Category: Videos

Patient Advocate Spotlight: Gwen Darien

Posted July 07, 2021

Gwen Darien is a longtime patient advocate who has played leadership roles in some of the country’s preeminent nonprofit organizations. As executive vice president for patient advocacy, engagement and education at the National Patient Advocate Foundation and the Patient Advocate Foundation, Gwen leads programs that link PAF’s direct patient services to NPAF initiatives to help ensure access to equitable, affordable, quality health care.

A three-time cancer survivor, Gwen came into cancer advocacy to change the experiences and outcomes for the patients who came after her and to change the public dialogue about cancer and other life-threatening illnesses.

Gwen serves on a wide range of program committees and workshop faculties. She is the Chair of PCORI’s Patient Engagement Advisory Panel and serves on the Board of Trustees of the USP. Gwen also writes about her experiences as an advocate and cancer survivor.

Public Agenda is building trust with patients

Posted June 21, 2021

During July’s Building Trust webinar Public Agenda shared how they crowdsourced ideas to build trust with patients and what they learned from the exercise.

Patients play a vital role in building trust in health care. Public Agenda and the Patient Advocate Foundation also facilitated a series of discussions with patient and consumer advocacy organizations for Building Trust, which yielded five principles patients and consumers believe will build trust and improve the health care system.

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Conversation Series: COVID-19’s impact on trust

Posted June 15, 2021

Dhruv Khullar, MD, MPP, Weill Cornell Medical College, joined Richard Baron, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation, for our June 15 Building Trust Conversation Series to discuss COVID’s impact on trust in health care.

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Introducing the Building Trust Initiative

Posted May 21, 2021

Poll shows gaps in public’s trust in health care systems and clinicians—and how COVID affected how physicians gauge trust

The ABIM Foundation officially kicked off Building Trust, a dynamic initiative to improve health care by fueling conversation, research and promising practices that help increase trust between patients, physicians and other stakeholders on May 21, 2021.

New polling data from NORC at the University of Chicago provide a look at the current state of trust in health care in the United States. Declining trust affects nearly every facet of society, and health care is no exception. To improve relationships between heath care stakeholders and bolster clinical outcomes, leaders from all parts of the health care system are coming together to consider how to elevate trust and improve care.

Speakers included:
Panel discussion:

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Vaccine hesitancy impacts on state and local vaccine planning

Posted April 23, 2021

Daniel Wolfson, Executive Vice President, COO, American Board of Internal Medicine Foundation had a conversation on how vaccine hesitancy and deliberation impacts state and local vaccine planning with Lisa Letourneau, Maine DHHS. 

During Part 1 of our April 2021 Learning Network Webinar, Dr. Sandra Quinn from Maryland Center for Health Equity, University of Maryland started our by sharing experiences that she believes might help in enhancing influenza and COVID19 vaccine uptake. WATCH >

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Enhancing Influenza and COVID19 caccine uptake

Posted April 23, 2021

Dr. Sandra Quinn from Maryland Center for Health Equity, University of Maryland started our April 2021 Learning Network Webinar by sharing experiences that she believes might help in enhancing influenza and COVID19 vaccine uptake.

During part 2 Daniel Wolfson, Executive Vice President, COO, American Board of Internal Medicine Foundation had a conversation on how vaccine hesitancy and deliberation impacts state and local vaccine planning with Lisa Letourneau, Maine DHHS. WATCH >

In this video Dr.Quinn addresses:

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Tools for building institutional trust

Posted March 18, 2021

Speaker Jennifer Stephens, MPH, from Essential Hospitals discusses the tools needed to build institutional trust.

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The evolving role of Community Health Workers as trusted messengers

Posted February 15, 2021

Denise Octavia Smith, survivor of a rare kidney disease and the founding Executive Director of the National Association of Community Health Workers, hosts the February Learning Network webinar “The Evolving Role of Community Health Workers as Trusted Messengers”.

She also spoke at the 2020 ABIM Foundation Forum about health equity and trust through the lens of a patient during the pandemic.

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Health care leadership

Posted July 10, 2020

The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in health care.

Stephen Swensen and Don Berwick, both physicians and IHI senior fellows, focused on efforts to build trust by better integration of systems.


