Tag: Building Trust
Grief and gratitude
“Covid-19 was initially hailed as the great equalizer…but it arrived in America and immediately became American: classist, capitalist, complacent.” Teju Cole, “We can’t comprehend this much sorrow.” New York Times, May 24, 2020
I have had the opportunity to deeply listen and pay attention to my own and many health care providers’ intense grief over how our health care system has failed people of color. None of this is new; it has merely been intensified and unmasked in the pandemic. To be clear, my experiences come as the result of a lifetime of immense, largely unearned, privilege – professionally, socioeconomically and racially.
I hear this grief because of my role in helping organizations develop and sustain peer support programs. Since the pandemic began, I have provided virtual peer support to dozens of peers. Many of them share their grief and anger over the widespread structural inequities that our society has ignored and sometimes actively perpetuated. They speak about their mistrust of a health care system that has prevented and at times even co-opted us into propping up structures that prevent us from providing the kind of care we entered the profession to provide. They voice anger and mistrust of government and leaders for their lack of transparency and ultimate failure to provide resources that are needed to protect our particularly vulnerable populations.
As with many intense and complicated life challenges, my personal experience of these times holds a paradox: grief and gratitude.
As with many intense and complicated life challenges, my personal experience of these times holds a paradox: grief and gratitude. I feel grief and anger over our failures and the resulting burdens that have been placed on so many marginalized communities. Grief and guilt for all that I did not do and did not see. Gratitude for activists both within and outside of health care who have long been working towards a better way, and to those activists and many more of us who are now redoubling or joining that work. Gratitude for my opportunity to learn and do more. Gratitude for those health care leaders who are now listening and acting on behalf of those marginalized groups. And gratitude for the honesty and intensity of caring I have been privy to hearing in providing emotional support for health care providers, as they share their depth of caring, helplessness and hopefulness.
I have long trusted in the overall integrity and caring of my peers. Trust in government and health care leaders has been significantly damaged and will need to be rebuilt. I feel an awakening of possibility.
Jo Shapiro, MD, FACS is an associate professor of Otolaryngology-Head and Neck Surgery at Harvard Medical School and a consultant for the Massachusetts General Hospital Dept of Anesthesia, Pain and Critical Care. She is Senior Faculty for the Center for Medical Simulation in Boston and was the founding director of the Center for Professionalism and Peer Support at Brigham and Women’s Hospital.
Check-out etiquette
I had been building a therapeutic relationship with a patient over her last three visits. We bonded over being newly married, our mutual excitement about married life and the varying definitions of cleanliness partners could have in a relationship. During this visit, she had been experiencing abdominal discomfort and nausea. A simple test revealed she was pregnant.
The patient looked stunned and began to cry softly. She had previously told me that she and her husband were struggling financially and were not planning to become pregnant for several years. We had discussed contraception at her last visit and she was considering several options. She explained that she had been thinking seriously about contraception and was frustrated that she had not moved forward with an intrauterine device (IUD) prior to becoming pregnant.
As a trainee, I am constantly working on the therapeutic relationship which begins with trust. I learn every day the impact that the small things that I do have on my patients.
Through our previous interactions I had a sense that what she needed after receiving this news was time to process. We initially sat in silence and I held her hand. I then stated that I was here to listen and help support her. I was not there to judge her and would give her all the information to make whatever choice was right for her. At that moment I felt as though our therapeutic relationship, which initially started with a bond over shared lived experiences, had developed into a trusting patient/physician relationship.
She felt comfortable telling me that she wanted to terminate the pregnancy and would like an IUD placed after the procedure. I included the address for Planned Parenthood in her after-visit summary along with a note to my checkout staff to assist in scheduling the IUD placement appointment.
She later told me that when she went to check out, the clerk was adamant that she schedule a follow-up appointment for the IUD placement. This was an uncomfortable question for her and she felt pressured into explaining the need for an initial appointment at Planned Parenthood. She felt embarrassed and upset.
