High expectations. Unwavering support. A shared promise.
Accountability is a persistent leadership challenge. In research reported by Gallup in March, creating accountability ranked lowest among seven leadership competencies, whether leaders assessed themselves or managers assessed their leaders. That finding should prompt more than another call to “hold people accountable.” It should prompt a closer examination of what people are being asked to do, when they are expected to do it and whether they have the support to succeed. Accountability begins with a shared understanding of the commitment.
In healthcare, one fundamental question deserves particular attention: Is a behavior expected or optional? Lack of clarity about that distinction should be treated as a major threat to reliable, safe care.
When leaders consider a behavior essential yet staff understand it as something to do when time permits, the organization has left a critical decision unresolved. The person facing the greatest pressure must decide which promises the organization intends to keep. An essential safeguard can quietly become discretionary without anyone explicitly deciding to remove it.
Consider a nurse beginning a shift or a physician beginning a day, each facing more demands than any checklist can make manageable. Leadership considers a behavior essential, the manager expects it whenever circumstances allow, and those doing the work understand it as something to do when time permits. Each believes the expectation is understood, yet each is working from a different promise.
When the behavior is missed, the scorecard turns red and the conversation turns to accountability. Before asking why someone failed to follow through, leaders should ask whether everyone understood what follow-through required.
Accountability is a personal and shared commitment to results, supported by our systems and relationships. Its foundation is high expectations with unwavering support. Expectations without support can become punitive, while support without expectations can leave essential commitments unfulfilled. Leaders are responsible for making the work clear and helping create the conditions in which people can do it. Three practical commitments bring that responsibility to life.
First, distinguish expected behaviors from optional actions for every role, from the bedside to the boardroom. Expected means a shared commitment whenever defined conditions apply; optional means a discretionary action that adds value when circumstances allow. Translate broad aspirations such as “communicate well” into observable behaviors with clear owners and purposes. Ask leaders, managers and the people doing the work independently to describe those expectations, then compare their answers. The differences reveal where a policy or reassuring nod has concealed an unresolved commitment.
Second, define when each expected behavior applies and what happens when it cannot be completed. For each expected behavior, specify what triggers it or when it is scheduled, which exceptions are acceptable, and which tasks take priority when demands compete. Staff need a practical way to seek help, and leaders need a corresponding commitment to respond. Clarity cannot create time or staffing, yet it can make competing demands visible and guide decisions about what must take precedence. An expectation becomes credible when leaders address the conditions that threaten it.
Third, separate an improvement target from the expectation for an individual action. A team working toward full reliability may set an interim target below complete performance. That target measures progress; it does not make the behavior optional on some applicable occasions. “Most of the time” may reveal how someone interprets an expectation, yet it offers little guidance about which occasions justify an omission. Review missed occasions to understand the circumstances, preserve the standard and improve the support needed to meet it.
These commitments establish clarity, yet they do not explain every performance gap. When expectations are unmet, use five As to investigate: aware, ambiguity, agreement, ability and aligned incentives. Each points toward a different potential barrier and a different leadership response. Several may be present at once, and the questions apply equally to the commitments leaders make. Understanding why accountability fails is the beginning of deciding how to strengthen it.
Aware asks whether people know the goal, understand why it matters and recognize the current gap. An email announcing a priority does not establish shared understanding.
Ambiguity asks whether people know the specific behavior, whether it is expected or optional, and when it applies. Ask people what they would do on a difficult day, when priorities collide and help feels far away. Their answers reveal whether the expectation can survive contact with the work.
Agreement asks whether people have explicitly committed and had a meaningful opportunity to raise concerns. Silence may conceal uncertainty or reluctance to challenge an unrealistic plan.
Ability asks whether people have the skills, time, resources and authority to succeed. Someone can understand and embrace a commitment while facing barriers that require executive action. Leaders must account for the support they promised as carefully as they review the performance they requested.
Aligned incentives asks whether organizational priorities, rewards and consequences support the expected behavior. A team may hear that a task is essential while learning that completing other work earns greater recognition. Leaders must examine what operating reviews emphasize and how they respond when priorities collide. Calling everything essential leaves the hardest choices with those who have the least authority to resolve them. Accountability requires leaders to make those choices visible and help teams navigate them.
These conversations require courage to name the gap, humility to examine leadership’s contribution, curiosity to understand conditions and compassion to preserve dignity. They should end with clear commitments about action, support, ownership and review. Follow-through includes recognizing progress and addressing persistent gaps through fair, proportionate processes. Accountability is a handshake, not a hammer. Its strength comes from promises honored on both sides.
Love says, “We believe in you enough to set high expectations.” Accountability says, “We will keep our commitments, provide unwavering support and follow through together.” Every role deserves that clarity, and every patient deserves the reliability it makes possible. Excellence becomes dependable when people know what is expected and can count on one another to achieve it. Patients should never have to wonder whether the care they need was considered optional.
Peter Pronovost, MD, PhD, FCCM, Chief Quality and Clinical Transformation Officer, University Hospitals Cleveland, and President of the UH Veale Healthcare Transformation Institute
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