Transcript

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Steven Swensen and Don Berwick, both physicians and senior fellows focused on efforts to build trust by better integration of systems.
Steve Swensen: Don, I’m Steve Swensen. We’re longtime friends and colleagues. It was good to spend some time with you here.
Don Berwick: Indeed. I’m Don Berwick President of Emeritus and senior fellow at the Institute for Healthcare Improvement. Great to see you.
Steve Swensen: When I think of trust, I think of you and IHI and I’d love to hear your thoughts about the last three decades at IHI. It started with this cool vision and about that much capital and in one city and 30 years later, you’re a global behemoth that you’ve made your power by influence and change and impact and in that probably had a little bit of charisma or maybe a lot of charisma behind it in a beautiful vision, but trust had to play a role with your staff and the partnerships with patients and colleagues and medical centers in every culture on the planet.
Don Berwick: Well, thanks for the question and for the kind comments. You know, I’m really, I feel lucky to have been associated with IHI and it has grown, but it’s always felt to me to be kind of part of a very big community of effort that you’re in, Steve. And it’s never felt to me like one thing that’s grown, but rather a collective effort that’s just, it’s thrived. To the extent that there’s something in IHI’s genetic code around that makes it successful. And I’ve always felt it’s friendship. The origins of IHI, which go back to the mid-1980s, was actually in a group of about seven or eight friends. We independently had discovered the work of the great scholars of improvement, Deming and Duran and others. We were independently interested in healthcare quality and we found each other.
There was a center point that was Paul Batalden who was cofounder of IHI, and Paul convened us, some of us strangers to each other, as a learning circle. And for a period of a few years, we studied together, we learned together, we wind together when we ran into obstacles. Each of us was in place in an organization, but a little bit lonely there. But we all believed it was possible to improve healthcare, and if we learned the right methods. The glue was affection and I think, I think it was the source of trust also. So we weren’t competing with each other. We’re helping each other and that ethos, it’s really stayed through even to today.
Steve Swensen: Yeah. It’s beautiful. And you probably, can you have friendship without trust?
Don Berwick: Very hard to do. No. I guess you can’t. Once trust is betrayed, a relationship severed. But that idea of relationship, which you’ve written so eloquently about, I think, I think it’s core. If we treat what we’re doing as transactional, it doesn’t work. It just doesn’t work. It’s not sustainable, really. It looks sustainable. It looks clever. It looks macho, but it’s not right. And yeah, just knowing we’re going to help each other and can count on each other, that was, that was really key. It’s still there now and now, I think it’s a global community.
Steve Swensen: Yeah. What a great story. So in its core is quality improvement about trust where the leaders in organizations or systems or clinics or groups say you’re doing the real work and we, instead of giving you the answer, we trust you to figure it out.
Don Berwick: Yeah. Yeah, of course. [Indiscernible] [04:02] famous in one of his last interviews, said qualities about love with we try preferably believe so. I think that there’s a technical side of this that actually roots it for me intellectually because improvement of the type we’re invested in is about, it’s about systems, about interdependencies, complex endeavors where what you do affects me and what I do affects you. When we understand that and we’re going to work together to create a better result for the people we’re trying to help. The core asset is cooperation. Tom Nolan, who sadly died this year, my most important mentor, Tom was interested in change concepts, things that actually make a difference. He said the premiere change concept, the real, when at bottom, the one that matters the most is cooperation. So, which means we help each other because we want to get something done for someone else and how it’s not going to happen without trust. Otherwise, I’ll be afraid you’re gonna take something from me in instead of share something with me.
Steve Swensen: It’s fascinating. We were talking about love and Demi talked about joy in work and cooperation and trust as attributes of some of the most successful businesses.
Don Berwick: Yeah.
Steve Swensen: These are lovely, but soft, psychological, sociological terms is not—
Don Berwick: It’s a contest. Do you think it’s naive? Do you think that you’re being a, you’re going to be taken? Because the world’s mean and you know, there’s a lot of bad stuff out there in the world can be mean and there is a lot of bad stuff out there. So it’s, you know, it’s understandable for people to listen to this conversation and say, boy, what are you guys smoking? But I’ll tell you, I’ve been there, done that. And without that form of bonding, I don’t know how you’d get complicated things done in a sustainable way. It’s not through accountability. It’s not through incentive. It’s not through yelling loud enough. It’s not through trickery. So show me something better. And I think your earlier concept at IHI is that manifestly, it works. I’m gonna say, Steve, you added something big to this because you’ve clarified for me more than any other scholar right now, the relationship between what we just are talking about and meaning because I think the why, why should I trust you? What’s the reason? And the answer is because we’re both want to get done with our lives something that matters to us. And if you don’t connect to that, you’re going to lose heart pretty fast.
Steve Swensen: Yeah. And leaders play a central role and have that happen. Whether you’re the founder, president, CEO of IHI, or whether you’re a nurse manager, the relationships you have with the people on your team are fundamental and the behaviors that you have as a leader make a difference in the wellbeing of your staff. And that then translates into better care for patients. You know, Marine taught us that you cannot give what you do not have and if you’re distressed in some way then patients suffer from experience and outcome and higher costs and less safe environments.
