We need more trust between managers, patients and the front line

The way we interact with healthcare, as patients, payers, and providers, is changing. We treat more people, at greater expense and at a much faster pace than ever before. An environment of mistrust, a focus on relentless measurement, not treating patients as equals and the rising use of faceless technology risks blurring the shared vision of far worthier goals.

In this “moral era”, Don Berwick, Institute for Healthcare Improvement, suggests we recommit to learning and listening to our patients and each other. At the core of all these relationships is trust. 

Candace Imison of the Nuffield Trust recently discussed how trust across organisational boundaries was key to success and Julian Stodd’s latest blog placed trust at the heart of collaborative and social organisations. 

Patient trust in new technology

The three of us are researching different aspects of US healthcare this year and between us have visited many different hospitals across America, interviewing clinicians, patient advocates, managers, leaders and support staff. A common thread underpinning success in each case was trust.  

“Trust me, I’m a doctor!” Trust is the cornerstone of the patient doctor relationship. This unique and privileged relationship has resulted in doctors being considered as one of the most trusted groups of professionals. 

As health technology becomes more sophisticated and easily available to patients and healthcare professionals, how will it affect this unique relationship and can the element of trust be maintained? 

This is particularly important in light of the recent global ransomware attack which affected several NHS trusts and impacted care delivery. 

Similar attacks have happened in the US disabling electronic records; however, as an upside, attacks are often limited due to standalone systems, making the US less vulnerable.

When using technology to facilitate the patient doctor relationship, trust is vital in order to encourage patients to use and trust the technology.

Trust is an essential prerequisite in engaging patients and consumers. Trust in doctors, lawyers, and others acting on your behalf is known as a “principal agent relationship’’ where there is an asymmetry of information; the expectation is that the agent is acting in your best interest. 

This basic premise is crucial, especially when the consumer is unable to fully evaluate the provider’s competence. Large tech companies such as Google, Amazon and Apple have demonstrated how important this is when gaining market share and have taken great steps to uphold this principle.

When using technology to facilitate the patient doctor relationship, trust is vital in order to encourage patients to use and trust the technology. On the other hand, if the technology fails as we have seen recently, it risks damaging the patient doctor relationship, resulting in loss of trust on the patient’s part and significant reputational risk for the provider.

A chief information officer from a health system spoke about leveraging the trust between a patient and doctor: “Your doctor is the person you trust the most. He or she is the individual that’s going to help you make the right decisions around what to do. So, we leverage the relationship that patients have with their doctor to engage them in their health and using technology.”

A resonating quote from a well known health tech company was: “One of our core values is to honour the trust of patients and the moment we lose that trust is the moment our site will no longer be relevant.”

Bridging organisational silos

Everyone knows how painful transitioning to a new IT system can be and that is as true in America as it is in the UK. One of the common friction points is the forced coming together of clinical leads, hospital finance and contract teams, internal and external IT experts and beleaguered front line clinical staff. 

One hospital I interviewed experienced the same delays and communication issues as other hospitals but they seemed, nonetheless, remarkably happy with the IT implementation. 

Everyone knows how painful transitioning to a new IT system can be and that is as true in America as it is in the UK.

The clinical lead told me: “Although I get frustrated at times with the timing of some of the things that happened around here, I also have a lot of confidence in the missions and the value of our individual silos… Maybe the timeframe could have been expedited, but that’s probably not a limitation of the personnel individually … it’s higher level things that are preventing them from doing their job and I think our team did well. So, I think having lots of trust in your resources at your institution, I think is important.”

Probing the interaction, the IT team explained they had been involved very late in the process which greatly complicated the implementation but that “Well, I just – every time I come up here and these are like the nicest people I’ve ever met… they’re just pleasant, actually something that you want to keep – nice interactions. Yeah, I was thinking it’s just a lack of understanding of the rules in the institution”. 

This was the first time these two teams had worked together but they trusted in their shared mission at the hospital and so forgave each other for the snags. 

Trusting the system for the surgeon

Across the US, Accountable Care Organisations delivering better quality surgical care at lower cost within these new payment models are pursuing an aggressively data driven approach to value – and trust lies at its core. 

Trust in this context can be seen as the confidence that you will be treated fairly, even in situations that you have not even thought of.

A high level of internal transparency and accountability was successful in generating change and improvements only when trust had been established between clinicians, clinical leaders, fellow clinical colleagues across specialties and with the hospital administration. 

The outstanding organisations I visited were committed to a) the timely collection and sensitive feedback of outcomes and cost data to drive genuine improvements and b) cross specialty and cross disciplinary collaboration. 

A high level of internal transparency and accountability was successful in generating change and improvements only when trust had been established between clinicians, clinical leaders, fellow clinical colleagues across specialties and with the hospital administration

Underpinning the effectiveness of both initiatives is trust. One system was moving from internal reporting of hospital and departmental specific outcomes to surgeon specific outcomes. 

This was a slow process, approached from the ground up, from a position of respect, often enabled by close interpersonal relationships, with constant clinical involvement and input. Surgeon leaders trusted that the organisation’s ultimate goal was to deliver the best care for patients and this filtered down through to the front line. 

Primary care physician/ACO leader 1: “Our leadership has been influential and I think they’ve done a lot of work because (the CEO of the ACO) has really been able to embrace the trust of these physicians….And so I think you have seen a lot more collaboration. The surgeons are happy; they’re willing to kind of let (go of) stuff because they trust you. We develop that trust.”

Surgeon 1: “The way we presented this (outcomes data) we are able to really talk about it. So, we get representatives from every campus plus there are open meetings so, I invite everybody to come… they discuss all these topics, nothing is hidden from anybody and as a group, they come and I gotta lead them the best way I can.”

A long game

You can’t demand trust from people but you can create environments that encourage it. Healthcare systems in both the UK and the US will be facing some incredibly difficult challenges over the next few years and beyond – their workforce often feels stressed, overburdened and asked to do the impossible on a daily basis.

You can’t demand trust from people but you can create environments that encourage it

If we can build trust between each other and our management, trust that we are trying to do the best we all can, then not only will it be easier to meet those challenges going forward, but our patients will trust us leading to a better relationship with, and a better experience for, our patients.

Dr Saira Ghafur from The Commonwealth Fund, New York; Alice Murray from Department of Healthcare Policy and Practice, TH Chan School of Public Health, Boston; and Dr Christina Pagel from Brigham and Women’s Hospital and Institute of Healthcare Improvement, Boston