Article 1: The Age of Accountability

“Not everything that can be counted counts, and not everything that counts can be counted.” Albert Einstein.
 
Over the last few decades, computing has become the norm in modern society. Smart phones, Bluetooth connectivity, the internet of things, smart cars, and high-definition smart televisions are prevalent in our daily lives. We are rapidly converting all that we know into searchable discrete elements of knowledge and online opinion.
 
Coincident with this reality, we see a shift in generational expectations. Immediate responsiveness, instant gratification, online purchasing with mass customization in color, size, and other options and ultimately a life perspective that sees work and employment as something to be managed inside of one’s life.
 
During this time, we also see classic performance improvement methodologies, as were largely created for the manufacturing industries and pioneered by giants in history such as Edward Deming and Joseph Juran, now being applied to everything, including high touch service industries.
 
Each of these factors (digitization, immediacy for answers, and extended use of performance improvement methodologies) in some way has led us into what I am terming “the Age of Accountability.” We are reducing the world to one in which we believe we can increasingly measure everything and one in which we can reduce the essence of everything into a series of zeros and ones immediately consumable on a desktop or mobile device. 
 
Digitizing everything into searchable bytes of information is a wonderful development of recent times and has massive implications to the good.  We carry more computing power in our mobile devices than was available to place a man on the moon some 50 years ago. 
 
However, as with all things, when over applied or “over cooked” this idea of reducing everything to digitally consumable and therefore actionable data elements can have deleterious and unintended consequences.  Nowhere is this more pressing than in high-touch and service professions such as teaching and healthcare.  Teachers are leaving their fields of passion for a variety of reasons one of which we contend relates to this notion of overly applied accountability.   Doctors and nurses are similarly hitting all-time highs for burnout and suicide. This push to hold everyone accountable to drive results, while inherently intended for good, is having a negative impact on the people doing the work. 
 
How do you measure empathy, kindness, inspiration, engagement, joy or love?   
 
Teachers are being held to ratios, statistics, and accountability metrics which may or may not be reflective of their educational effectiveness and which are felt by many to miss  the human elements of dealing with people – in this case students and parents. In healthcare, a similarly high-touch industry, we are seeing the workforce deteriorate before our eyes as the well-intentioned industry slowly grinds the providers into a matrix of numerical accountability. Productivity, efficiencies, returns on investments, patient caseloads, relative value units, codified patient diagnoses, procedure volumes, patient experience surveys, ICD-10, MACRA, utilization rates, scorecards and digitizing care into the electronic medical record have had their impact upon the workforce. As a result of taking a high-touch industry and treating it like a manufacturing industry, we are seeing physicians leaving their chosen craft to retire early, change careers, or sadly, commit suicide. It is approaching and many argue has reached, crises proportions.  
 
Now please understand, we are not suggesting that measuring things is bad, nor that holding people accountable is wrong. Quite the contrary, the teachings of Demming and Juran are vital to success of contemporary industries.  Nor are we suggesting that accountability alone is to blame for the state of mind of people in these industries – it is far more complex than that. Instead we are highlighting that most things taken to the extreme create tension, not all of which is healthy. Using the wrong tool for the wrong job is equally disastrous and so we contend that overcooking this idea of accountability on high-touch professions is fraught with unintended adverse consequences. In industries such as healthcare which are largely led by non-clinicians and one impacted by government regulations, legal maneuverings and misaligned incentives, it is an industry that is perilously transforming itself and not necessarily for the better as it relates to the foot soldiers who actually deliver the care. 
 
A November 11, 2019 article in Modern Healthcare quotes references Health and Human Services as collecting 2,300 different measures.  It goes on to acknowledge the widespread dissatisfaction with the measures and the need to rethink those metric selection and collection efforts.  We would agree.
 
We are telling our providers to be safer, deliver greater value, do more, do it faster and do it better and keep everyone happy along the way.
 