Don Berwick: Yeah. You know, ask you a question because I think one verge of vision of leadership is that you get other people to do things that, you know, you’re smart enough and good enough at using the levers that you can kind of make people do stuff so that you align efforts and things like that. But you know, I don’t, I’m not so sure. I think that leadership is much more about releasing people to do what they want to do. Again, that sounds a little naive, but I think—well, Demi used to say all people want us to be proud and joyous in their work, as you said, and the smart leader makes it possible for that. It doesn’t command it.
Steve Swensen: Yeah. It’s a social process to engage colleagues and teams of colleagues to meet challenges together. And the leader behaviors that are fundamental for this are basically are participatory management where it’s not the sage coming in with the answers, it’s he or she humbly listening and inquiring and engaging the team so that everyone collectively configured out together. And then that engages them, and you see higher levels of fulfillment and meaning and purpose because now, you’re a respected and trusted part of the team and then you don’t care about your job description anymore because you come to work because you can’t wait to work with people to get something done.
Don Berwick: Yeah. I once called a friend of mine who had been promoted to a much more senior job and say congratulations in being the boss and he said, you’re never the boss.
Steve Swensen: You’re never the boss.
Don Berwick: And I think that’s take home.
Steve Swensen: Yeah. And if you think you’re the boss, then you failed because then you’re being more impressed with a number of the back, the name of the back of your jersey instead of the name of the front of your jersey. And you’re, you made the title, you made the salary, but you won’t have the results.
Don Berwick: So one of the things I admire so much about your work at Mayo was you were able to take rather area ideas about leadership and converted into a leadership index and really discover some strong relationships quite formally. What spurred you to do that?
Steve Swensen: It’s a decade ago now that we started working on this. I was, that year I was appointed to head up organization and leadership development. And we look, we’ve been serving all 60 some thousands of our staff every year since 1981. And that year when I started in that role, we saw that there was a huge variation among physicians in their levels of satisfaction, fulfillment, and professional burnout. And so we said, well, why is this such a variation?
Don Berwick: And you could measure those things.
Steve Swensen: We could measure those things. So we measured those down to the unit level. We also measured leader behaviors, but we never did anything with them. And then we talked about this among all the chairs one morning, every Wednesday, all the chairs would meet with our CEO. John knows where the time and we all have had a cardiologist, said, well, let’s look for the positive deviance. So what were the departments and growth groups that had the highest levels of fulfillment and satisfaction and the lowest burnout? And then we ended up linking that to the behaviors. It turns out we did a deep dive, 130 different units and found that 47% of the variation was due to the leader behaviors.
Don Berwick: How much variation was there?
Steve Swensen: It was staggering. We had a twofold difference of professional burnout between the highest and lowest areas. And then so on the 60-point scale, the staff would answer questions about their leader. And for every one point up, single point up, there was a 9% higher level of professional fulfillment satisfaction. And for every single point upwards, there was 3.3% lower rates of burnout. So we knew we were, and it was statistically significant. And so we started managing that.
Don Berwick: So what were the elements of the index?
Speaker2: Index are, Don, the behaviors are common sense. They’re not rocket science. They’re just not, they’re just not common practice. Appreciation. Thank you for what you did with the team today for this family. It made a difference. It wasn’t your job description but thank you. I’m interested ideas. I communicate transparently. What do you want to be doing five years from now and how can we help your dream come true? And no, we should invite her. Everybody on the team should be welcome and comfortable and respected. So basically, inclusion and appreciation and transparency, those simple behaviors. If the staff thought their chair live those authentically, they thrived.
Don Berwick: Did you ever worry that you were being too soft, that this stuff is too nice and that there’s an edge to leadership where you have to really, you know, be strong and commanding? Or is it, is this really the heart of it?
Steve Swensen: Well, when we got criticized by a board member when we went with our results and our plan saying this is soft science. And I said, no, it’s not soft science. It’s rigorous science with controlled studies and key values. But it’s about social scientists, about psychology. It’s about sociology and people and behaviors. But it matters. And look what we’ve shown. When we work on those leader behaviors, burnout rates plummeted over a three-year period while the national rate went up nine points.
Don Berwick: Yeah. I remember reading your first quantitative paper on this and the relationship between the variables you talked about and the burnout levels was stunning. I mean, really, really strong correlation.
Steve Swensen: So rigorous science of randomized controlled trials with, you know, common salady in meals. It’s a soft science, but that we’re people—we have, that’s the nature or not.
Don Berwick: So what’s the—explain this common salady concept, which I first learned from you.
Steve Swensen: It is a great word and it means a precious thing for human beings. It’s sharing a meal with someone and it makes a difference in our wellbeing and our ability to take care of patients in a better way. In the randomized controlled trials, you know, one of them we showed our cortisol levels went down.
Don Berwick: Which is a measure of stress.
