Home

CCA Purpose

How the web site works

Concepts and Terms

Why We Need Public Accountability

Principles of Accountability

Standards for Public Answering

Legislating Accountability

The Equity Statement

Steps in Holding to Account

CCA Blog

Citizen Audit

CCA Convenors

Journal of Public Accountability

Contact Us



 


II. An Article on Accountability in a National Journal


In Issue 2 of the Journal we noted that the 2001 Massey Lecturer chose not to say what she meant by "accountability" while using the word nearly a dozen times in the first 10 pages of her published Lectures, "The Cult of Efficiency." The problem is not the academic rule that authors are to define their terms at the outset. It is the fact that the prestigious Massey Lectures command people's attention. Thus if the Lecturer doesn't define accountability, the audience and readers of the Lectures may think that they should already know what it means. In any case, no one will to ask the commonsense naive question, "What, exactly, do you mean by accountability ?" This refusal to say what one means by accountability can lead politicians and other authorities to bandy about "accountability" without fear of anyone asking them what they themselves mean by the term.

Our example here is different. It is a journal author's earnest attempt to clarify accountability in Canadian policy for, and delivery of, healthcare.

The article appears in the June 2004 issue of Healthcare Management Forum, the journal of the national Canadian College of Healthcare Executives. The article was written by a Director in the Vancouver Island Health Authority in Victoria, Canada, based on a doctoral dissertation. The article's title is "Understanding Accountability in the Canadian Healthcare System" and its stated twofold aim is to "clarify the concept of accountability" and "discuss the issues related to improving accountability in the Canadian health system."

The article fails to succeed in either aim. This suggests that the author hasn't grasped the subject adequately and wasn't helped by the journal's reviewers (or her thesis advisers, for that matter). Governing board members and managers in healthcare skimming the article can be expected to say to themselves, "If this is the state of current thinking about accountability for healthcare, I'll wait until I see something of practical help to me."

The failures in the article are serious.

1. Understanding the concept of accountability

The article starts with the statement, "Accountability is an essential ingredient of our systems of government, management and justice, and of democracy itself....However, because of its chameleon-like nature, definitions of accountability tend to be vague, incomplete or convoluted."

The first half of this assertion is correct. The second half is not.

The question is whether those authorities whom citizens can reasonably expect to have forged by now a common operational definition of accountability (mainly politicians, bureaucrats, professionals and governing body members) have avoided doing so because they themselves would then have to publicly account for their own performance. Thus the claim that a simple and powerful society imperative has a "chameleon-like nature" really means that authorities have tried to keep it that way and have thus far been successful.

In fact, the meaning of public accountability has been clear for Canadian governments' responsibilities (and therefore healthcare and all other important government responsibilities) since the mid-1970s. And for all who seek an operational definition of the term, it is entirely logical. Yet the author talks about "wide use of vague and confusing terms such as 'public accountability.'" In society, no accountability is more important than public accountability, but authorities can keep it "vague and confusing" unless made to come clean on its meaning.

While the author of the article could not have known it would happen, the Canadian first ministers' joint communiqué at the conclusion of their 13-15 September 2004 summit meeting on healthcare made the meaning of governments' public accountability clear. (See A Breakthrough in Public Accountability in Canada)

The author is correct in saying "Without a clearer understanding of the concept of accountability, (healthcare) practice models may be built on a shaky foundation."

But, given her intention to be helpful and serious in writing on accountability, the author can reasonably be expected to have found and assessed for herself the authoritative definition of accountability of the prestigious mid-1970s Independent Review Committee on the Mandate of the Auditor General of Canada. That committee defined accountability is the obligation to answer for a responsibility conferred. By "conferred" the Committee meant a government responsibility formally conferred by statute. But healthcare governing bodies and executives must identify their own commonsense duties if they are not clear from an Act, and identify reasonable standards of answering.

The Review Committee's definition is in fact quoted in one of the literature sources the author cited. It stems from the centuries-old meaning of public answering known to all in the business world: financial statements as the accounting for the results of business operations. The new component in modern-day accountability for all important responsibilities is publicly answering for intentions -- answering before the fact -- as well as answering for results

The author could also be expected to have used the core quote from the researchers most quoted on the subject, Patricia Day and Rudolf Klein, rather than the quote she chose from their work. In a 1987 UK study on accountabilities in public services, these authors stated:
"It is a tradition of political thought which sees the defining characteristic of democracy as stemming not merely from the election of those who are given delegated power to run society's affairs ... but from their continuing obligation to explain and justify their conduct in public."

