There is growing recognition that a social accountability framework, as defined by the World Health Organization (WHO) for medical schools, can also apply to other health institutions. Social accountability could help identify the priority health needs, reflective of the values of relevance, quality, efficiency, and equity, of the people health institutions serve through a unique approach to stakeholder engagement. Patient encounters from the frontlines of the emergency department (ED) in an Academic Health Sciences Institution (AHSI) inspired the question: Could social accountability help an AHSI identify, understand, respond to, and impact the health needs of the people and communities it serves? The AHSI in Northeastern Ontario, Canada -- Health Sciences North (HSN) -- was well positioned to test the appetite for a social accountability framework outside of medical schools. HSN’s 2018 strategic plan presented an opportunity to advocate for social accountability at the health institution. Work that seeded this idea, however, was underway long before the strategic plan process. In response, the AHSI created a leadership position to oversee its need to “Be Socially Accountable.”
The Motivation for Social Accountability Outside of Medical Schools
Social accountability, in medical education, has had a positive impact on retention of a health workforce (Hogenbirk et al., 2016), economic development (Strasser et al., 2013), and population health indicators (Wooley, 2018). Specific criteria have been established that reflect institutional social accountability of medical schools (ASPIRE, 2018; Rourke, 2018; THEnet, 2018). Social accountability is also now being proposed as the guide for the practice of medicine and in the delivery of rural healthcare (Wilson et al. 2017; Goel et al., 2016; Woollard et al., 2016; Meili et al., 2016). It has further been highlighted as a framework for AHSI to address health inequity (Smitherman, 2019).
The idea that social accountability could help identify, understand, respond to, and impact the health needs of the people and communities an AHSI serves was inspired from the frontlines of the ED. In the ED, the elements required for social accountability are in front of healthcare workers every day. These include: (i) an understanding of who the people, populations, and communities are that are being served; (ii) their priority health needs reflective of the values of relevance, quality, efficiency, and equity; and, (iii) engagement with the very people who need to define their own priority health needs (Boelen & Heck, 1995; Boelen, 2000). In HSN’s ED, there was no shortage of examples to support this claim. For example, the region that the AHSI serves, has high rates of overdoses and deaths related to narcotics. The impact of addictions on a community is undeniable when 16 patients on a night shift in the ED are intravenous drug users. Similarly, the region’s high rates of heavy alcohol consumption could be linked to the one in five traumas that come through the ED that involve alcohol (Sudbury & Districts Public Health, 2014; Moggy, 2018). Further, culturally safe access to care for Indigenous people was a concern because Indigenous people would sometimes state that “it took everything for me to walk through the door and ask for help.” The community that the AHSI serves has a significant Indigenous population with dramatically poorer health outcomes.
There was an urgent need to identify the priority health needs that were being observed in the ED from the people and communities the AHSI served. The AHSI HSN, which is affiliated with the Northern Ontario School of Medicine (NOSM), was well positioned to test the idea that a social accountability framework from medical education could also help an AHSI.
Intervention & Methods
In January 2018, HSN’s strategic plan process presented an opportunity to advocate for social accountability at the AHSI. A call-to-action was drafted by a NOSM charter class graduate, which urged stakeholders to contact the AHSI CEO and the head of the strategic plan process to request social accountability as a foundational priority for the institution. “Social Accountability as a Framework for the Moral Obligations of Health Institutions” became the focal point for advocacy efforts (Anawati, 2018). The call-to-action was distributed by email, text messages, social media, and through one-on-one meetings. Three key strategies of engagement were planned -- engagement with key influential individuals, outreach to community organizations, and engagement with frontline staff. However, work to seed the idea of social accountability at the AHSI had been underway long before the strategic plan process.
The call-to-action specifically asked HSN to include four goals to achieve institutional social accountability: (i) ascribe to social accountability, (ii) true, meaningful, and empowered community engagement, (iii) synergistic partnerships built on social accountability, and, (iv) constant evaluation and evolution of the organization’s social accountability.