I have reflected on this many times since it occurred. She trusted that I understood the sensitivity of the matter. In my effort to be helpful and efficient, I feel damage was done to our relationship because of the way the checkout process unfolded. I have thought about various ways in which I could have made this experience easier on her, including asking her to contact the clinic when she felt she was ready for contraception or adjusting my communication to my checkout staff to include a note about the sensitive nature of this visit. Fortunately, the patient did come back for follow-up so we have a chance to continue to build our therapeutic relationship.
We all strive to do our best for the patients that we serve. As a trainee, I am constantly working on the therapeutic relationship which begins with trust. I learn every day the impact that the small things that I do have on my patients. I am humbled in this endeavor and hope that the hard lessons are few.
Adetoye is a third-year resident in Family Medicine at Michigan Medicine, the University of Michigan Health System.
Patient Portal: A platform for trust
As a physician, I use the electronic health record (EHR) to educate patients and empower them to make knowledgeable decisions about their care. However, as a daughter of elderly parents with complex medical conditions, the EHR takes on a more personal meaning – it’s my lifeline to their care team, and it enables me to coordinate their health care needs.
There’s a term for those of us in our 30s to 40s who are raising children while caring for elderly parents: the Sandwich Generation. As this generation grows, so does a unique subgroup of “long-distance” caregivers – those of us juggling medical decision making remotely. For me, the EHR and, more specifically, the patient portal allows me to fulfill this critically important role in my parents’ lives – from 2000 miles away.
Via the patient portal, I can order, pay for and arrange home delivery of their medications. I can communicate every six weeks with their geriatric pharmacist about the impact of tweaks in their medication management. I can schedule three-way phone or even video conferences with my dad and his geriatrician.
By developing platforms that are grounded in the patient and family experience, we can make real strides toward improving engagement, trust, and the overall experience of care.
The patient portal enables me to communicate, advocate, and facilitate on behalf of my parents. More importantly, I’m made to feel my engagement on the portal is positive, and that feeling promotes trust – my trust in their care team, the care team’s trust in me as their partner, and also my parents’ trust and confidence knowing we’re all working together.
That being said, technologies such as patient portals and EHRs can be far from perfect. On my parents’ portal, a change to the pharmacy interface left me struggling to refill medications for nearly a half hour, which was worsened by the lack of a tech support option. A search for their annual residential care facility form unhelpfully generated hundreds of unrelated results, and still didn’t provide a way to submit it online to medical records. And then there are small things, such as that I can only know what their physician looks like; the rest of their care team (and my parents) don’t have the ability to upload their headshots. That might seem trivial, but putting a face to the pharmacist I speak to every six weeks would make me feel more connected to the team.
For patient portals to facilitate real meaningful use, they must evolve to meet the needs of patients and their families. Technical support such as a live chat feature, as well as advance notice of layout or functionality changes, can help alleviate user frustration.
Ongoing end-user input from patients and caregivers is critical – both in the form of real-time feedback about the user experience and through dedicated organizational engagement with patient and family advisory council representatives to seek their perspectives on the use of technologies such as EHRs. By developing platforms that are grounded in the patient and family experience, we can make real strides toward improving engagement, trust and the overall experience of care.
Lollita Alkureishi is a board-certified pediatrician with UChicago Medicine and Associate Professor in Academic Pediatrics at the University of Chicago & Clerkship Director at the Pritzker School of Medicine. Her goal is to provide continuity of care and preventive health care services for medically underserved youth. She was among eight winners of the ABIM Foundation’s Trust Practice Challenge in 2019.
Trust as an antidote to the viral spread of medical misinformation
The existence of medical misinformation is palpable for anyone scanning recent news headlines. Journalists and commentators often point to the spread of misinformation as a regular aspect of contemporary life, as we have seen in reporting on the novel coronavirus, which causes COVID-19. Faced with emerging and continued threats to public health and the simultaneous specter of patients being misled by misinformation, some health care professionals are frustrated and wonder what they can do to help.
