The Issue of Accountability in Healthcare

By Rose O. Sherman, EdD, RN, FAAN

The late President Harry Truman had a sign on his desk that said “the buck stops here”. The phrase refers to the fact that the President has to make the decisions and accept the ultimate responsibility for those decisions. Truman was willing to accept that ultimate responsibility. One of the challenges cited in the health care reform debate involves this issue of accountability. Our health care system today is fragmented which has led to uncoordinated care with no clear accountability among the many providers who care for patients. In an important new book, Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Dr. Marty Makary proposes that accountability in health care would expose dangerous doctors, prevent over-treatment, reward good performance, and force positive change nationally through the power of transparency.

What consumers don’t know can hurt them is an important theme in this book. Dr. Makary, a John Hopkin’s surgeon and researcher, points out that published studies in the New England Journal of Medicine concluded as many as 25 percent of all hospitalized patients will experience a preventable medical error of some kind. Other studies indicate one in every five medications, tests and procedures is unnecessary. He observes that consumers have the tools to comparison shop when deciding on a new car, home or other major purchase. But when it comes to choosing a hospital or doctor, they are largely in the dark. Most patients do not have access to data on safety and quality from individual hospitals and doctors.

Asking the Right Questions to Determine Quality

How to measure quality and the current metrics that we use are controversial issues. Based on his research with safety, quality and teamwork, Makary is convinced that the best measure of quality is the simple percentage of hospital employees who would answer yes to the question I would definitely go here for my own care. OR nurses, he believes, are good judges of the skills of surgeons. He suggests that based on their research with hospitals throughout the country other key questions include:

Is teamwork good?
Do people work well as a coordinated team?
Do doctors and nurses do what’s in the best interest of the patient?
Is communication strong?
Do you feel comfortable speaking up when you have a safety concern?
Are administrators and managers in your hospital responsive to patient-safety concerns?

Culture Matters

The Mayo clinic is considered by many to be represent the very best in US health care. Makary attributes this to a strong culture of quality, safety and patient-centeredness. Hospitals with intimidating cultures lead to an unwillingness among staff to point out problems. There is a lack of honesty when errors are made and impaired physicians continue to practice. Building a strong culture, he proposes, begins with building a culture of communication and a sense of community among providers. Anonymity fosters incivility.

More Patient Involvement in Decision Making

Makary is a strong advocate of a shared-decision making model. Patients, he contends, are often not informed of their options and challenged when they try to make decisions that the medical team does not recommend. Some patients who might have benefited from minimally invasive surgery have more extensive surgery, requiring longer recoveries and risking infection. We sometimes have measures such as the door-to-balloon metric for angioplasty without asking whether the patient needed the angioplasty in the first place. Too many patients receive care including chemotherapy that is clearly futile. Hospitals and physicians are rewarded for doing more versus less when it comes to care. Allowing patients access to their complete access to their records would help to build transparency.

Makary believes that any discussion about health reform must begin with the issue of accountability. He contends that “the simplest, most economic solution to the problems of our complex system is to empower patients with information”. This book is an important addition to the discussion about how to reform. Many of the answers will not be in elaborate new reimbursement systems but rather in system and culture changes that can be done inexpensively.

Read to Lead

Makary, M. (2012). Unaccountable: What hospitals won’t tell you and how transparency can revolutionize health care. Bloomsbury Press.