Dissertation (Doctoral) Accountability in Ontario’s Acute Care Hospital Sector and its Effect on Organizational Strategic Priorities


Seija Kristina Kromm


Background: In health care, organizations are faced with new and changing requirements for accountability. The province of Ontario, Canada has increased its focus on accountability over the past decade, including efforts directed at acute care hospitals.

Objectives: To examine the environment of accountability in Ontario's acute care hospital sector, and its effect on hospital strategic priorities, perceptions, and behaviours.

Methods: This mixed methods study used three methods: 1) document analysis of three policies introduced between 2004 and 2012: Hospital Service Accountability Agreements, Ministry-LHIN Performance Agreements, and Quality Improvement Plans; 2) a survey of Ontario's acute care hospitals (53 of 116 responded); and 3) thirteen interviews with hospital executives and health system leaders.

Results: The three policies employed performance measures. Since 2004, the focus of performance measurement has expanded from financial and service volumes to include quality and patient safety. Survey findings revealed shifts in perceptions of strategic issues by hospitals in 2011 compared to 2004. Hospital priorities have shifted towards convergence of strategic priorities. Shifts also moved some priorities to align with external accountability requirements. Interview findings confirmed that accountability is being used as a management tool; hospitals have adapted and purposely adjusted their priorities; accountability requirements provide hospitals with a focus; and unintended consequences may result.

Discussion: The success of legislated accountability may be dampened as hospitals struggle to meet performance targets and reporting requirements. Shifts towards standardized organizational strategic priorities may be a benefit of accountability. Misalignment of requirements and levels of accountability is perceived as a challenge by hospitals, but they continue to adapt. Hospitals are also challenged by low controllability of performance indicators and an uncoordinated environment of accountability. Even so, accountability requirements provide organizations with a focus, an important benefit.

Conclusions: Accountability may be challenging, but it provides a focus for organizations. Added supports for capacity building may be necessary for some organizations, particularly small community hospitals.


Raisa Deber