At Duke University, I recently spent time talking with health care professionals in a workshop for the Duke AHEAD program that I organized with Dr. Jamie Wood, a medical education faculty member at Duke’s School of Medicine. Many participants had stories to tell about patient encounters with misinformation. Participants also were eager to talk about hypothetical scenarios we introduced as prompts to consider how we might optimally talk with patients about misleading information they reference, e.g., regarding an untested treatment for cancer.
We do not have the time or resources to argue against every false claim to which patients are exposed, but we do have opportunities to build and reinforce trust by acknowledging and listening to patients.
In many instances, health care professionals’ first response is to generate a reasonable counterargument regarding misinformation, e.g., “my argument to them would be…” That well-intentioned response to patients, however, misses an important opportunity that could be central to our systemic response to the spread of medical misinformation.
What if our first response to patients who reference clearly problematic claims was to ask: “Why are those claims important to you, and what concerns or questions do you have about your health?” We do not need to validate false claims in order to acknowledge and validate our patients’ interest in well-being. If we can take a deep breath and focus on listening rather than counterarguing, we often can find opportunities to redirect patients to credible sources of information.
At a system level, we also could better monitor patient encounters with misinformation and develop easily accessible information sources that respond to the questions those encounters raise, rather than simply bemoan the falsehoods. We could be systematically tracking patient questions and learning from those questions to craft educational resources for communities. In this way, patient encounters with sensational misinformation could help crystalize their questions and concerns (even if at the same time also offering a frustrating distraction), which means that with the right monitoring and learning tools we could improve patient health education.
We do not have the time or resources to argue against every false claim to which patients are exposed, but we do have opportunities to build and reinforce trust by acknowledging and listening to patients. Such trust could inoculate against future acceptance of medical misinformation by encouraging conversations. From this perspective, patient references to misinformation in the clinic can be a victory of sorts if we consider that the alternative is patient refusal to show up at all or reluctance to mention their concerns in the first place.
Brian Southwell is Senior Director of the Science in the Public Sphere program at RTI International and Adjunct Professor and Duke-RTI Scholar at Duke University. He has written and edited numerous articles and books on misinformation and public understanding of health, including Misinformation and Mass Audiences (University of Texas Press). He also hosts a public radio program called The Measure of Everyday Life for WNCU.
To heal, first build trust
My first job in health care was at the Harvard Square Homeless Shelter. Together with other energetic undergrads, I helped raise money to start a clinic inside the shelter.
I thought the homeless people who came to the clinic would immediately gravitate to us and the services we provided. But they didn’t. In fact, I remember one patient, whom I’ll call “Fred,” regarded the clinic with outright suspicion. For the life of me, I couldn’t figure out what we were doing wrong.
Years later, I came to understand that, though we’d built a great facility, what we’d failed to build was trust. Men and women like Fred had been bounced around from one end of the health system to the other, receiving fragmented care from any number of providers who treated the ailments in front of them and then sent them on their way. These anonymous clinicians failed to build trust with Fred. So he viewed them — and the whole health system — with suspicion.
We can build trust by doing what we say we’ll do, by being responsive, by being transparent, and by being authentic.
I think about this experience a lot these days. We live in a time when the democratization of information is eroding people’s trust — in one another, in expertise, and in institutions. As my experience in the clinic shows, as physicians, we can’t hope to heal people who don’t trust us.
That’s a problem because trust is fundamentally about longitudinal relationships that are developed over time. And yet, in our fragmented, fee-for-service-based health system, patients often see a multitude of clinicians, with whom they spend very little time. At best, this system undermines continuity of care. At worst, it undermines trust.
So it’s incumbent on us to go against the grain and take meaningful steps toward trust-building. We can build trust by doing what we say we’ll do, by being responsive, by being transparent, and by being authentic.
