Author: Building Trust

We discussed trustworthiness in health care and honored the tenure of Richard Baron, MD, MACP, whose stewardship at the American Board of Internal Medicine (ABIM) and the ABIM Foundation has been defined by a deep commitment to fostering trust among patients, clinicians, and health care institutions.

During this special webinar, we explored the impact of initiatives like Building Trust and Choosing Wisely and discussed Dr. Baron’s vision for cultivating trustworthiness at all levels of health care. From his roots in community practice to influential leadership roles, we uncovered the strategies and insights that propelled the ABIM Foundation’s trust-building efforts forward.

While more than 90% of the US population is covered by some form of health insurance, medical debt remains a persistent problem. For families with limited wealth, even a small unexpected medical expense can quickly become financially overwhelming. The evolution of medical debt into a multibillion-dollar industry raises critical questions: When and why did this transformation occur, and how has it impacted the once sacred clinician-patient relationship?

This conversation will transcend the immediate financial strain that medical debt imposes on families, delving into historical perspectives, examining aggressive debt collection tactics, and exploring medical debt’s impact on the erosion of trust within the healthcare system. 

Trust at multiple levels – between patients and clinicians, between those within a system that must collaborate to create high-quality care, and between communities and their health care institutions and systems – is essential for optimal functioning of the health care system. But, over the past 50+ years, this trust has measurably declined.

In response, the ABIM Foundation partnered with the Institute for Healthcare Improvement (IHI) to lead an initiative aimed at understanding and enhancing trust within health care systems. In 2022, this partnership embarked on a journey to develop a theory of change and intervention strategies to bolster trust, and in 2023, six health care systems from across the US piloted these strategies, focusing on acknowledging historical harms, addressing current trust gaps, and implementing systemic improvements.

Margaret Flinter, APRN, PhD, FAAN, FAANP, senior vice president and clinical director of the Moses Weitzman Health System and its Community Health Center, Inc., Nancy Oriol, MD, faculty associate dean for community engagement in medical education at Harvard Medical School, and Harvard Medical School students Tyler LeComer and William Zhuo-Ming Li, spoke about how mobile health clinics, like The Family Van, are addressing the challenge of providing high-quality, accessible health care while also fostering invaluable community engagement.

• Community Health and Patient-Centered Engagement: Mobile health clinics foster trust and deliver tailored care to diverse communities. They adapt to evolving needs and enhance health care accessibility.
• Personalized Care and Community Outreach: Personalized interactions are key in health care delivery. Understanding patients’ backgrounds, languages, and cultures is essential for effective outreach.
• Trust Building and Equitable Health Care: Mobile health clinics bridge gaps between communities and health care systems. Health care professionals must understand and honor community intricacies. Shared responsibility and partnership with community leaders are vital.
• Human-Centric Medicine and AI Integration: Human interaction is irreplaceable in medicine. AI tools must complement, not replace, human empathy and nuance. Continuous dialogue and active listening are essential. seizing opportune moments is crucial for community medical education.

Susan Edgman-Levitan, PA, the executive director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital, and Mike Woodruff, MD, an emergency medicine physician and senior medical advisor for Fidelum Health, discussed strategies to support team member safety and well-being, and offered insights on how to collaboratively enhance the overall quality of patient care and elevate the patient experience.

• Patient-Centered Care and Psychological Safety: Open communication and psychological safety are imperative for improved patient outcomes. Prioritizing patient-centered care and involving clinicians in shaping narratives are essential.
• Leadership, Psychological Safety, and Trust Building: Leadership thrives on psychological safety, emphasizing curiosity, vulnerability, and human factors design. Genuine apologies, deep listening, and co-creation of action plans rebuild trust effectively.
• Trauma-Informed Care: It is crucial to offer trauma-informed care training to all staff and apply social and psychological learnings to elevate care delivery. Additionally, a mindful approach to providing support for health care professionals during challenging events is essential.
• Healthcare’s Emotional, Tech, and Financial Future: The emotional and technological future of health care involves patient-specific data analysis, transparency in health care costs, and empowering patients to ask difficult questions.

Ruth Landé and Noam Levey shared their experiences and insights with Richard Baron, MD regarding medical debt, highlighting the widespread nature of the problem and its effects on individuals and communities.