Putting these two authoritative sources together would have told the author that accountability in healthcare is not fuzzy at all: it is a simple concept no different in its application from accountability in business, general government or any authority.

Accountability is the obligation to REPORT on the discharge of responsibilities.
The logical extension of the obligation to answer for (report on) the discharge of responsibilities is that when authorities' intentions and performance affect the public in important ways, their accountability reporting is to be given publicly, both before and after the fact, and to be given fairly and completely. Healthcare decisions affect the public in important ways.

Surprisingly, given her experience, the author does not deal with the behavioural effect of the public answering obligation on those accountable. The obligation to answer publicly can be expected to exert a powerful and beneficial self-regulating effect on those with the responsibilities. People who must report publicly on their responsibilities will want to say something praiseworthy. Since what they say will be subject to scrutiny and validation by knowledgeable organizations, any exposed lying brings high personal cost to those reporting. Intentions that would lead to harm or unfairness thus tend to self-destruct. The author mentions this aspect being raised by one of her interviewees, but seems not to have grasped its importance.

The alternative to installing this self-regulating influence is what we have now: outside agencies such as official health information gatherers and auditors general supplying the information that those accountable should be providing in the first instance.
The website of the Citizens' Circle for Accountability is rigorous in its explanation of accountability and is based on A Citizen's Guide to Public Accountability. The author could have found the CCA website by internet search through the words "public accountability."

Suggesting that there is no valid definition of accountability because definitions are "vague, incomplete or convoluted" can be attributed to an author's unfamiliarity with the subject. But the problem is that this public article can support the same assertion by bureaucrats or academics who, knowing the implications of the accountability obligation, can be expected to try to keep the meaning fuzzy, both to protect officials and ministers of the Crown who could otherwise be held rigorously to account, and to cause endless funded academic study of the subject.

A federal government example is the Clerk of the Privy Council, called in September 2004 to testify before the inquiry into the federal government sponsorship program disgrace, and trying to portray as important, and somehow different from accountability, a former colleague's published idea of "answerability." That person's attempt sank without a trace because the commonsense definition of accountability is the obligation to answer.

Full and fair public answering for responsibilities is an issue of increasing importance to citizens concerned with how well healthcare is being delivered -- including those concerned with how well British Columbia's Vancouver Island Health Authority delivers healthcare.

2. Distinguishing concepts

The author asserts, "Confusion and debate about accountability and its most common surrogate term, responsibility, occur regularly." The author doesn't state whether she herself regards responsibility as a surrogate of accountability. This is a critical issue for the article's rigour and usefulness.

It is therefore reasonable to infer that the author hasn't grasped that responsibility and accountability are related but totally separate concepts -- responsibility being the obligation to act, and accountability being the obligation to answer for (report on) the discharge of the responsibility. The most common wrong impression of accountability is that it means responsibility (a diligence obligation).

The author's failure to distinguish these concepts is egregious because allowing them to be equated means that the needed public answering needn't be given so long as the accountable authority keeps talking about effort -- and effort is not accomplishment.

A related example is the author's statement, "...there is general agreement on the narrow definition of accountability as assessing and reporting on performance..." Yet it is perfectly clear that assessing performance ( discharging a responsibility) and reporting whether one is meeting a reasonable performance standard (an answering obligation) are two entirely different functions.

A third example is the author's statements: "The traditional model of health system accountability is the professional model where control rests mainly with professionals or professional administrators" and, "Accountability has traditionally focused on competence and on ethical and legal conduct." Here the author is back to viewing accountability as responsibility: the doing of something. The same holds for the author's comments on "the managerial model of health system accountability": viewing accountability as managerial concentration on value for money and the determinants of it.

Even when the author comments on "accountability to patients" she gives the impression that it is synonymous with "citizen participation" -- the usual form being citizens giving input to authorities. Giving input is quite a different thing from holding to account, which is the process of citizens exacting and validating needed public answering from authorities. In any case, "citizen participation" most often means that authorities will take from citizen input only what they want and not account back to the citizens for how they used the input.

Finally, in commenting on "social policy issues" and the difficulty citizens have in locating accountabilities in healthcare, the author suggests that elections provide "some" accountability but that election promises may not be kept. The fact that they are too often not kept ought to have prompted the author to speculate on why that is -- for example, the lack of before and after the fact public answering by governments, given to a reasonable standard of public reporting. In any case, elections are not accountability.