Sometimes the steps are harder. Sometimes the best way to build trust is to work closely with our patients to get to the root causes of their ailments, whether those causes are health-related, behavioral, economic, or social. It’s easy to write a prescription for an illness. It’s harder to talk to a patient about how they came to contract that illness, or why it might be recurring.
In the years since I worked at the homeless clinic, I’ve made it my priority to take the time to listen to my patients, to answer their questions, and to understand how my actions look from their points of view. As clinicians, we may not always have all the answers, but the least we can do is be present and intentional in our efforts to establish and nurture trust.
That’s not always easy. But as I learned from patients like Fred, it is always necessary.
Sachin H. Jain, MD, MBA, FACP is CEO of SCAN Group and Health Plan and Adjunct Professor of Medicine at Stanford University School of Medicine.
Health care leadership
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.
No posts found.
A tribal partnership and “Wacinyapi”
In memory of Mark Herzog
A tribal leader explained to me that the Lakota word wacinyapi, meaning both dependable and accessible, represents a key virtue of both traditional and Western healers. The conversation took place in February this year, after a student from Harvard Medical School, Mark Herzog, passed away. To the tribe, Mark embodied wacinyapi, which was bestowed upon him posthumously as part of an honorific Lakota name. There is no better way to highlight the centrality of trust in health care than through reflecting on wacinyapi and on Mark’s legacy.
In 2012, the Indian Health Service invited a primary care team from our teaching hospital to partner in Rosebud, South Dakota. Rosebud Sioux Tribe leaders described their goals for an academic medicine partnership to involve clinical care from physicians they could trust. This request has a 150-year history: the 1868 Treaty of Fort Laramie guaranteed the tribe “a physician.” This and other treaties furthermore led the U.S. Supreme Court in 1983 to declare a “trust responsibility,” or a moral obligation of the government, to honor the spirit of its treaties with tribes. However, as history shows and recent federal watchdog reports describe, the government has often failed to make good on that trust responsibility.
Wacinyapi also has been translated as “works for the people.” This sense of dependability – that one is engaged in doing the right thing for a community – captures many of the highest aspirations of the medical profession.
Our now eight-year partnership with the tribe has had trust, or wacinyapi, as its foundation. Collaborative efforts include expanding access to care, recruiting high-quality clinicians, and supporting tribal health programs. These efforts ultimately depend on each member of our team embodying wacinyapi, as Mark Herzog did so well. In Mark’s case, he modeled wacinyapi by being a thoughtful listener, demonstrating altruism, travelling multiple times to Rosebud, participating in community-based research, writing a grant with the tribe, assisting with the emergency response after a mass casualty event, and staying engaged whether he was near or far.
Wacinyapi also has been translated as “works for the people.” This sense of dependability – that one is engaged in doing the right thing for a community – captures many of the highest aspirations of the medical profession. Although our profession has lost a role model in Mark Herzog, reflections on his example and on wacinyapi, which will forever be part of his Lakota name, provide opportunities to rededicate ourselves to shaping a better society through our shared work. We remain sincerely grateful to our tribal partners – and to Mark – for all they have taught us about trust and meaning in medicine.
Matt Tobey is the Director of Massachusetts General Hospital’s Rural Medicine Programs and an Assistant Professor of Medicine at Harvard Medical School. He founded and directs partnerships between MGH and both the Rosebud Sioux Tribe and the Indian Health Service. In addition to serving as a primary care and hospital physician in Rosebud, his academic work focuses on addressing health systems gaps in rural, reservation-based communities.
Serving underserved communities
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
No posts found.
Addressing inefficiencies
The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in health care.
Christine Sinsky, a physician and AMA official, and Melinda Ashton, a physician, and chief quality officer, focused on efforts to build trust by eliminating inefficiencies.
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Christine Sinsky, a physician and AMA official and Melinda Ashton, a physician and chief quality officer, focused on efforts to build trust by eliminating inefficiencies.
