Three Tools for Cultivating Patient Accountability

April 11th, 2014

Health care reform, whether governmental, institutional or informal, frequently includes substantial discussion of an increased level of accountability for caregivers. Primary care providers are engaged to serve in a coordinating role for patients – sourcing and compiling specialist providers and diagnoses as warranted by patient needs. States are experimenting with Accountable Care Organizations (ACOs) in various forms to find a method within which improved patient outcomes pair with decreased costs. These changes will eventually result in substantial benefits for patients – and hopefully for providers as well. But often, the idea of patient accountability is missing from the conversation. Even in an accountable care model, the best outcomes will flow to those patients who assume accountability for their own well-being.

In an earlier piece on the Four Stages of Change, also covered in Lifeline’s eBook, Engaging Your Patients in Effective Health Management, we learned how different messaging reaches patients differently depending on their psychological relationship to their condition(s). Here, we’ll look at a few ways to pair this awareness with knowledge about learning styles and accountability triggers. When used together, they provide a powerful tool to boost your patients’ accountability.

The Accountable Patient

Prior to passing the Affordable Care Act in 2010, congress spent years considering ideas on how best to reform the American health care system. Much of the media discourse centered on costs, plans, public options and politics. But in public testimony before committees, experts of every conceivable persuasion proffered their best ideas on how to build the best new plan. Most of the testimony is public record, and much of it is remarkably interesting.

Donald Kemper, MPH, the Chairman and CEO of Healthwise and Founding Chairman, Ix Center Board of Directors, addressed the Joint Economic Committee in May of 2006. His testimony and accompanying written statement is full of great tips for encouraging patient accountability.

After thanking the Committee for hearing his message, Kemper said:

“I have a simple message. The greatest untapped resource in health care is the consumer…The recommendation I would like to make to you today is the most powerful of them all. It is simple — remarkably simple. But it has the power to impact the quality and cost of care like nothing else that has ever come before this Committee. This is it: Prescribe information to every patient. Prescribe information to every patient, at every moment in their care.”

More recently, Kemper has written that three items are critical to “trigger accountability.”

  1. To know what’s reasonably expected of us.
  2. To have the information, skills, and tools to do what is reasonably expected.
  3. To be either economically or socially accountable to do what is expected.

Knowing what’s reasonably expected of us is something many people take for granted. But when you’re trying to get a patient to adopt new behavior and action, it’s important to be explicit. To meet those expectations, the patient may need to learn new skills or avail themselves of community resources that are also new. Especially for seniors, it can be challenging to do new things. Be sure to highlight ways in which action or inaction will have an impact on the patient’s finances, family and friends. Together, an active awareness of these triggers make it more difficult for patients to give up on a plan of action.

Providing this sort of guidance and coaching need not wait until it’s a legislative or insurance requirement. Give your patients extensive information, tailored to their state of change. Make sure to employ each of Kemper’s three factors above. You’ll set your patients up with the best chance to effectively participate in their own care.

Listening and Framing

People generally have a primary sense through which they acquire knowledge. The four most common learning styles are auditory, visual, reading/writing, and kinesthetic. A 2006 American Psychological Society article described a preference for one or another style as, “A learning style or preference is the complex manner in which, and conditions under which, learners most efficiently and most effectively perceive, process, store, and recall what they are attempting to learn.” Well-trained sales professionals often glean this information during their first interactions with a potential customer in order to craft a sales pitch that will resonate especially well. It’s a simple yet powerful tool that can help you frame your conversations for the best chance of achieving patient buy-in.

To get a read on your own learning style, visit VARK and take their free 16-question quiz. Then, listen to the way your patients discuss their conditions and treatment to find out their primary learning style.

If a patient says, “I was looking for information about X” or “I saw a commercial about Y,” it’s likely that the patient is a visual learner. These folks talk in terms of things they “see,” so you should frame your discussions in visual terms (even if you yourself are not oriented visually).

Patients who report “hearing a story about A,” or “a friend telling me that medication B worked well,” are usually auditory learners.

Kinesthetic learners are sometimes difficult to identify. Listen for patients using “feel,” “touch,” and relating situations in which they’re doing the things they’re describing.

Those with reading/writing learning style will describe articles and web resources they’ve read, and may express a desire to email you (write) for further information.

As you might imagine, if you’re primarily visual and your patient is auditory, you’re going to be predisposed to deliver information in terms that won’t optimally resonate with your patient. Practice listening for these learning style hints. Then, work on framing your conversations in the same terms your patients use when describing their own experience.

Put It All To Work

Here is an example of how you might use the above to improve patient outcomes and encourage your patients to assume greater responsibility for their own heath.


“Ron” is a 72-year-old senior with diabetes. He is obese and has recently been suffering episodic arrhythmias, which you are evaluating for Diabetic Cardiomyopathy. He has seen the Nutritionist in your practice group several times to encourage weight loss. Unfortunately, his progress has been minimal. From your conversations with the Nutritionist, you learn that Ron reports eating lots of salad and cutting back on “fatty foods.” This is good, as decreasing Ron’s dietary sodium intake has been a priority. He says things like, “My niece came over and we made soup and salad – without bacon bits – and even measured the salad dressing to make sure we didn’t have too much.”

Ron is engaged in his weight loss at least as far as his understanding of nutrition takes him. He’s willing to attempt to make a change, but is not actively seeking the details of what might make that change worth attempting.

When pushed, Ron admits to frequently pairing the salads with canned soup. Instead of bread, he’s been eating saltine crackers with his soup. Rather than grilling a steak, Ron has been eating packaged chicken patties and sausages. It doesn’t occur to Ron that the substitutions he’s made may actually be increasing the sodium in his diet, thereby putting him at higher risk for high blood pressure and further complications.

Ron is in the action state of change – willing to pitch in to the best of his ability but not in possession of sufficient information to make his efforts especially powerful. Plus, he’s shown that conceptual discussions about the changes he needs to make are not effective. Ron needs detailed specifics, a meal plan, and social support. Optimally, he needs this information delivered with an awareness of his primary learning style.

To employ Kemper’s three factors that trigger accountability, start by interviewing Ron to gauge his awareness of the reasonable expectations placed on him. For the dietary changes, he’ll need to monitor his actual daily sodium intake – not just eliminate foods he’s previously thought of as salty. Since Ron frequently talks about doing things, he’s probably a kinesthetic learner. Describe what’s necessary for monitoring sodium in terms that will make sense to him. Instead of asking him to read nutrition labels, tell him to pick up the box of Saltines to get the sodium content. If he wants to eat them anyway, tell him to brush off the visible salt on top of each cracker. Better yet, use a prop box of Saltines, and have Ron physically pick up the box to note the sodium, and scrape the salt off of a cracker.

These kinesthetic instructions stand a much better chance of being meaningful to Ron, and give him the best opportunity to be accountable for following through on your instructions. Remember, knowing what’s reasonably expected of us is only part of the accountability picture. Having sufficient information and ability to take action is also important. Remind Ron of the financial consequences of not participating in his own care (complications are expensive!), and inquire as to how his niece might help in getting him to do better with his meal planning.

By spending some time listening to the ways your patients describe their world, you’ll gain a powerful insight into what types of language and information will be most meaningful to them. Note their state of change, and address all three of Kemper’s accountability triggers, using interventions and information tailored to your patients’ learning styles. You’ll see your patients’ accountability start to grow, and their outcomes get better and better.