Redefining accountability in health care: managing the plurality of medical interests.

Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of ;futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment. We contend that managing the plurality of medical interests is essential in achieving a more managed and positive experience for patients and families of the care they receive, and for achieving standards of quality and resource use. From an ethnographic study undertaken in a large ICU in Sydney, Australia, we found that the knowledge and practice differences of multiple medical decision-makers generated conflict, inconsistency of practice and subjectivity of decision-making that impeded coherent clinical decision-making and integrated patient care planning, coordination and care review. Improving patients' and families' experience of care requires medical clinicians and medical managers to accept responsibility for institutionalizing effective communication and decision-making processes within clinical networks and between clinical and managerial domains. Thus, strategies to improve patient care will need to extend beyond the medical profession to incorporate administrative management. We conclude that restructuring communication and decision-making processes is imperative to achieve clinical accountability in the workplace and systems accountability in the organization.