Steve Swensen: And we measure stress and we saw that demotion, that social isolation went down and emotional exhaustion went down and cynicism about the organization went down all by having professionals and colleagues have a view of someone in a conversation. And that, is that soft science? Well great, bring it on. Because we know that that makes a difference for patients. And that’s so.
Don Berwick: So you said earlier that the science is clear, the results are strong, it makes sense. And yet it’s not, these behaviors are not as widespread as you wish they were. Why not? What’s in the way? It seems so obvious.
Steve Swensen: They aren’t. And I think it’s starting to spread that there are people that are measuring it. So many of our healthcare organizations on their planet have a razor thin margin and there is an inducible rock solid return on investment for patient-centered quality improvement and for working on engagement of professional burnout and joy of work. But it doesn’t show up on the balance sheet tomorrow or next week or next month. It shows up next quarter and next year.
Don Berwick: They’re alongside.
Steve Swensen: You do. And so that’s where, that’s part of the problem.
Don Berwick: You think it’s harder to be nice?
Steve Swensen: You know, I think it’s everybody has more fun and there’s more joy in work, in collegiality if you do that, but it’s not the last generation of what bosses did. You know, you’re not, the reason we pay you is if you’re not supposed to have fun at work.
Don Berwick: Yeah. I remember going to a group suggesting that joy in work become a goal and that group laughed me out of the room. You gotta be kidding. And I, you know, made me sad. You know, you were asking earlier about IHI’s successes. You know, one of the most satisfying eras was the campaigns we ran, the 100,000 Lives campaign, you remember? That was I think 2004 to 2006 or something like that. And it was an amazing experience. We had our board and the staff had looked at our results. We were a little impatient with spread. And so we, and we had some changes that we thought would make a difference in survival in the American hospitals. And so we just called it out. We said, how about, hey, would you like to join? Would like to save, you know, tens of thousands of lives through adopting some changes?
And that one of the lessons I learned through that period that always comes back to me when I read your work, is we had no power. There was nothing that that little organization could have done to order anybody to do anything. We couldn’t pay them. We couldn’t create contingencies. We couldn’t reward them or punish them. All we do is invite them. And that idea of invitation to do something that your heart wants you to do, it was so powerful, Steve. We had 3,100 hospitals. We had, every meeting I remember going to all over the country was like, it was like I don’t know, a festival of commitment to something really important.
Steve Swensen: And you saved countless lives and as important or more important, you engaged thousands and thousands and thousands of healthcare professionals in a long-term passionate need. I remember going home from that meeting with Dave Herman that was just new in the quality leadership to Mayo said, we’re doing this and we’re starting tomorrow, and we can’t wait to get going. And Mayo that, you always make decisions and committees and groups, and we said, we’re not waiting. This is so important. We have to do this right now. And we did. And no one objected. And because it was, because you inspired us, and we trusted you and it made a difference.
Don Berwick: Yeah. I mean, of course, they who saved the lives of watching these hundreds and hundreds of people around the country dig in and try to do this. It was, it was amazing. We released something and I wish we could hold onto that and build on that.
Steve Swensen: With the power of the spirit and passion, it unleashes so much good. And I think that’s, that doesn’t happen unless people trust leaders. And that’s a wonderful case study for now that can work.
Don Berwick: I know we’re almost out of time, but I gotta ask you one question on top of it. Is your experience with the work you’ve done at Mayo on burnout and the leadership index, is this a globally useful, that have you gone to other countries and found the same dynamics at work, or is this pretty much an American model right now?
Steve Swensen: I think the two core improvement efforts which one is a quality improvement, you know, core that the IHI’s white paper. The two core strategies for addressing professional burnout are universal as long as you have human beings working. It’s basically identifying frustrations as a team and then fixing the processes or helping leaders be more humane and sensitive and participative at the end. I think that no matter what the language or culture, it’s that’s universal, like the language of quality improvement.
Don Berwick: And it probably goes way beyond healthcare for sure.
Steve Swensen: It does, yeah.
Don Berwick: So does your use of and teaching about the leadership index itself build trust? And if so, how does it do that?
Steve Swensen: You know, I think it does. So imagine if you had a leader who authentically appreciated you, was genuinely interested in your ideas, opened the books for you to see all of the information, all the data, all the blemishes and warts, had a special interest in your career and worked with you to become better and included everybody, regardless of genome or phenome or creed, how could you not trust someone like that?
Don Berwick: The other thing is it strikes me, maybe, maybe I’m wrong, that the leader who believes your science has to trust the workforce. You’re going to be seeding quite a bit of control or the illusion of control and you better trust them or that’s not going to go well.
Steve Swensen: All right. So if you’re looking at really interested in their ideas, communicating transparently and doing this together, that is a surrogate for I trust you.
Don Berwick: One of my early teachers in the field of improvement was a guy named John Dowd, who was a protege of Dr. Deming’s, and he was, he taught me so much, and I remember one of the things Dowd told me once was, if you’re a leader and you don’t trust your workforce, don’t even start. He viewed it as a precondition for improvement.
Don Berwick: Profound. Don, it’s great to visit.
Steve Swensen: Great to visit. Thanks.
Narrator: Visit buildingtrust.org to learn more.

