple Aim: better quality of care, better safety of care and better health outcomes at a minimal cost.