Christine Sinsky: Well, hi Melinda. I am so thrilled to meet you. I’m Chris Sinsky. I’m a general internist. I also work at the American Medical Association as vice president of Joy in Medicine.
Melinda Ashton: Chris, it’s so nice to meet you. I’ve been looking forward to this. I’m Melinda Ashton. I’m the chief quality officer at Hawaii Pacific Health and also a pediatrician.
Christine Sinsky: Great. Great. Well, I first learned about you in your New England Journal article and the work that you’ve been doing about getting rid of stupid stuff and I wonder if you can tell me a little bit more about what you did and why.
Melinda Ashton: Yeah. It’s a funny story really. I had seen over the years that there were the occasional documentation thing in the chart when I was reviewing a chart where I was pretty sure that whatever was being documented wasn’t actually really accurate to what occurred. And then we bumped into a couple of more worrisome areas where we had clearly allowed to be created in our EHR documentation requirements that just were plain stupid. And so we talked to our—I’m a member of the executive team, we talked to the rest of the executive team and said, maybe we should do something about this. We’ve stumbled on these. I wonder what else is out there. And we decided that we would create this program at our place where we just invited anybody who was, you know, using the EHR in any way to tell us what was just plain stupid. None of that was intentional, of course. We sort of started off by saying stupid is in the eye of the beholder here, you know, what we now are saying is stupid was well intentioned when it was started. And we’ve been really pleased and surprised by the amount of interest and involvement from our staff and outside of our hospital as well. Health system are it.
Christine Sinsky: Well, one of my favorite examples was a nurse had mentioned that she thought it was odd that she was having to document the status of at the umbilical cord in the teenager.
Melinda Ashton: Yes.
Christine Sinsky: And perhaps you can tell me more about that.
Melinda Ashton: Yeah, that was one of the very early nominations as we call them. And we were just beside ourselves. I mean it was hard to believe that we had had this particular documentation requirement in our EHR for patients in the pediatric hospital that we have for at least ten years. And this was the first time that we heard from a nurse that she really would hope that we would take away the need to document that the cord was absent in the patients that she cared for, which were adolescent and oncology patients, almost never newborns. All that was was a simple failure to put in the age restriction that was intended when we built the EHR. And it was just mind boggling that for year after year, patient after patient, a nurse who was actually very strong advocate of her patients hadn’t spoken up for her own behalf to say, please make this go away. And as soon as she did, we made it go away.
Christine Sinsky: But you had a process, right?
Melinda Ashton: Right.
Christine Sinsky: I’ve been through two different EHR implementations, actually three, if you count our hospital implementation, and I and others filled out many forms for suggestions for enhancements or improvements or getting—we didn’t have that term—getting rid of stupid stuff. But after a while, you learned that that was a futile exercise and yet there’s something different in what you did that made it not a futile exercise.
Melinda Ashton: I think that is one of the things that we’ve heard that has made it a bit different than others. Now, we are well past implementation, we implemented our EHR back in the 2004 to 2010 time range. So it’s been a long time. At that time, we had our IT staff got really good at building because they built four separate hospital implementations, each one a bit different. They got very good at that. So over the ensuing time, what happened was, they were really good at responding to requests for improvement. And now, what we found is some of those improvements actually have turned out to be, you know, unintendedly bad. At the same time, the EHR, any EHR is so complex that any implementation, I think, is likely to miss some of these little things. And so we found a few of those. Not as many as perhaps we thought we might, but those are the fun ones. Those are the ones that you just sort of shake your head and say, how could that possibly be true? But those have been there, just some, but many of them have been things that, you know, a group of folks thought was a really good idea to do something. And then, you know, years later, you look at it and you think, oh, that was, that did not work out as intended. That was kind of stupid. It results in a lot of road work by nurses, by therapists, by staff, like just pulls into their time for talking to their patients, relating to one another, doing the work they really should be doing.