Serving underserved communities

Posted July 10, 2020

The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in health care.

Kyle Christiason, a physician, and Donald Wesson, a physician and health system chief executive, focused on efforts to build trust by understanding marginalized populations.


Transcript

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Kyle Christiason, a physician and Donald Wesson, a physician and health system chief executive, focused on efforts to build trust by understanding marginalized populations.

Kyle Christiason: Don, I’m Kyle Christiason. I worked with UnityPoint Health in Iowa and Wisconsin and Illinois and I practice medicine there about halftime, but the other half of my work is helping lead the Accountable Care organization and one of the biggest in the country. And we’re proud of being heavy into risk and the idea that we get to collectively own the wellness of a population that we serve.

Don Wesson: So owning the wellness of the population you served. I love that because that’s in our name. So I am Don Wesson. I’m a nephrologist by training and a recovering basic scientist, literally. I’m president of the Baylor Scott and White Health and Wellness Center.

Kyle Christiason: I notice that you had the in the title.

Don Wesson: Yes. And that’s by design because we are trying to design methods of population health for this very low income, predominantly minority community in the southern part of Dallas. We recognized a long time ago that the most expensive patients to manage in our system came from these five zip codes that we serve. And so nine years ago, the organization thought, well, why don’t we try some proactive measures to try to reduce the rate of folks with very expensive to manage chronic disease came into our system. And most of these the patients, in fact, 85% of our patient population is uninsured and recognize that Texas as a state that did not expand Medicaid.

And so in addition to the altruistic mission of our organization, has a very pragmatic role of trying to reduce the proportion of patients from this community coming in to see us with very expensive to manage healthcare needs and address them proactively. And we’ve had some success in doing so but continue to try to refine the models that would allow us to be able to manage a community, which I really find interesting because I was trained as a physician to manage individual patients. But now having to scale up to figure out how a health system can manage the health and wellness of a community.

Kyle Christiason: So that, yeah, it goes from a reactive legacy of health care. We’re here when you need us, come to our big shiny and tower to one that you are reaching out to a community to make some connections and be proactive about their health.

