The Accountability Dodge

Dr. Walter O'Donnell, a pulmonologist at Massachusetts General Hospital writing in the New England Journal of Medicine, tells a gut-wrenching story. His patient, Mr. P, a 59-year-old with multiple lung cancers and worsening pulmonary disease, needed critical vascular surgery but was struggling to quit smoking – a prerequisite for the operation. The hospital had a proven, effective inpatient tobacco treatment program with success rates 50-70% higher than standard care. Mr. P was finally ready to accept help. But when Dr. O'Donnell tried to connect him with the program, he learned it had been shuttered months earlier. Why? Budget cuts. An administrative decision, made somewhere up the chain, by people who never examined Mr. P. or any other patient. Mr. P. relapsed, so his surgery was postponed and his condition deteriorated. O'Donnell gave this a name: adminogenic injury – harm originating not from clinical care, but from the administrative machinery itself.

This harm permeates hospitals and forces doctors to navigate impossible situations where they must choose between following administrative directives and serving patients' needs—no doubt contributing to a burnout epidemic among clinicians. But the problem is pervasive, and it’s likely happening in your organization, right now. It's the product innovation suffocated by a 15-signature approval process. It's the customer service rep who can't issue a $50 refund without three levels of approval. It's the promising hire who walks away after a six-month recruitment process. It's the market opportunity missed while the strategic plan languishes in committee purgatory. It's the performance management system that measures everything except actual performance. This is the daily toll of bureaucracy, and it inflicts substantial damage.

The Accountability Asymmetry

O'Donnell's essay does a great job at exposing a troubling double standard. When it comes to patient care, there's a lot amount of transparency and accountability for decisions. Every medication carries a physician's electronic signature. Every procedure requires documented informed consent. Surgeons' outcomes are tracked, analyzed, and increasingly posted publicly online. When patients suffer complications, cases are presented at Morbidity & Mortality (M&M) conferences where peers conduct searching reviews to identify failures and prevent recurrence. Personal responsibility is inescapable, and improvement is systematic.

Now, flip to the administrative side. When Dr. O'Donnell attempted to file a safety report about the harm caused by eliminating the smoking cessation program, he found the software offered no category for "administrative harm." His attempts at a root-cause analysis hit a wall. The decision was, in his words, "opaque and anonymous." No documentation trail showed who had made the call. No signatures appeared on the budget cut. No one personally acknowledged responsibility. No equivalent to the clinical M&M conference existed to review the real-world consequences of the administrative decision. "Administrative outcomes such as program closures, shortfalls in personal protective equipment, and abbreviation of patient visits to the point of clinician overload remain obscure, unexamined, and unimprovable," O'Donnell writes. Administrators operate "in a parallel universe far from Mr. P's stretcher."

This accountability vacuum creates the perfect conditions for bureaucracy to metastasize. When nothing checks its growth, administrative functions expand unchecked. In healthcare, administrative personnel make up the fastest growing segment of the workforce and outnumber front-line workers two to one. The same pattern plays out across the US economy.

Bringing Bureaucracy to Account

If we want truly responsive management and administrative functions, we must close this accountability gap. Here are five concrete steps.

One: Track administrative drag. Don't let the costs remain hidden. Use tools like the Bureaucracy Mass Index survey to measure how much time is lost to bureaucratic chores that add little value, the cycle times of important decisions, how hard it is get a new idea off the ground, etc. Implement systems to specifically capture and categorize "administrative harm" or near misses, as O'Donnell called for in his essay. Make the costs visible to everyone.

Two: Run administrative post-mortems. When administrative processes or decisions lead to bad outcomes (project delays, cost overruns, customer complaints, employee exodus), conduct rigorous reviews with the same rigor as clinical M&Ms. Bring together the process owners and those who suffered the consequences. Ask tough questions: What was the real impact? Was the process flawed? Who was responsible? What must change?

Three: Shift the burden of proof on the administrators--and make it personal. For any significant new process, layer, system, or mandate, demand a clear, documented justification signed by named individuals. This justification must include an honest assessment of the total impact – including the time and productivity costs imposed on others – not just the supposed benefits to the center. Svenska Handelsbanken, the highly successful and radically decentralized Nordic bank, provides an instructive example. Every year, a committee of branch managers reviews and provides feedback to the plans of central administrative departments before agreeing to pay for those services – subjecting them to the same rigorous scrutiny as any frontline business plan.

Four: Give those on the receiving end a voice. Let operating teams compare bureaucratic processes with simpler alternatives. If a corporate mandate hinders their ability to serve customers or achieve results, allow them to seek exemptions or propose alternatives. Stop forcing them into O'Donnell's colleagues' position of devising "workarounds and apologizing to customers for the breaches in service," and empower them to prevent the breaches. At Handelsbanken, branches have exercised their right to go outside the organization when internal service providers fall short, creating healthy pressure for support units to be truly supportive.

Five: Tie administrative incentives to real-world impact. Tie administrative functions' rewards directly to their contribution to overall business success and internal customer satisfaction, not narrow, synthetic functional KPIs. Where feasible, introduce market dynamics – let operating units choose service providers based on actual value delivered. At Haier, the global appliance manufacturer, support functions must compete for the business of internal operating units, who have multiple options for service providers. Staff compensation is also directly tied to the commercial success of the products they support—creating genuine skin in the game and transforming bureaucrats into business partners.

When Dr. O'Donnell's colleagues learned about the eliminated smoking cessation program, they responded with resigned sighs and mutters of "tough budget year" – as if administrative decisions were immutable forces of nature rather than human choices with consequences. This "fiscal fatalism," as O'Donnell calls it, is what allows stifling bureaucracy to get a pass.

This must stop. We wouldn't accept unaccountable harm from our surgeons, engineers, or salespeople. So why do we tolerate it from from our administrative structures?