“No Blame” Doesn’t Mean “No Accountability”


Wachter's World : Physician Accountability for Violation of Safety Rules: The Time For Excuses Has Passed

I think Bob Wachter has it completely right in his blog post. He also makes the same point in his book Understanding Patient Safety.

While Dr. Deming taught (and patient safety experts like Wachter have emphasized) that most problems are due to the system, that doesn't mean it's ALWAYS the system.

There's a difference between a nurse or physician being part of a systemic multiple-failure medication error and someone intentionally choosing to not follow a process. Now, if someone chose to not follow a process because they didn't have time, management has a responsibility to help improve the system so that people DO have time. But “no blame” can't be taken to an extreme where personal accountability isn't part of the picture.

Wachter's piece starts:

In this week's New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it's time.

At most hospitals, hand hygiene rates hover between 30-70%, and it's a near-miracle when they top 80%. When I ask people how they're working to improve their rates, the invariable answer is “we're trying to fix the system.”

Now, don't get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can't fix the fallibility of the human condition.

But not washing hands? When I hear, “It's a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn. I think all of us realize that in 2009, failure to clean hands is no longer primarily a systems problem. It's an accountability problem.

Click on the link up top to read the rest. What do you think? Where do you strike the balance between “no blame” (systems view) and personal accountability?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I agree and well said, but when did people start thinking that 'focus on the system' and 'accountability' are mutually exclusive? Having a system for accountability means there is a way to know if people aren't following the system and a consistent means of corrective action, even if that leads to dismissal. Not having a system is randomly seeing things get out of control and then finding someone to 'make an example.' There is a difference.

    It's not ether or.


  2. In general I agree. Ultimately, failure to adhere to standard work is grounds for dismissal. Having said that, let me express a concern about the work "accountability." Perhaps it is time to rethink. Isn't this word "code" for management accounting? As a practical matter, the audit system of management accounting is all about blame. I prefer the term "responsibility." Actually, this is the term that John Shook uses in his latest Shingo Prize winning book, Managing to Learn.


  3. I never thought the dictionary definition of "accountable" had anything to do with "accounting" even though they start with the same letters. I think you're nit picking about semantics, Tom. I'd rather hear an example of where you think accountability or responsibility is called for instead of vaguely blaming "the system."

    Rather than being cute about language, please give us an example that helps.

  4. I think that hand-washing is a personal accountability issue. I wonder if proper hand-washing and hygiene rates would be higher if the focus shifted from keeping patients healthy to keeping the health practitioners healthy. Would people be more likely to engage in proper hygiene practices if they are thinking about their own health? I'm sure this will not completely solve the issue (some people will simply not be responsible, regardless of the motivation), but taking a 'personal safety' instead of a 'patient safety' stance could be a more effective motivation for some.

  5. I tend not to agree. What en how do people learn the first weeks at their new job? How do clinical leaders and team leaders respond when someone does not wash their hands? How does the team reflect on this issue? How does the team receive feedback on the consequences of not washing their hands?

    In my experience hospitals put a lot of energy in putting up signs and similar actions to remind people of the desired behaviour, but this is in miy view the least effective part of changing the system. More effective is the system by which people learn and by which dominant thinking patterns and dominant behaviours develop.

    I learned from Toyota 'be hard on processes and soft on people'. I think also washing hands is a system problem.

    Manager Innovation
    St. Elisabeth Hospital
    Tilburg, the Netherlands


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