Accountability Frameworks
Programs must know which patients they are responsible for, how promptly care must be provided, and how to respond when demand exceeds capacity.
Executive Summary
Accountability frameworks are critical but oddly rare in healthcare. They specify accountability zones — which program is most responsible for which patients — and they define program expectations, including timely care access and the need for effective queue management and surge strategies.
Without defined accountability zones and care expectations, an acceptable program response to care gaps is, “Sorry, we’re full” (i.e. join the queue). In an accountable system, program leaders would instead ask, “How can we change our systems if closing the door is not an option?”
This is system failure, not provider failure. Our two main recommendations are operational improvement and accountability frameworks. Operations researchers suggest that process optimization can increase flow and throughput by 30–50%. A large Canadian ED study found that even small 2–4% hospital flow enhancements would enable EDs to rapidly manage all high acuity patients and eliminate waiting room deteriorations.
No Patient Left Behind promotes and supports operational innovation, develops effective leaders, and drives policy change that leads to a more accountable system.
Accountability Framework Overview
An accountability framework assigns ownership of patient access and flow to specific programs. It sets out:
- Accountability zones: which program is most responsible for which patients
- Program expectations: timely care access, effective queue management, and surge strategies
- Consequences and support: what happens when expectations are or are not met
- Continuous review: goals and targets for flow and access that are monitored over time
Types of Accountability Frameworks
Frameworks operate at two levels: within a single facility and across the wider health system.
Facility Accountability Frameworks
Assign accountability zones and care expectations within a single hospital, covering ED inflow, throughput, outflow, and alternate level of care.
Coming soonSystem Accountability Frameworks
Assign responsibility for access and flow across health regions, programs, and community partners, including primary care, long-term care, and specialist services.
Coming soonHow to Implement an Accountability Framework
Implementation begins with structured questions for program leaders, including who they serve and how they would operate if closing the door were not an option.
Strategic Planning
Confirm your team understands its accountability zone and its queuing patients.
Challenge Assumptions
Ask teams: How would you change if closing the door was not an option?
Optimize Utilization
Yes you are full, but do all the patients need a hospital bed or ED stretcher?
Operate & Smooth Flow
Fix bottlenecks, smooth demand, admit-discharge 7 days/week, and reduce variability.
Plan for Surge
Implement a demand-driven overcapacity plan and ethical triage/reverse triage.
Set Goals & Monitor
Establish explicit goals and targets for flow and access, and review them continuously.