To ascribe to social accountability, the AHSI was requested to declare a commitment to, and understand the principles of, social accountability. They were asked to create a social accountability mandate; and, to translate social accountability knowledge into practice for the AHSI. To achieve true, meaningful, and empowered community engagement, the AHSI was requested to engage equitably with all community members and populations. They were asked to remove barriers that excluded participation from marginalized groups; and, to re-distribute power to the community. To achieve synergistic partnerships built on social accountability, the AHSI was requested to advocate for social accountability with all their partners and to utilize the WHO’s partnership pentagram to build partnerships. To achieve constant evaluation and evolution of the organization’s social accountability, the AHSI was requested to create specific metrics that would demonstrate an impact on the priority health needs of the people it serves and to create processes that allowed the community to hold the AHSI accountable for their health.
The first step was to engage with key influential individuals. To begin with, the head of the strategic plan was given a presentation on social accountability, who then brought the call-to-action to the attention of the strategic plan steering committee. All HSN senior level administrators, department heads, and health professionals within the AHSI were emailed copies of the call-to-action. Many key individuals requested in-person meetings and became champions for social accountability.
The second step was outreach to community organizations involved in health and social sectors. Locally, the Community Development Coordinator with the municipality of the City of Greater Sudbury circulated the call-to-action to more than 50 community organizations. Church leaders, professors from the schools of nursing, dieticians, the Northern Initiative for Social Action, the March of Dimes, and Family Health Teams, amongst others, added their voices to the call for social accountability. Organizations, such as Child and Family Services and the local Public Health Unit compared social accountability to anti-oppressive frameworks and health equity strategies that they use. Regionally, NOSM as an institution already ascribed to social accountability, added a very strong voice to advocacy efforts. Nationally, the College of Family Physicians of Canada’s (CFPC) Social Accountability Working Group (SAWG) wrote a letter of support citing that social accountability is included in the CFPC’s strategic plan and encouraged HSN to do the same.
The third step was to engage with frontline staff about social accountability. These engagements were framed around lived experiences at work that reflected the need for social accountability. These engagements allowed for the opportunity to share the call-to-action with frontline staff and requested their help to advocate for social accountability in the strategic plan.
Long before the strategic plan process, efforts were underway to seed the idea of social accountability at the AHSI. These efforts were threefold -- create a base of support for the idea, bring credibility to the idea, and highlight it as a solution. Efforts to create a base of support were focused on medical learners, faculty, sympathetic health professionals, and people from the community. A base of support was created through lectures at the medical school, hospital grand rounds, day-to-day teaching responsibilities in the ED, faculty development sessions, and conversations in coffee shops. To bring credibility to this idea, networking and leadership endeavors were pursued. These included participation on NOSM’s Board of Directors, with AMEE’s ASPIRE for Excellence in Social Accountability Panel, with the CFPC’s SAWG, and pursuing research. Longitudinal sustained advocacy efforts for social accountability as a solution to frustrating systemic experiences at the AHSI also helped. In the end, these efforts helped brand social accountability as an important aspect of a health professional’s identity. Across all these efforts, social media proved to be a very effective tool. Additionally, it helped that the CEO of the AHSI and the head of the strategic plan process envisioned and also valued the fundamental principles of a social accountability framework for the AHSI.
In response to this advocacy work, HSN has stated in its strategic plan that to “Be Socially Accountable” they “will seek and value community engagement and stakeholder participation to address the priority health concerns and health equity gaps for Northerners” (HSN Strategic Plan, 2019). HSN has listed social accountability as a top five priority and assigned a Vice President of Social Accountability to oversee it. This is evidence that there is a need and desire for a social accountability framework to guide other health institutions.
Thank you to Dr. Chris Bourdon, Dr. David Boyle, Dr. Robert Lepage, Dr. Dominique Ansell, Dr. Roger Strasser, Mrs. Maureen Mclelland, Mrs. Lisa Smith, Mrs. Crystal Pitfield, Mrs. Sherri Morosso, members of HSN’s strategic plan committee, and all those who supported this idea.
