The culture of accountability.

RECENTLY, A POSTANESTHESIA care unit (PACU) manager was advocating for staff during a difficult crucial conversation. The manager offered to continue a phone conversation with an MD as it was evident that an argument was brewing. The staff nurse kept steady and calm and did not hang up until the manager could assist her. A hospitalist was actively resisting ownership of medical direction for care provision in PACU. It was ‘‘one of those days,’’ with multiple intensive care unit (ICU) patients boarding in the room. Some patients were covered by the Anesthesia Department, some by the Department of Surgery, and others by intensivists. However, some patients were ‘‘in limbo,’’ not actually medically covered by anyone, as they had been displaced from the ICU to the PACU out of an urgent need for critical care beds. It was unacceptable to have an ICU patient—one might say, a ‘‘bumped’’ patient, from ICU to PACU with no medical ownership or direction for care. So, the conversation was as follows: