Accountability in Medicine

Accountability in Medicine

• Accountability is vital in medical practice
• A focus on the virtue of accountability is beneficial:
  • Differs from simply being held accountable
  • Involves embracing responsibility and welcoming input
• Accountable practice limits moral distress caused by institutional pressures on doctor-patient relationships
• A welcoming mindset towards feedback enhances learning
• Analysis of failures provides opportunities to improve clinical care

Conceptual Description

• Accountability, though implicit, is an important value in medicine
• There's a distinction between being held accountable and embracing accountability
• The virtue is essential for accountable relationships to form in healthcare
• Practitioners lacking a strong commitment to accountability struggle to serve patients, colleagues, and institutions effectively
• Linda and Ezekial Emmanuel (Seminal paper on accountability) described three components of the concept:
  • Loci: Parties involved
  • Domains: What they're accountable for
  • Procedures: How parties are held accountable
• Gerrit Glas clarifies the functions of norms/values in medicine:
  • Qualifying moral norms/principles focus on practice's nature and purpose
  • Foundational principles are the basis of the practice (scientific, technological expertise)
• Conditioning norms are legal, administrative, institutional, and economic conditions, enabling practitioners to fulfill their role
• Values are things deemed worthy and valuable
• Norms are standards to meet to attain these things
• Exhibiting values is 'norm-responsive' behavior that are internalized and become virtues
• Glas alerts to the risk of overemphasizing micro, meso, or macro spheres, and allowing foundational norms to function as qualifying ones
• Ultimately, a lack of clarity on how, and to whom, healthcare practitioners ought to be accountable has important downstream consequences
• The term "burnout" describes the demoralization and moral injury when professionals violate their values due to economic or institutional norms

Practice of Accountability

• Accountability as a virtue needs cultivation to promote flourishing
• The practice entails:
  • Welcoming accountability to others, receiving input, & providing transparent explanations
  • Being accountable for one's own attitudes, thoughts, emotions, and actions
• Requires practical wisdom, clarity about obligations, empathy, and self-regulation
• A welcoming mindset values feedback, the supervisor's perspective, and one's ability to learn
• A resistant mindset devalues feedback and change
• Contemporary healthcare acknowledges accountability through methods for reviewing/improving care
• The Accreditation Council for Graduate Medical Education (ACGME) includes accountability as a core competence

Exploration of Failures

• Absence affects patient care, and experience in healthcare systems
• Contemporary healthcare acknowledges accountability through reviewing and improving care
• A lack of accountability in these examples can be attributed to:
  • Hierarchical medical culture
  • Stress on co-practitioners
  • Larger competitive economic or political forces
• Practicing accountably requires clarification of priorities, recognition of collective responsibility, and a systems approach to safety and quality

More Failures

• A progressive health care organization's CEO cutting clinic staff without consulting clinicians, object to the CEO. Failures include:
  • Failure to involve clinicians
    • Discussion of shared accountability to patients
    • Discussions on the financial viability of the organization
  • Lack of healthy, transparent communication
  • Insufficient awareness of social responsibility
  • Succumbing to market-driven competition
• Accountable practice in the micro-sphere can occur by questioning productivity metrics if patient care is impacted

Institutional Failures

• An academic medical center recruits a division chief based solely on reputation, creates arbitrary changes to staff roles and requirements
  • Results lead to complaints, resignations, and concerns of clinical care
  • Leaders of institution exercise concerns with competitive reputation - comparative measure of worth
  • Exercising institutional virtue would involve recruiting one whose character dispositions include empathy, humility and self regulation
  • Support and engage others vs dominance and servile acquiescence
• Patient experiences severe pain after procedure and dismissal
  • Covering surgeon has burgeoning caseload, dismissively discharges patient with issue
  • One wonders about personal character, culture and stress imposed on the covering Neurosurgeon
  • The covering surgeon should review the patients evidence and symptoms
  • Address culture to promote support for medical staff

Toward Cultures of Accountability in Medicine

• Hierarchical cultures, personal narcissism, deficient communication, institutional competition, and work stress can undermine the practice
• Suggestions;
  • Systematic root cause analysis
    • Examining responsibilities and obligations to stakeholders
    • Consider work overload and lack of support
  • Explicit discussion of core values of healthcare
    • Guard against lapsing into comparative valuing with such pressure that creates
    • Inadvertently place productivity and or reputation ahead of quality

Further points

• Awareness needed for corporate responsibility with developing system approach to quality, safety, and prioritizing care
• Medical flaws are seldom errors with one accountable.
  • Deserve to be investigated in the whole
• Awareness and ability to negotiate the conditions which are delivered.
• Need for reviewed social contract
• Discernment important at individual level
• Navigating accountable with frequent case of competing claims for loyalty.

Conclusion

• Important to discuss the failures and prevention
• Focus on improving care
• Proactive cultivation of the virtue,