3. Usefulness of the article

The test is, what does the article say that a smart cookie manager wouldn't already know about accountability, and would it help such a person? Is the author able to identify and distinguish important concepts for boards and executives that can make a difference to their diligence and public answering?

The author states: "The main research objective (of her doctoral dissertation) was to clarify the concept of accountability by employing a concept analysis methodology to identify attributes, antecedents, consequences, surrogate terms, related concepts and references" and goes on to state that the "discussion primarily focuses on philosophical debates."

In an unduly complex diagram in her article, the author cites four "antecedents or prerequisites" to accountability in the health system: "Renewed Culture, Strategic Direction, Citizen Engagement, and Information Management, Performance Measurement and Reporting."

But health executives surely grasp already the logic sequence missing from the article: that identifying and ranking healthcare responsibilities and who has them produces commonsense reasonable performance standards that in turn produce the logical public answering standards for healthcare performance that citizens have the right to see met. This is not rocket science.

For example, a frequent assertion by accountable officials is to claim that they can't concede to answering obligations for themselves until they have established performance standards for themselves (which of course will take forever). The truth is the other way around: the public answering obligation drives the production of reasonable performance standards.


One clear statement is in the diagram box "Defining Attributes" (of accountability). The author's text says ""Obligation to render account - report" and "Answerability to community served." These obligations surely supply what ought to be the core of an article for boards and executives on accountability for healthcare.

It is surprising that the author, given her years of experience in healthcare and the intended readership for her article, does not suggest reasonable expectations for health authorities' answering to the public.

Stemming from her research and work experience, common sense would have allowed the author to propose a set of public answering standards specifically for key healthcare governing-body members and executives. Their responsibilities would be known to the author. Doing so would have side-stepped the claimed differences in people's understanding of accountability and could have helped executives and governing bodies get on with what accountability for healthcare ought to mean in practice.

Thus the article can be expected to have two results unintended by the author. It will likely not help hands-on healthcare executives, and it can be expected to satisfy those senior bureaucrats who have no wish to account publicly and who are happy to have the concept of accountability kept muddy.

4. Barriers in the way of adequate public answering

It is surprising that the author, in listing things "standing in the way of improved accountability" ("improved" suggesting that there already exists meaningful public answering) would not have discussed the most obvious barrier. The people who must install public answering standards are the people in authority. They can be expected not to offer public answering obligations for themselves for at least three reasons.

First, accountability forces the giving of information that stakeholders would not otherwise have. This forces sharing of power, or at least it opens avenues for external questioning that are predictably unsettling.

Secondly, the self-regulating influence of required public answering, when coupled with audit of the assertions, may disturb the comfort zones of those in authority.

Thirdly, especially in an area such as healthcare, honest and public accounting for performance will include reporting performance failures and their causes, when they occur. One example is fatal errors by hospital physicians. Opposition politicians can be expected to seize on reports of failures (and not just policy failures) to blame and get political "ink." Accountable governing bodies and officials therefore don't expect fair responses from politicians on accountings given in good faith, but they haven't tried to set up a contract with politicians to deal with this problem.

The obligation to answer publicly for responsibilities will force identification of who in common sense has what important responsibilities. "Direction", "culture" and "citizen engagement" are foggy terms serving the aim of continuing study rather than accountability-forced hard examination of who has what responsibilities and achievement objectives (whether political or administrative) and what answering standards must be met.

5. Governing bodies

The author fails to discuss the respective responsibilities and accountabilities of the health ministers and the boards of health districts and hospitals. It is settled in law that the board of an organization is the "directing mind and will" of that organization.

This raises the obvious research question of which governing body (eg health ministries) is to account publicly for what policy decisions (decisions about whose needs are to honoured and whose are not) and who is to account for management control (maintaining adequate quality control in hospitals, home care and medical practice, which is the issue of deciding who is to accept what risk)

A board has the duty to publicly account for the extent to which it informs itself and meets a standard of self-informing that citizens are entitled to see met. This includes knowing what decision-making and public answering obligations lie with the minister and what lies with the board. The author doesn't mention this accountability issue, which is a critical one. For example, in the early 1980s the federal Ministers of Health and the Board of the Canadian Red Cross Society did not inform themselves to any standard about the extent of lethally-contaminated blood being distributed, when the evidence of it stared them in the face.

An article on accountability for healthcare that does not include the issue of the accountability of governing boards is significantly flawed.

The author concludes her article with the plausible statement that "confusion exists over the meaning of accountability in the Canadian health system." It is "confusion" only if people with responsibilities prefer it portrayed that way.