Accountability has become part of the lexicon of health care. Besides creating a culture of safety, we now talk about creating a culture of accountability. And this accountability no longer rests solely on the shoulders of physicians and nurses but is shared by administrators and trustees.

As many as 11 different parties can be held accountable or hold others accountable in health care, according to a 1996 Annals of Internal Medicine article, "What Is Accountability in Health Care?" by Ezekiel J. Emanuel, M.D., and Linda L. Emanuel, M.D. Written almost 15 years ago, the authors' accountable parties were individual patients, physicians, clinicians such as nurses and physical therapists, hospitals, managed care plans, professional associations, employers, private payers, the government, investors and lenders of capital, and lawyers and courts. The authors describe the list as "neither exhaustive nor immutable" and note that "other parties may develop important roles in health care." And though the article points to "organizations and to their individual patients" as "loci of accountability," there is not much discussion or emphasis on the role of administrators and trustees to ensure accountability.

The Board's New Role

What a difference a decade has made. In their 2009 article in The Health Care Manager, Joshua O'Hagan and David Persaud describe six steps to create a culture of accountability in health care organizations and cite "provide leadership" as the first step. "Strong leadership enhances employee responsibility, morale, cooperation, and trust and reduces turnover. Leadership that exemplifies accountability should be pervasive at all levels of the organization," they write.

"It's a new era," says Jeffrey J. Tomlin, M.D., chief medical officer at Evergreen Hospital Medical Center in Kirkland, Wash. A practitioner for 24 years, Tomlin recalls his medical school days when physicians were deemed individually responsible for quality and what happened to the patient. Now the "system of care" is so important to the patient, Tomlin explains. "The quality of patient experience starts before patients come into the walls of the hospital," he observes.

The Evergreen board's interest in and understanding of its role overseeing the delivery of quality health care—and being accountable—has come to the forefront in the past few years. "[Before] the board didn't think it was their responsibility. Their responsibility was operations, finance and infrastructure," Tomlin says. This year Evergreen's board, which is composed of five publicly elected commissioners, plans to participate in national safety and quality meetings. One board member sits on the performance excellence committee, which tracks operational excellence projects on patient flow, diabetes, heart failure and more, and "is actively involved," Tomlin explains. "It is not passive information exchange."

Fighting Infection from the Top

Trustees for Abington (Penn.) Memorial Hospital make hand hygiene an annual organizational goal, according to Debra Miller, R.N., director of infection control. When the hospital launched its hand-hygiene campaign in 2007, its administration kicked off the campaign by setting a 70 percent compliance goal and offering an incentive of $300 per employee when it was attained, Miller says. When staff reached the goal, administrators paid the bonus to AMH's 5,600 employees. The hand-hygiene committee presents data to the quality board monthly. The board also receives monthly reports on infections and interventions and in-depth reports twice a year.

Accountability has become part of the current AMH campaign called "caught clean/caught dirty." Staff members seen washing their hands receive a thank-you card they can turn in for raffle prizes. If a staff member is caught out of compliance, he or she receives a note from a supervisor describing the noncompliance. After three times not complying, the staff member receives a note from the hospital's chief of staff. Accountability at all levels of the hospital has helped AMH increase its hand-washing compliance rate to 90 percent, and health care-associated infections have decreased.

Cynthia Hedges Greising is a communications specialist for AHA's platform, Hospitals in Pursuit of Excellence. Visit www.hpoe.org for more information.