• Role of hospitals: Hospitals can build trust or destroy it depending on their approach to billing and debt collection.
• Scope of medical debt: Medical debt is widespread and takes various forms, including credit card debt and payment plans.
• Debt collection practices: Outside vendors often collect medical debts, leading to confusion and mistrust.
• Financial assistance: Financial assistance programs should be simplified and standardized to prevent medical debt.
• Insurance and providers: Insurance companies and providers play a role in medical debt and should be held accountable.

They also emphasized the need for policy changes and better communication between health care providers and patients to address this issue.

Additional resources:

• 100 Million People in America Are Saddled With Health Care Debt (KFF Health News)
• Trapped: America’s Crippling Medical Debt Crisis (RIP Medical Debt)
• Debt Collection in American Medicine — A History (NEJM)
• Preventing Medical Debt From Disrupting Health and Financial Health – Recommendations for Hospitals and Health Systems (Financial Health Network)

The COVID-19 pandemic brought unprecedented challenges to the US health care system that created ethical tensions among clinicians, leaders, health care organizations, and the public. Those tensions ultimately resulted in broken trust – a foundation for ethical practice – across the system, and symptoms of moral suffering, burnout, workplace violence, and alarming shortages of health care workers.

This conversation explored the complexities of health care in the aftermath of the pandemic, its effects on communities and the people delivering care, and provided a roadmap for health care leaders to restore a foundation of trust.

Cynda H. Rushton, PHD, MSN, BSN, RN, is the Anne and George L. Bunting Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, and co-chairs the Johns Hopkins Hospital’s Ethics Committee and Consultation Service. A founding member of the Berman Institute, she co-led the first National Nursing Ethics Summit that produced a Blueprint for 21st Century Nursing Ethics. In 2016, she co-led a national collaborative State of the Science Initiative: Transforming Moral Distress into Moral Resilience in Nursing and co-chaired the American Nurses Association professional issues panel that created A Call to Action: Exploring Moral Resilience Toward a Culture of Ethical Practice.

Cynda is the chief synergy strategist for Maryland’s R3 Resilient Nurses Initiative, a statewide initiative to build resilience and ethical practice in nursing students and novice nurses. She is co-creator of the Mindful Ethical Practice and Resilience Academy (MEPRA). She serves on the Nursing Advisory Board for Corporate Counseling Associates. Cynda is a Hastings Center Fellow, Past-Chair of the Hastings Center Fellows Council, and Trustee Emeritus and a Fellow of the American Academy of Nursing. The recipient of many awards, she received the Marguerite Rodgers Kinney Distinguished Career Award and the Distinguished Researcher award from American Association of Critical Care Nurses. She is the editor and author of Moral Resilience: Transforming Moral Suffering in Healthcare and co-creator of the Rushton Moral Resilience Scale (RMRS).

Jessica Perlo, MPH, is the Executive Vice President of the ABIM Foundation, a nonprofit focused on advancing medical professionalism and clinician leadership to improve the health care system. Jessica is an expert in workforce well-being, quality, and safety and teaches and coaches around the globe, building individual and organizational capability for improvement and well-being, and has authored publications on these topics.

From its start in 2014 to its completion in 2020, the 100 Million Healthier Lives (100MLives) global movement fundamentally transformed the way the world thinks and acts about health, well-being, and equity. Grounded in trust, and interconnected in partnership at every level, the initiative explored the relationship between the social determinants of health and well-being and revolutionized how the public health sector works together to scale and sustain equitable outcomes. 

Drawing on the lessons learned from 100MLives, this conversation explores the power of trust in fostering collaborations among different stakeholders and outside of conventional siloes, how to contribute to a positive culture of health, and the ways in which organizations can foster a culture of well-being.   

Somava Saha, MD, MS, is President and CEO of WE in the World, and Executive Lead of the Well Being In the Nation (WIN) Network. Dr. Saha has dedicated her career to improving health, well-being, and equity through the development of thriving people, organizations and communities. She has worked as a primary care internist and pediatrician in the safety net and a global public health practitioner for over 20 years. While difficult, she has witnessed and demonstrated sustainable transformation in human and community flourishing around the world. As Vice President at the Institute for Healthcare Improvement, Dr. Saha founded and led the 100 Million Healthier Lives (100MLives) initiative, which brought together 1850+ partners in 30+ countries reaching more than 500 million people to improve health, wellbeing and equity. She and her team at WE in the World continue to advance and scale the frameworks, tools, and outcomes from this initiative as a core implementation partner in 100MLives.  