Don Wesson: That’s correct. That’s correct. And in order to do so, we have to learn that community and have to be able to gain their trust. And over the decades, we’ve done plenty to earn their mistrust and now we are having to work in a way that allows us to be able to gain their trust. And as we were discussing earlier, there was a time when our community members could not come into our health system to see if they were turned away from our health system and direct it toward the county system that supports the poor in our area. But now, the law says, thankfully, that we can’t turn them away. And so now , the thought is, well, since we can’t turn them away and they’re very expensive to manage, let’s see how we can proactively manage not just the individuals but manage the community in a way that keeps them healthier, such that there is less of a need for them to come in to use expensive services in our system.

Kyle Christiason: Emergency department, admissions.

Don Wesson: Exactly.

Kyle Christiason: I mean, the high cost is high acuity care, maybe conditions that could have been better managed further upstream and before the illness has progressed or you expand that to a population then before conditions become really heavily prevalent within a population.

Don Wesson: Exactly.

Kyle Christiason: So, was it, it fits with our altruism as physicians. Was it a financial pressure that really helped kind of push the effort to seek how we can get ahead of those conditions or reach out to that population? Tell me how the leap was made because that’s different than many, many health systems around the country.

Don Wesson: Well, and in part it was financials. So I’m a nephrologist by training and what we’ve recognized, not just our health system, but most health systems have recognized that measured per patient. Chronic kidney disease is the most expensive to manage chronic disease there is.

Kyle Christiason: More than oncology? More than some of the things we might think of.

Don Wesson: That’s correct. So if you think about oncology or you think about cardiovascular disease as a disease entity, they are more expensive than chronic kidney disease. But if you measure it per individual, then chronic kidney disease is the most expensive chronic disease to manage. So our system thought, well, if that’s the most expensive disease entity to measure, to manage, then the more of those individuals that come to our system, the more expense that will be for us. And as I said, most of our patients are uninsured.

Kyle Christiason: Yup. So that’s on you.

Don Wesson: So it’s on us to try to manage them proactively because as they come into the system, they are very expensive to manage, and we get little to no revenue for these uninsured individuals. So, in addition to the altruistic proactive route, there certainly wasn’t an economic and financial initiative that was related to this because we were trying to figure out how can we lower expenses. So my conversation with the CFO, the chief financial officer, relates to the expense side of the income state. And he is constantly saying, we’re looking for revenue for the system, and my retort to him is that we’re managing the expense side of the income statement.

Kyle Christiason: yeah. And that really connects because you’re talking about better care, earlier care, better care. So, so that of course is better for the population and for the patients. You focused on chronic kidney disease as your first foray into this because of its great opportunity or…

Don Wesson: Actually no. So my particular focus is chronic kidney disease, but my center got started with a focus on diabetes. So as I said, chronic kidney disease is the most expensive to manage per patient. But when we as a system measure it across a disease entity, overall, it was diabetes and continues to be diabetes. And with all of the additional heart disease, kidney disease, blindness, high blood pressure, all of those things that come from diabetes collectively looking at the whole cadre of patients that we measured, it was diabetes. And so it actually started with a focus on diabetes. And when you recognize that much of the management of diabetes that lends value has to do with nutrition and has to do with physical activity. We don’t use that four-letter word: exercise. When it relates to those two things, those are the things that patients do outside of the doctor’s office. And so we recognize much of what was related to improve diabetes management happen outside of that 15-minute doctor visit. How well they ate. Whether or not they increase their physical activity. All of those things that science shows enhances the management of folks who had diabetes.

But that was not occurring. And since those things were incubating in the community, outside of our control, that influenced them coming in to see us. And so we looked at ways by which we might structure nutrition management, structure physical activity management, outside of the health system. And so that has been the predominant focus of our system, working proactively in the community through what we call trusted agency institutions in the community.

Kyle Christiason: What would be some examples of that?

Don Wesson: Well, we have focused primarily on churches and with the realization that we had a bad history in our trust from the community as I mentioned. However, we figured if we partnered with institutions in the community that already had the trust of the community, then we could leverage their trust for our benefit in terms of the service delivery of the care that we were providing. But also in terms of our research enterprise. Because as I mentioned, we are trying to design effective models of care, and in order to show that this care is both effective and cost effective, we have to have our research enterprise document that. And so in an effort to do that research in the community, we needed the trust of them. I mean, recruiting patients for these long-term studies requires that we have the community’s trust to be able to do that. So I’ve talked a lot about what we’re doing and the struggles that we’ve had and the struggles that we’ve had to overcome. So Kyle, tell me about the challenges that you’ve had and how you’ve gone about addressing them.

