A recent post elicited a request, “Please share your thoughts on how you see the importance of performance data in accountability”. I make no claim to have expertise in the theory and science of performance management but accountability is undoubtedly linked to measures of performance. As is my wont, I went to the dictionary for the a definition of the verb, “account” and found “to furnish a justifying analysis or justification”. It follows thus that accountability is the state of being accountable i.e subject to giving account. In my initial post I had listed accountability as a characteristic of good governance. I used the word more in an ethical sense which is a readiness to provide an explanation for one’s actions set against the benchmark of the highest ethical standards. However, providing that justifying analysis or justification, as in the definition above, in terms of performance clearly requires performance data measured against a benchmark or target.
In my experience both as manager and clinician, I have found many managers, and indeed clinicians, unable to account for either their decisions or the consequences thereof based on data. Sometimes the required data was available and sometimes it was not. In truth, the culture of accounting for one’s actions appears foreign to some. Coming to management from an academic and clinical background it was nevertheless surprising when important decisions in government were based seemingly on the flimsiest of information.
Those who know me well as a manager will know my focus on the control of expenditure learnt through bitter experience. Something that led to the criticism from senior clinicians that I “put cash before care”. It will not surprise therefore if my first response refers to accountability with respect financial management. In my time as Head of Department and Accounting Officer, the Public Finance Management Act (PFMA) held me accountable to a formidable array of issues. These ranged from maintaining an effective and transparent system of financial and risk management to taking effective and appropriate steps to prevent overspending. In reality the relevant government systems that were supposed to support my decisions as required by the PFMA were unable to provide me with access to the type of information that I required to fulfil these obligations. This reality remains today in many government departments.
With the assistance of a capable Chief Financial Officer who responded to the challenge, departmental systems and processes were developed to draw down data from the available government systems so that I and my management team were able to accurately monitor and control expenditure. With access to the relevant data, monthly reviews allowed rational decisions to be taken to address over and under expenditure across the department. In time I was able to meet my obligations as an accounting officer, which at the outset had seemed impossible. Consequently, for almost all of the financial years during my 12 year term as Head of the Western Cape Department of Health expenditure remained within 2% or less of the allocated budget. My experience subsequently has been that many in similar positions today remain unable, in the absence of accessible and reliable financial data, to effectively manage the financial resources for which they are accountable. The results are over expenditure, unpaid service providers and burgeoning accruals.
Performance is however a wider issue than just financial management and the criticism of clinicians that I put cash before care reflects a view that remaining within an allocated budget does not equate to a valid performance measure as seen from the perspective of a clinician or that of the patient.
In recent years governments worldwide, and South Africa is no exception, have made efforts to develop performance measures and performance matrixes. However, despite every government department in South Africa being required to publish an Annual Performance Plan with performance targets, in truth many of these targets are of such a nature that they pay only lip service to performance and accountability.
The metrics of measuring performance are important and measurements can reflect Input, Output, Efficiency, Quality and Outcome. While it is a requirement of government departments that that their performance indicators should be “SMART” (i.e Specific, Measurable, Achievable, Realistic, and Timely) many fall short of this requirement. In the health sector “outcome” is of cardinal importance. Accountability must therefore reflect a requirement to provide a justifying analysis that indicates that the intended outcome has been achieved. While a hospital may achieve a target of 80% bed occupancy it may fail if measured against the metric of rising postoperative infection rates. A health service may achieve the target of a “clean” financial audit but fail when surveyed patient satisfaction is at an all time low. Without the setting of performance indicators that meet the SMART criteria and their effective measurement, holding managers accountable will not be possible.
An interesting interface between financial management and clinical management in my experience has been the development of the concept of the functional business unit (FBU) within a hospital setting or at a larger scale the health maintenance organisation (HMO) where clinicians with management operate within protocols that outline the most cost-effective manner to manage clinical conditions to attain the most favourable outcomes both financial and clinical. Systems of this nature provide clinicians and managers the opportunity to assume co-responsibility measured against the outcomes of patients. Again accountability in this setting is not possible with effective measurement of performance data.
In the end accountability is being held to account be it to moral and ethical standards or the metrics of performance data. In whatever context I believe that its remains an integral component of good governance, which will reflect in the performance of the organisation.