Is this possible? How does one become operationally efficient in caring for a dying patient and their family? Is that what we want for our loved ones? How about treating a child with cancer or any chronic condition? Do we want efficient, effective, measurable, statistically proven accountability or do we want compassion, consistency, and simply time spent? Can we have it all? Time will tell. Yet in these author’s opinions, compassion, empathy, deep personal understanding and love will never be digitized and will never be measurable in such a way as to make people accountable for these ingredients of caring.
 
These are not manufacturing ingredients such as steel, or rubber or plastic. Teachers and providers  are not manufacturing cars or gadgets or gizmos. Manufacturing analogies - and even traditional innovation techniques - seem to break down when applied to high-touch industries outside of their intended use. We wonder if we can ever truly measure the value of a priest, a rabbi, a clergy, a social worker, a grandmother, a parent, a son, a daughter, a teacher, a doctor, or a nurse in such a way as to hold them truly accountable using dashboards, or discrete data reports. No doubt there are, and will continue to be, metrics. What is apparent, however is that the healthcare industry and the teaching industries are both in the midst of this transformational clash of measuring “human doing” vs “human being”.  We can measure doing with productivity and agreed upon metrics.  But human being, the soft skills, the essence of being human seem far too complex and far too important to be reduced to a satisfaction score.
 
Clearly, we are comparing dissimilar markets. Assembly line production has its place no doubt, but does it compare to something that is “hand crafted?” Is this a fair comparison? Simple economics would argue that not everyone can afford hand crafted items and that mass production is a valuable and necessary thing in today’s rapidly moving world. Planned obsolesce, use it and toss it, keep the cost down and the value high – all realities of the day. And yet in some circles what about craftsmanship? Do we want everything to be assembly line like? Shouldn’t high-touch industries have a different measure of success that takes this into account in some way? 
 
Whether you agree or disagree, the realities are that this experiment is playing out in front of us today. 
Like two grasses meeting each other in the backyard there is a silent battle happening. Each segment is working hard to prevail, to transform the lawn into one type of grass or the other. We may not notice the struggle, but it is there. Hand-to-hand combat as roots grow and extend into where others have been before, places where new grass blades grow and others die, and places where territories are being won and lost. 
 
Yes, healthcare is in an age of accountability. The accountable care organizations are held to be accountable for the money, for the patient outcomes and for the entire book of business. Yet clinicians are asking what of individual accountability. What of the patient who continues to smoke, to miss their appointments, to forget their medications, or do drugs, or any number of other personal behaviors. Where is their accountability? Can we regulate that? Should we? These are complex questions with no easy solutions. What is clear, however, is that we are in this age and there are ongoing struggles happening before our eyes. 
 
Similarly, what of children in abusive homes or with underfunded school systems.  How do we hold the teacher accountable for the ills of society?  Again, complex challenges to be sure.
 
Certainly, from a societal perspective it would seem that we would want   to see safe, effective healthcare for all. We would also want to see caring, compassionate and effective education and we would want those services delivered by people who care, who are happy, healthy, resilient and who themselves have a sense of fulfillment and meaning in their lives. While no one intentionally wishes to drive these attributes out of our high-touch industries this, at least in part, appears to be occurring. In some areas it may be getting replaced with fear, anger, depression, mistrust, and a variety of emotions contrary to the very fabric of the careers these people have chosen. 
 
Change will continue to occur, and change is good. However, we should at least take pause to examine the consequences of change and look for productive ways to get the desired outcomes. Let us not over manage with mathematical accountabilities and algorithmic predictions of performance haphazardly. Instead let’s exercise discretion in how we apply these tools. Let’s ask the difficult questions. Let’s not wake up one day to find our lawn has been overrun with crabgrass particularly when each replaced blade of grass was a person, a family, a story or a life!
 
Let’s instead tend to that lawn, to judiciously apply the right levers and not overcook the concept of performance accountability just because we can. Let’s instead explore behavioral accountabilities and Involve the people who know their industry the best to create a sustainable future.  

Copyright © 2020 Bruce Flareau
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