Kyle Christiason: Now, one of the things that, that I think resonates with what you describe is the focus. You chose diabetes as a very intentional focus. We were recognizing in in our community, which is Northeast Iowa, relatively rural, we were seeing a significant marginalization of the LGBTQ population. These folks were traveling two hours, three hours, six hours, just to access basic primary care. And so the research that we did was consistent with what the national findings are, which are really appalling, as in addition to the social stigma LGBTQ folks also experience discrimination within healthcare. And it’s along the lines of the perception that physicians are using harsh or abusive language that, that we blame patients for their health conditions. And even up to one in five physicians flat out refusing to care for someone because they identify as transgender.

 

And it was these types of disparities then that lead to all kinds of health complications. So increased risk of depression and anxiety and suicide attempt, utilization of hospital services, similarly delaying basic care until a very high acuity at high cost need was there. So it was these disparities and really legacy of poor experiences that prompted us to explore, see what we could do. And so with the effort of focus groups, trying to understand what would be the ideal scenario, if we could create something from scratch, what would that look like? And that led to the creation one and a half years ago of a dedicated LGBTQ clinic to stage a safer and more welcoming place to access healthcare, primary care. So a lot of the care we do provide is transgender related. But it is a full primary care clinic. Immunizations preventive screenings for cancers along with comorbid conditions.

I think the exciting part of the clinic experience has been very affirming for patients, new for many of them, never having a provider asks them about their pronouns or honor the name that that person would want to use. Just really kind of food and shelter type of things. You know, when that core hierarchy of need is not met, in other words, you in health care not seeing my most authentic self, then you’re not, you’re showing that you don’t care about that part. Well, then that neither should I care about my health. The flip of that then is our patients tell us that when you honor simple things like my pronouns or my name and see me for my authentic self, show me love and compassion as an institution of healthcare, I now flip that equation and that translates to me as I should, I will also show myself love and compassion and care for myself and wellness. So it’s been a fantastic experience for our patients. Another important benefit, although truthfully unforeseen, is for the caregivers themselves.

Don Wesson: That’s was going to ask about. I can imagine.

Kyle Christiason: It’s been amazing.

Don Wesson: The recipients of the care being excited, but I was wanting to ask about what the providers of that care, what their experiences are like.

Kyle Christiason: So it’s kind of our own little contribution to fighting burnout, what we’ve learned is that when we are very intentional about many steps in the clinic process, we begin the clinic with a centering exercise of some sort. We all come in from busy days and we kind of descend on one space where we’re co located with the full team that’s done all of the sensitivity training and bias training. So that’s kind of the core training for this group. But we’re busy. We come together and we’re just, we get our clinic rolling. We center with something like an education or a quote or something that brings us together and we practice this enough that we get right into our groove and we’re ready to go.

Don Wesson: All right.

Kyle Christiason: And then after the clinic has done, we finished with two steps. One is a rapid cycle improvement process. What didn’t go well tonight. We call them pain points, and we not just encouraged, but we expect each team member, from scheduler to the lab tech to the pharmacist to the nurses and physicians, look relentlessly, seek out inefficiencies, moments where there was a near miss and the experience, so to speak. What didn’t go as well as it could have been. And it might be simply how we write down vitals. It might be how we communicate someone’s pronouns to someone else on the team. So again, we’re looking for ways to improve the experience. At the end, we finished with what we call joy bombs.

Don Wesson: Joy, J-O-Y? Joy bombs? Okay.

Kyle Christiason: And it is a moment where everybody can share something that really brought them joy.

Don Wesson: And everybody being who?

Kyle Christiason: Anybody on that team. So this is a full team, robust huddle. Again, from scheduler to a provider.

Don Wesson: Wow..

 

Kyle Christiason: Anybody is encouraged. And so it’ll be moments, it’ll be moments like I remembered it was somebody’s birthday today and I said, happy birthday. And she loved that. To a patient’s sharing with a provider recently that I want you to know because you showed me love and compassion in this setting, I want you to know that I chose to not kill myself. Because of what you’ve done for these last few months for the first time in ten years, I don’t feel suicidal. And it’s those kinds of affirmations that we actually think are just as important as the objective measures of success that we have. Because those moments, again, they really connect our physicians and everyone on the care team. We’re all vulnerable to burnout, but this is how we finish our clinic.

