The word we get wrong
When I visit hospitals — or any organization — I often start with a simple question:
“What do you think of when you hear the word ‘accountability’?”
And almost always… people flinch. They think of punishment, of blame, of being called out.
Across healthcare, engagement surveys tell the same story. One of the lowest-rated statements year after year is: “People are held accountable for their performance.”
That’s not because people reject accountability — it’s because we’ve confused it with control.
We’ve turned a noble idea into something people fear.
Accountability was never meant to be a hammer. It was meant to be a handshake. A shared promise to do what we said we would do, in the way we said we would do it.
Reclaiming accountability as noble
True accountability is not punishment — it is a beautiful and noble idea.
It means keeping promises, showing up with integrity and being trustworthy with one another. It’s the foundation of reliability, belonging and growth.
When we reclaim accountability as noble, it becomes a source of pride, not pressure; learning, not blame. It transforms compliance into commitment and responsibility into connection. When accountability is weaponized, people hide. When it’s grounded in love and trust, people shine.
The three levels of accountability
Accountability operates on three interconnected levels:
1. Personal accountability — Each of us must own our commitments and outcomes. It begins with integrity and the willingness to see our own gaps honestly.
2. Team accountability — Teams hold one another accountable with respect and care. When a nurse or a manager sees a missed step, they speak up — not to shame, but to protect and improve.
3. Organizational accountability — Systems and leaders ensure that accountability is fair, transparent and aligned. No one should succeed or fail by luck.
When all three levels work in harmony, fear diminishes, and performance soars.
Building a true accountability system
To make accountability consistent, humane and high-performing, we need a system built on five essential components:
1. Clarity of expectations — Ambiguity destroys accountability. Define what success looks like, what behaviors are required and how results will be measured.
2. Ease of execution — People cannot be accountable for systems that set them up to fail. Make it easy to do the right thing — simplify workflows, remove friction and provide tools that help people succeed.
3. Transparent feedback — Share results openly. Use dashboards, run charts or scorecards that show how individuals and teams are doing. Transparency drives shared learning and collective pride.
4. Shared review and coaching — Accountability should feel supportive, not punitive. Leaders must hold themselves accountable for providing clarity, resources and empathy before expecting performance.
5. Escalation with support and standards — When targets are not met, the response should be structured, fair and focused on improvement. Begin with additional coaching and resources, then involve higher-level oversight if progress stalls. The message must be clear: excellence is not optional, and support is available to help achieve it. Consequences should be transparent and consistent — not as punishment, but as a safeguard for quality and trust.
Publicly celebrate what’s working. Privately coach where it’s not. Always aim to learn, not blame.
When accountability works
When we practice this kind of supportive and disciplined accountability, both performance and morale transform. At University Hospitals, we saw dramatic improvements:
- Medication safety behaviors rose from 95% to 97% and some departments sustained as high as 99%.
- Annual wellness visits increased from 33% to 73%.
But the real success wasn’t the numbers — it was the people. Teams stood taller. Pride returned. They felt trusted, valued and united. Accountability didn’t crush them. It lifted them.
Why it’s still hard
So why does accountability still feel so hard? Because it demands courage. It means facing the truth, even when it’s uncomfortable. It means replacing silence with candor and excuses with ownership.
Too often, accountability is used as a weapon of control rather than a tool for growth. But systems built on fear eventually collapse, while systems built on trust endure.
Embedding accountability into our daily work — into how we meet, communicate and review — is how excellence becomes a habit.
The path forward
To create a culture of true accountability, we must make it part of daily management — not an occasional event or a slogan. Start small. Pick one behavior, one process or one promise. Define it clearly. Make it easy. Measure it. Review it together. When you do, something beautiful happens. Performance improves — but so does pride.
People begin to see that accountability isn’t about control; it’s about commitment.
Not about fear; it’s about trust.
Not about compliance; it’s about connection.
When accountability and love walk hand in hand, teams flourish — and organizations thrive.
That is the beautiful power of accountability.
Peter Pronovost, MD, PhD, is Chief Quality & Clinical Transformation Officer and President, Veale Healthcare Transformation Institute at University Hospitals in Cleveland, Ohio.
