There is a remarkable story in today's Sunday NYT detailing problems with the New York State program of homes run to house developmentally disabled persons. (http://www.nytimes.com/2011/03/13/nyregion/13homes.html?_r=1&ref=todayspaper)
It is both shocking and yet not unexpected, given the long history of how these environments tend to attract those who prey upon the weak and helpless. There are a number of elements of this story which perhaps are instructional for many other environments.
One particular thrust of the story is the role of the public employees union in preventing particularly abusive employees from being held accountable for their egregious behavior. While these organizations may make it more difficult to hold state employees accountable, I think there is a more fundamental issue which is at play which operates in the presence or absence of institutions like unions which may shelter members from accountability.
My experience in various workplaces leads me to believe that most people want to have nothing to do with holding others accountable for their actions. Holding people accountable means having to stop what you are doing and investing a substantial amount of time and effort to an endeavor where you derive no immediate gain and perhaps no personal gain whatsoever. Even if your particular work environment has created tools to facilitate the process, the time and effort to document and respond to incompetence is substantial. Look at the events leading up to the Fort Hood shooter's killing spree. Dr. Hasan was recognized informally by his peers as being a incompetent and possibly a radicalized but no one put a stop to his rise through the ranks. To do so required a commitment which could not be justified by any single individual at any single moment of time. He kept getting passed on to the next level because the immediate cost associated with not doing so was sufficient to discourage those involved from responding.
For the most part, not holding people accountable does not lead to spectacularly bad outcomes. In the short term nothing much happens. It slowly undermines workplace morale and cohesiveness of operating units. No single episode of incompetence or or outrageous behavior generally takes down the enterprise and survival from any given episode tends to reinforce the avoidance behavior. Taking on incompetence requires time, tools for assessment of performance, and a willingness to experience pain in the form of difficult personal encounters. Those whose positions are impacted will fight very hard to protect their turf while few others are so vested in taking on such fights. Economists view these circumstances as non-Pareto equilibrium. They are not desirable but when no parties have an incentive to make dramatic change, change does not happen. Until there is some terrible event which thrusts responsible parties into the spotlight, organizations tend to limp along. Then everyone asks how this could happen! Action tends to be prompted by back outcomes in the spotlight. It is too bad that transparency tends to require bad outcomes to operate.
Within the realm of health care, we are also facing difficult decisions. Within the health care field, we have similar issues with holding ourselves accountable. Long standing dubious practices and a culture of financial gaming continue relatively uncriticized because the revenues are needed to make the expensive health care enterprise work. Who in their right mind would want to take this on except in the circumstances where some whistle-blower windfall was involved? However, the health of any enterprise is ultimately dependent upon creation of an environment where leaders have incentives to take on these challenges. You have to ask, where will those leaders come from and what reasons will we give them to take on the tough challenges which require them to confront their peers?