And so at the end of the day, we finished with joy bombs and that’s how the team is going back to their homes, engaged, you know, and refreshed already, instead of this typical or traditional model of working like crazy all day long, tired, a little bit upset and frustrated going home to my family with that mindset. We flipped that. Now, we’re sending everybody back home feeling something that’s really reconnecting them to medicine and their purpose in what they’re doing in a way that they hadn’t been feeling for quite a while.

Don Wesson: It’s interesting, Kyle, that the experiences are similar, and I mean we’re both dealing with an underserved community and each of us had to make a proactive on treaty to that community to try to gain their trust. And so it sounds like you’ve reached out to the community. What have you heard from them that says this is the way by which we would like for you to conduct our care?

Kyle Christiason: It’s been an intentional bi-directional dialogue from the very get go. So with the launch of the clinic, we started with focus groups. What would this clinic look like if you could idealize it? If you could create it from scratch, what would it look like? What would be necessary? And so that continues to inform us. So we seek input from patients every visit. So we have, we created a survey, short survey, only three or four questions and right to the nuance of what we’re trying to get at. More or less, how was your experience and what be done differently next time to make it better?

Don Wesson: Wow.

Kyle Christiason: And so we have a greater than 60% return rate, which is really high by survey’s standards. And yes, we like the numbers and the scores, but it’s the sentences that people write in at the bottom that really influence us and make us change things. So their input continues to be essential. And I think that’s important for all of us. In medicine, we often measure our success by our own industry to find standards. And we’ve often left the center of the whole reason we do this out of the picture. And we focused on our measures, our assumptions.

Don Wesson: You know, I didn’t realize it. Well, certainly, we get individual input, but it reminds me of an interesting story. So we meet with the pastors of these churches. So there’s 31 churches that we partner with now and we meet with them quarterly. In fact, we just met with them last week before I came. And we solicit their input as a group, as to how we can best deliver the care, much of which is being done at their churches. And I can remember, this was a couple of years ago, one of the pastors said, you know, Doc, we love this, these physical activity classes that you do, that Zumba stuff. We like it, but that secular music that you guys use for that, that ain’t working for us. You think that you can do the classes using gospel music? And we said yes because gospel music rocks as well. And so we changed the music format, but the same activity we were doing, we did not change. We just changed the music format to gospel music, and they changed the name of it from Zumba to Praise and Flow. And that’s now our most popular physical activity class that we do within the system. And so I keep reminding myself of that because that’s an opportunity for us to gain input from those that we serve as to how best we can serve them. And had we not been having these quarterly meetings and they felt comfortable enough to offer it.

Kyle Christiason: That’s why I’m curious about. So you made it safe, comfortable, almost an expectation that we want your feedback. What can be better about this? Okay. That’s something that I think we need to continue to think about and keep front of mind is how do we make this, make sure that we are getting the connection there and something that we’re seeking the input of patients and families and the community that we serve.

Don Wesson: Absolutely. And so that’s an ongoing process right now because we recognize that in order to gain the trust, we have to do these proactive measures that we’ve just talked about. But to maintain the trust, we need to have it be a continuous process and not just episodic.

Kyle Christiason: Yeah. Yup. You got to keep showing up.

Don Wesson: Yup.

Kyle Christiason: That sounds like partnership. And again, I’m inspired really by what you describe as nontraditional partnerships in medicine, and you know, that when we, in healthcare, to lead the journey to transformation of that experience and redesign that experience that we do collectively own the wellness of the communities in which we live. And we should be the ones leading that, but we can’t do it alone. And you’re describing partnerships with our community that is just, it’s a wonderful thing.

Don Wesson: Well, and I liked the marginalized community, at least the previously marginalized community, that you have been working with. You’ve also given me some insights as to how we might use some of the techniques that you’ve just described in our community back in Dallas. And so, thank you.

Kyle Christiason Yeah, likewise. It’s been a real pleasure. Terrific. Thank you so much.

Don Wesson: Thank you, Kyle.

Kyle Christiason: Appreciate this conversation.

Don Wesson: Absolutely. Thank you.

Narrator: Visit buildingtrust.org to learn more