Accountability is at the heart of nursing, weaving its way through nursing practice in all settings and at all levels. It’s an energizing force throughout an organization. Where a culture of accountability exists, people do what they say they’ll do. Everyone builds credibility for themselves and for the organization by holding themselves and each other accountable.

In contrast, an organization lacking accountability is full of excuses for not meeting objectives. Staff sense that "close to the target" is good enough as no one will notice the difference. Or worse yet, they sense that goals are arbitrary or stupid, so the best they can do is invest their energy in beating the system.

Defining accountability

Most of us have heard many definitions of accountability and have repeated these on tests, job descriptions, or performance evaluations. But knowing a definition doesn’t always translate into living its meaning.

The various definitions of accountability share common concepts. They mention obligation—a duty that usually comes with consequences. They speak of willingness—accepted by choice or without reluctance. They include intent—the purpose that accompanies the plan. They touch on ownership—having power or control over something. And finally, they suggest commitment—a feeling of being emotionally compelled. Mix these concepts together and you have accountability; leave any out and you don’t.

Many people assume accountability and responsibility are the same, but they’re more like two sides of a coin. For example, you get a paycheck for a job in which you’re responsible for something—a service or overseeing other employees. Your responsibility relates to what you’re required to do in that job. Responsibility encompasses the expectation of accountability—that someone is holding you answerable for your outcomes.

Three crucial elements

Where an expectation of accountability exists, three elements—clarity, commitment, and consequences—must be present.

Clarity

Clarity means expectations and goals are clear and specific. You can’t hold others accountable for reading your mind. "The variance report for your unit is due by 11 A.M. Thursday" is clear and specific. "Get the report to me in the next few days" isn’t.

Clarity also means explaining why. If staff members know the reasons behind the expectation, they’re more likely to commit themselves to meeting it.

Commitment

You have to ask for a commitment to get it. Simply giving an order isn’t enough. The accountable employee must listen, understand, agree, and commit to achieving the objective.

After you ask for a commitment, listen to the person’s answer. "I’ll try" isn’t a commitment. If a staff member objects to your expectation and offers valid reasons for doing so, you can either negotiate the expectation or discuss tactics.

Consequences

Think carefully when designing appropriate consequences; they can add or subtract clarity. Suppose a teenager misses his curfew by 10 minutes or a phlebotomist makes only 90% of his quota for four quarters—yet they experience no consequences. They’re likely to think that being 10 minutes late or 10% below quota is acceptable.

To come up with appropriate consequences, you need to know the people involved. What makes them tick? What are their goals? How do they define success?

As a leader, you have consequences, too. To increase accountability, you’ll have to increase your responsibilities and hold yourself accountable for meeting them. Also, you must be able to hold accountability conversations with staff—effective, brief conversations. Although challenging, these conversations go a long way toward creating clarity, gaining commitment, and enforcing consequences. Without these conversations, your attempts to establish an accountability culture could fail.

Be sure to always write down the specifics. Ideally, write meeting recaps that document who agreed to what and when. Whether they’re in memo or e-mail form, recaps are the single most important way to hold people accountable. It’s easy to forget the specifics if months pass before the team gets together again and no one took clear notes of previous meetings that were shared with the team. Writing meeting recaps and distributing them to those involved take time but reap large dividends. They produce clarity and ensure everyone has the same expectations.

So why don’t we step up to the plate?

Being accountable has more to do with giving up certain behaviors, beliefs, and attitudes than with trying to behave differently. Becoming upset
is one of the most common defense mechanisms used to avoid accountability; if you’re upset, you can’t effectively handle the matter. Going "unconscious" is another defense mechanism. You do this simply by tuning someone out or having your own mental conversation when someone tries to point out how you could have assumed greater responsibility. Yet another defense mechanism is playing the role of victim to escape accountability. Expressions common among "victims" are "I can’t" and "I’m unable to." What the person may really be saying is "I’m unwilling." (See What gets in the way of accountability by clicking on the PDF icon above.)

The aware person recognizes when personal accountability is lacking in his or her own life; the wise person listens to feedback openly; and the brave person says, "OK. I’ll do what it takes to change and improve my own life."

Chain of accountability

Accountability is doing the right thing consistently, day in and day out, in task and relationship interactions, to fulfill or further the organization’s mission. Accountability is only as strong as the weakest link in the system. If the admissions department operates at 100% accountability but escort services operates only at 20%, customers will perceive the admissions department as only 20% accountable.

Each person must take maximum accountability to fulfill a mission. One break in that chain can lead to failure. To forge the chain of accountability among the team, managers must achieve the following goals.

Create trust

Without trust, accountability doesn’t exist. Instead you see dissent, blame, and passing the buck. Without trust, employees hide information they think could give someone an advantage or could be used against them. Creating trust requires an honest dialogue—and this means the leader must offer a safe space for staff to share concerns, ideas, and problems. It also requires an environment of respectful engagement and communication.

Provide direction

To perform at their best, people must know where they’re going and why that direction is important. Leaders not only must articulate a vision but engage employees in discussing what that vision means to the organization and the team’s work.

Provide metrics

Provide clear and appropriate metrics or measurements by which all team members know they will be measured. Measure what really matters and link it to commitments and actions undertaken. Make sure what you measure will increase productivity, lead to better quality of care, or improve customer service.

Engage employees

Take the hard steps needed to engage and tap employees’ motivations. Use such methods as brainstorming sessions, roundtable discussions, question-and-answer sessions, and employee committees.

Provide support

Provide effective systems support. E-mail and voicemail protocols, effective performance appraisal systems, and employee development programs can work well together to drive accountability.

Strive for cultural alignment

Culture is "how we get things done around here." It’s tied to clear values, supportive supervision, clear expectations, and team work protocols.

Provide leadership consistency

The power of leaders acting and speaking consistently about values, performance, culture, and modeling accountability and personal responsibility can’t be overestimated. It’s the final ingredient in ensuring strong, enduring links in the chain of accountability.

Becoming more accountable

This is where the rubber meets the road. Personal accountability provides an opportunity to contribute to the organization, to be counted among those we truly admire and respect. It’s a chance to ask, "What can I do to contribute?" and "How can I make a difference?". (See Are you personally accountable at work? by clicking on the PDF icon above.)

Are you willing to make the necessary changes in yourself? Can you commit to each of these statements?

• I take full responsibility for myself, my decisions, and my actions.
• I’m willing to take responsibility for my mistakes and learn from corrective feedback.
• I commit to actively supporting my teammates and helping them remember to honor their commitments, even when it means respectfully confront­ing them.
• We, as a team or department, commit to doing our best to serve both internal and external customers and all partners in the process.
• As a leader, I sign on to all of the above and commit to working to be a positive role model for
  others.

Changing yourself is powerful but necessary. As Gandhi said, "You must be the change you wish to see."

Selected reference

Staub R. Accountability and its role in the workplace. The Business Journal. January 13, 2005. www.bizjournals.com/triad/stories/2005/01/17/smallb3.html. Accessed January 11, 2012.

Marcia M. Rachel is associate dean for Academic Programs at the University of Mississippi Medical Center School of Nursing in Jackson.