Constantly improving the care we provide patients is the goal of nearly every healthcare professional — if not every single one. It's what motivates our quality reviews and our clinical and health services research, with thousands upon thousands of efforts to find better treatments for our patients and the smartest way of delivering them. But all this work has an inescapable fact: We in healthcare often fall short of the goals we're trying to achieve.
While none of us is perfect, this inevitably raises the question: Who is accountable when things don't go as planned? Once we answer that question, there comes an even more important one: How do we build necessary accountability into achieving the care improvements we seek for our patients?
As it currently stands, healthcare has weak forms of accountability in the form of peer pressure. At the local level, accountability systems for maintaining performance are underdeveloped. Part of this is something I've written about called the "problem of many hands." With our large, diverse teams in healthcare, we're particularly susceptible to this. In care at almost any level — from an individual patient to a hospital floor — there are many actors involved, but often no clear role definition. Even at the federal level, there is no health official who has patient safety as part of their job description, so accountability from that venue is lacking, too.
At my institution, we're working to change that — with support from the highest levels of our government. Our CEO Cliff Megerian, MD, Jane and Henry Meyer Distinguished Chair, and I recently visited the White House to share our example and show how health systems across the country can achieve significantly greater accountability for performance.
Our approach first relies on tenets of good management. Caregivers need to answer basic, but essential, penetrating questions: What is your goal? Have you defined roles for your projects? Have you made it easy for people to do what you're asking of them? Do you give them feedback? And importantly, is there any kind of accountability for not meeting your goal?
Equally important is the idea of shared responsibility — the idea that higher-level leaders will only hold lower-level leaders accountable if they first hold themselves accountable to set that team up for success. When communication is clear, and people have the resources they need, there are fewer scapegoats. Shared accountability also requires looking at performance at different levels, from the individual physician or nurse to the hospital unit and the entire hospital. Without this stratification, an accountability system can't be effective.
Already, our caregivers are finding this approach empowering. They receive feedback, and when things are not going according to plan, they get help from peers who can help. Results show it's working — with improving metrics in medication safety, patient mobility during hospitalization and adherence to Enhanced Recovery After Surgery protocols, among other areas.
We've also seen this shared accountability approach come to fruition with Annual Wellness Visits under Medicare. In 2018, like many hospitals and health systems, we had completion rates for Medicare patients hovering under 20%. With so many demands on their time, providers just didn't have the resources to prioritize this. But six years later, our results now show that focusing on the problem systematically, with shared accountability at every level, can yield dividends. In 2018, our primary care practices reported 14% Annual Wellness Visit completion for Medicare patients. In 2023, that number was 80%. In fact, in 2023, our Primary Care Institute providers performed almost 10,000 more Annual Wellness Visits than the previous year.
The key was simply making it a priority. We identified patients who needed an Annual Wellness Visit and strategized at a granular level on how to contact them, even to the point of scripting phone interactions. Providers taught one another how to integrate these practices more efficiently. Because we see such value in these visits, we united behind a singular goal.
Ultimately, we're working toward a culture of learning, not judging, where strict accountability extends to all, regardless of level. With this approach, we know we can achieve the ever-improving outcomes for our patients that all of us want.
Peter J. Pronovost, MD, PhD, FCCM, is Chief Quality and Clinical Transformation Officer, Veale Distinguished Chair in Leadership and Clinical Transformation, at University Hospitals, Cleveland, Ohio.