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.
|