Jessica Perlo, MPH is the Executive Vice President of the ABIM Foundation, a nonprofit focused on advancing medical professionalism and clinician leadership to improve the health care system. Jessica is an expert in workforce well-being, quality, and safety and teaches and coaches around the globe, building individual and organizational capability for improvement and well-being, and has authored publications on these topics.

Over the past 50 years, trust in the health care sector has measurably declined, particularly in communities of color. But trust between patients and clinicians, between clinicians and the health care organizations where they work, and between communities and their health care organizations is essential for optimal health.

This conversation explored a blueprint for how health care organizations can build and strengthen trust, including acknowledging historical harms.

Speakers:

• Kedar Mate, MD, is President and Chief Executive Officer at the Institute for Healthcare Improvement (IHI), President of the IHI Lucian Leape Institute, and a member of the faculty at Weill Cornell Medical College. His scholarly work has focused on health system design, health care quality, strategies for achieving large-scale change, and approaches to improving value. Previously Dr. Mate worked at Partners In Health, the World Health Organization, Brigham and Women’s Hospital, and served as IHI’s Chief Innovation and Education Officer. He has published numerous peer-reviewed articles, book chapters, and white papers and has received multiple honors, including serving as a Soros Fellow, Fulbright Specialist, Zetema Panelist, and an Aspen Institute Health Innovators Fellow. Dr. Mate graduated from Brown University with a degree in American History and from Harvard Medical School with a medical degree.
• Dawn Johnson, MSN, RN is CEO and founder of DHJ Services. She has more than 25 years of experience in healthcare with a special focus on vulnerable populations, health policy and public-private partnerships. Johnson’s professional experience includes more than ten years of management consulting with health systems, payers, providers and government agencies on managing care for populations, developing and implementing performance improvement strategies, government relations, and interpreting health policy for market viability, operations and business development. Her background and experience in nursing allows her to apply an understanding that the health and well-being of individuals and populations are deeply rooted in their exposure to and experience in their community and the condition of their environment. Johnson’s fourteen-year federal career spans agencies that includes the Veterans Affairs and the Centers for Medicare & Medicaid Services (CMS).

Most of the existing literature on trust between patients and clinicians focuses on whether patients trust their care team – but what happens when clinicians don’t trust patients? Diminished relationships, less-than-ideal care, and professional burnout are just a few implications of these scenarios. And although there are differential power dynamics, the nature of trust in the patient-clinician relationship is reciprocal. Each version of trust informs the other, and both are necessary for a successful partnership.

This conversation with Rachel Grob, MA, PhD, and Tara Montgomery explored different facets of the patient-clinician relationship and possible approaches to build trust to improve quality and safety of care, patient health outcomes, and the overall patient experience.

Rachel Grob, MA, PhD, directs the Qualitative and Health Experiences Research (Q-HER) lab in the University of Wisconsin’s Department of Family Medicine and Community Health and in association with its Center for Patient Partnerships. She is also Chair Emeritus of the US Health Experiences Research Network, and Chair of DIPEx International. She is a sociologist whose career, both inside and outside academia, has been devoted to involving patients in the discourse, policy processes and institutional arrangements that impact their health care. Rachel has conducted research about patients’ experiences on a wide array of topics, her work has been supported by numerous funders including Robert Wood Johnson, the National Cancer Institute, and AHRQ.

Tara Montgomery is an EMCC-accredited executive coach and founder of Civic Health Partners, an independent consulting practice that works with purpose-driven organizations to develop trustworthy public engagement strategies and leadership practices. Her academic research on the role of trust in the US leadership response to COVID-19 informs her approach to galvanizing more trustworthy systems leaders. Tara previously spent 14 years with Consumer Reports, where she championed patient advocacy and public education campaigns and partnered with the ABIM Foundation on the launch of Choosing Wisely. Tara serves on the Board of Directors of the American Board of Medical Specialties. She is an Executive in Residence at the Saïd Business School at the University of Oxford, where she collaborates with the Skoll Centre for Social Entrepreneurship, facilitates workshops for MBA students on impact leadership, and contributes practitioner insights to graduate and executive programs in healthcare leadership.