Anawati, A. (2018). Social Accountability as a Framework for the Moral Obligations of a Health Institution. Submitted to Mrs. Maureen McClelland and Health Sciences North’s Strategic Plan Steering Committee May 2018. Circulated widely across the City of Greater Sudbury and Northeastern Ontario.
ASPIRE, 2018. ASPIRE Recognition of Excellence in Social Accountability of a Medical School Criteria - Version 2.0. Available at: < www.aspire-to-excellence.org/ >
Boelen, C. & Heck, JE. (1995). Defining and measuring the social accountability of medical schools. Geneva: World Health Organization; 1995. WHO document WHO/ HRH/95.7
Boelen, C. (2000). Towards unity for health: Challenges & Opportunities for Partnership in Health Development. World Health Organization; 2000. WHO document WHO/EIP/OSD/2000.9.
Goel R., Buchman, S., Meili R., & Woolard, R. (2016). Social accountability at the micro level - One patient at a time. Canadian Family Physician. April 2016, 62 (4) 287-290.
Hogenbirk, J., et al. (2011). Milestones on the social accountability journey Family medicine practice locations of Northern Ontario School of Medicine graduates. Can Fam Physician 2016;62:e138-45.
Meili, R., Buchman, S., Goel, R. & Woollard, R. (2016). Social accountability at the macro level - Framing the big picture. Canadian Family Physician October 2016, 62 (10) 785-788.
Moogy, L. (2018) Educating Teens About Poor Choices. CTV News Northern Ontario. Available at: < northernontario.ctvnews.ca/ >
Rourke, J., (2018). Social Accountability: A Framework for Medical Schools to Improve the Health of the Populations They Serve. Acad Med. 2018;93:1120–1124.
Smitherman, H., Baker, R. a& Wilson, R. 2018). Socially Accountable Academic Health Centers: Pursuing a Quadripartite Mission. Academic Medicine: accepted for publication DOI 10.1097/ACM.0000000000002486.
Strasser, R., Hogenbirk, J., Minore, B., Marsh, D., Berry, S., McCready, W. & Graves, L. (2013). Transforming health professional education through social accountability: Canada’s Northern Ontario School of Medicine. Medical Teacher. 35: 490–496.
Sudbury & Districts Public Health. (2014). Public Health Sudbury & Districts Population Health Profile: Heavy Drinking by Geographic Area. Available at: < www.phsd.ca/resources/research-statistics/ >
THEnet. (2018). The Social Accountability Framework for Health Workforce Training: Volume II. Available at: < thenetcommunity.org/framework-toolkit/ >
Wilson et al. (2017). Advancing Rural Family Medicine: The Canadian Collaborative Taskforce - The Rural Road Map for Action – Directions. Mississauga, ON: Advancing Rural Family Medicine: The Canadian Collaborative Taskforce; 2017. CFPC.
Wooley, T., Halili, S., Siega-Sur, J.L., Cristobal, F., Reeve, C., Ross, S. & Neusy, A.J. (2018). Socially accountable medical education strengthens community health services. Medical Education 2018: 52: 391–403.
Woollard, R., Buchman, S., Meili, R., Strasser, R., Alexander I. & Goel, R. Social Accountability at the Meso Level – Into the Community. Canadian Family Physician July 2016, 62 (7) 538-540.
HSN Strategic Plan. (2019). Your HSN: HSN & HSNRI Strategic Plan 2019-2024. Available at: < yourhsn.ca/read-the-plan/#be-socially-accountable >
Dr. Alex Anawati is an ER physician at Health Sciences North in Sudbury, Ontario, Canada. A member of NOSM’s charter class, he has continued his involvement at the medical school as an Assistant Professor, Global Health Coordinator, and member of the school’s board of directors. He is also a member of the College of Family Physicians of Canada’s Social Accountability Working Group and represents NOSM on AMEE’s ASPIRE for Excellence Social Accountability Panel.