Balancing Just Culture and Accountability: Insights from Hospital Settings

Importance and Key Contributions: Accountability is a central mechanism of corporate governance. In a corporate governance context, risk management assuring the quality of product (for example safety of food chains) is... [ view full abstract ]

Importance and Key Contributions: Accountability is a central mechanism of corporate governance. In a corporate governance context, risk management assuring the quality of product (for example safety of food chains) is recognised as critical. In a life-and-death, not-for-profit healthcare setting, a more nuanced, subtle and sensitive approach may be more appropriate compared with traditional considerations of accountability. This paper examines how the practice of accountability for clinical governance in hospital settings is constructed and enacted. This research provides new insights into the practice of accountability in life-and-death clinical settings. The practitioner experience sheds light on the operation of accountability regimes and their impact on creating a just culture.

Theoretical Base: Practice Theory (Ortner, 1984) and just culture (Marx, 2001) provide the theoretical lens for the research. The tenets of Practice Theory are increasingly applied in accountability research (Ahrens and Chapman, 2007; Brennan and Kirwan, 2015; Conrad, 2013; Jorgensen, et al., 2010) along with the ideal-style accountability regimes (O’Dwyer and Boosma, 2015). However, in healthcare research and practice, concepts from just culture are invoked (Dekker and Laursen, 2007). These contrasting perspectives provide the backdrop to this study.

In a healthcare setting, clinical governance, a sub-set of corporate governance, is a central mechanism for quality focused on patient safety. Accountability is central to clinical governance. However, accountability in clinical rather than corporate settings manifests differently. The concept of accountability is amorphous and difficult to define in precise terms (Ebrahim 2003; Edwards and Hulme 1996; O’Dwyer and Unerman, 2008). Sinclair, (1995: 219) describes it as ‘a cherished concept, sought after but elusive’. However described, broadly speaking, accountability exists when there is a relationship where an individual or body, and the performance of tasks or functions by that individual or body, are subject to another’s oversight, direction or request that they provide information or justification for their actions (Frankel et al. 2006; World Bank Institute, 2007). Giddens (1984: 30) holds that ‘to be ‘accountable’ for one’s activities is to explicate the reasons for them and to supply the normative grounds whereby they may be justified’. In its simplest sense, accountability entails a relationship in which people are required to explain and take responsibility for their actions – ‘the giving and demanding of reasons for conduct’ (Roberts and Scapens, 1985: 447).

There is a growing literature in healthcare around just culture (Frankel et al., 2006; Khatri, et al., 2009; Marx 2001; Reason, J., 2000; Watcher, 2012). For this reason, hospitals today have moved away from operating a completely blame versus blame-free culture as some errors do warrant disciplinary action. The move to a just culture is a response to concerns about ‘blame-free’. A just culture perspective focuses on the question of how to improve safety while at the same time satisfying demands for accountability (Marx, 2001; Clarke, 2011). Finding a balance between the extremes of punishment and blamelessness is the goal of developing a just culture in which learning and accountability work in each other’s favour (Havinga and Dekker, 2014).

Practice theory is a theory of how social beings, with their diverse motives and their diverse intentions, make and transform the world in which they live. It is dialectic between social structure and human agency working back and forth in a dynamic relationship. Practice theory, as outlined by Ortner (2006), seeks to explain the relationship(s) that obtain between human action, on the one hand, and some global entity called 'the system' on the other. The core tenants of practice theory - ‘practices’, ‘practitioners’ and ‘praxis’ – provide the analytical framework (Whittington, 2006).

Research Questions and Method: The practice of accountability when things go wrong (i.e., outcome not as expected) gets to the heart of clinical governance. The context in which to address the proposed research questions therefore are the practices for responding to critical clinical events. The research questions are:

RQ1 How is the practice of accountability for clinical governance in publicly funded hospitals enacted?
RQ2 Are there differences between the expected practice of accountability and the actual practice of accountability in the particular context of responses to ‘critical clinical events’?
RQ3 If there are differences, what are the reasons for the differences?
RQ4 What are the potential impacts of these differences on practices?
RQ5 In what way do governors, managers and clinicians construct the practice of accountability for clinical governance in publicly funded hospitals?

The research is based on two hospitals which meet four criteria: large, academic, general hospital with an established hospital board. Individual practitioners (governors, managers and clinicians) participated in semi-structured interviews. Twenty eight in-depth interviews using semi-structured interview guides informed by the research questions, pre-field-work framework, and the outcome of documentary analysis, were conducted. Each interview was audio recorded and transcribed along with notes made by the interviewer during and after the interview. Research documentation was validated during pilot interviews (n=4). Interpretative analysis of interview data was conducted using the computer software NVivo 10 to manage data. This provided an audit trail for transparency and trustworthiness. The analytical process involved four processes (i) data preparation (ii) data coding (open coding and developing categories) (iii) analytical cycles and (iii) assessing outcomes.

Findings: Based on the pilot study of four interviews (clinician, manager (x2) and governor) practitioners shared their experiences of the practice of accountability responding to critical clinical incidents which ranged from (i) misdiagnosis, (ii) to defective breast implants, (iii) to complaint of adverse outcome, (iv) to complaint of unexpected death in hospital, (v) to maternal death. Some of the emerging themes were of ‘feeling responsible’, ‘seeking accountability’, ‘experiencing accountability’, ‘personal consequences’, ‘tenacity’, ‘staff resilience’ and ‘absence of closure’. An analysis of the narrative of each of the critical clinical incidents identified strong, weak, and absent features of accountability practices. This would suggest that there is inconsistency in the application of all features of the practice of accountability and that the existence of a guide for expected practice does not appear to impact on the praxis i.e. what actually happens. The pilot study leads to tentative insights and an analytical framework for thinking about the practice of accountability for clinical governance, in the context of critical clinical events, to explore further in the main study.

Implications: In business and accounting contexts, the conception of ‘accountability’ relates to oversight, monitoring, auditing, and obligation for transparency, justification of action and threat of sanction. In health care, the traditional focus on identifying who is at fault is moving to open disclosure, just cultures, quality improvement and learning. Thus, accountability derived from bottom-line oriented corporate settings cannot be applied without adaptation to life-and-death clinical settings.


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Clinical governance, justice culture, accountability, practice theory, hospital [ view full abstract ]

Clinical governance, justice culture, accountability, practice theory, hospital