Christine Sinsky: You know, we’re here at this conference around trust and I’m thinking about my own experience when I and other physicians did raise examples of things that could be eliminated, could be changed, ways to make the usage faster, quicker, more efficient, and almost feeling as if there was a social cost to be paid for those who raise those objections. And yet I’m understanding what you did as having been a source of building trust among the physicians and among the other clinicians. And I wonder, am I right on that?
Melinda Ashton: Yeah, I think you are. I mean, I can’t tell you how many nice emails I’ve had from people that rarely say nice things. And so I think that, and we’ve heard a little bit of a hey, I said something, and you changed it kind of a building of trust, I guess. In that term, the difference I think is first of all, we had executive sponsorship of this. This was something that our CEO on down really bought into. Our CEO, for example, found one of his own examples of something that was completely stupid that have been going on for years and years that he was willing to go out and talk about.
And so that was helpful. We had a couple of really good examples to start us off. I think that was helpful. And then our partnership with the IT was critical, and we already had an infrastructure. We had work groups that were specialty specific or discipline specific that were ready and in place and doing this kind of work. And they were able to then take those practice requests and actually implement them, actually—well, evaluate them. First of all, we don’t do things just because one person asks for it. We make sure that it’s not going to be another stupid something that we built. And so, but those work groups are really helpful in terms of doing the evaluation and then actually, you know, making sure that the build happens then that it gets done in a timely way and so forth. And we stay in touch with the people that make the recommendation to us as well.
Christine Sinsky: I would think there needs to be a fairly lead deep level of trust between IT and the physician leadership because they’re the ones who are probably going to feel the most judged.
Melinda Ashton: Yes.
Christine Sinsky: Or the most threatened by this. We built it this way, just live with it, or something along those lines. So how did that happen that they were not overly defensive?
Melinda Ashton: That’s actually a really interesting set of thoughts because when we were first known to be working on this, getting rid of stupid stuff, our CIO got a number of emails from friends and colleagues around the country all saying, what are you thinking? And he sort of chuckled and his response, at least internally, he was sort of saying, well I just say back to them, do you have that much stupid stuff that you’re worried about? But the real truth is that we’ve built the IT clinical relationship over years, and they are very much our partners. They really understand that their role is to help us provide really good clinical care. And I think that’s a little different than perhaps in other organizations. Now, I should say that years and years and years ago, when I first started to try to interact with it, I was told by the same CIO that he told every one of his people first answer to any question is no.
Christine Sinsky: Yes.
Melinda Ashton: And then you think about it, we changed that thinking.
Christine Sinsky: I think you’ve really hit on something there. As I was thinking about your initiative, getting rid of stupid stuff and trust, I was thinking about how as a physician, I, early on in my career, absolutely implicitly trusted my leaders to help me take good care of patients. And then the EHR was instituted and it made it really much harder for me to take care of patients in some regards, in other regards, that made it easier. But I felt like there was so much pressure and that trust was broken because I no longer trusted that the leaders were actually there to help me take better care of patients. The message became implement the EHR and don’t complain and stay quiet. And you may have started, that sounds like, with a little bit of that attitude, but that evolved and I’m guessing they’re getting rid of stupid stuff helped that, helped others trust that that had evolved.
Melinda Ashton: I think so. I think being able to go out there and say that we are gonna work on getting rid of stupid stuff, which by itself is a little bit in your face.
Christine Sinsky: Yes.
Melinda Ashton: That was helpful. And that message and actually, the article in the New England Journal of course gave it a bit more credibility as well. But I think all of that plus the fact that we were able to make the changes that were being requested. We really sincerely wanted to know what, what we had created that wasn’t helpful. And I think it is absolutely true that it’s the leadership’s role to set the environment. You know, the individual clinicians can’t change that by themselves. It’s only leadership that can, and leadership can’t do it if they don’t know what’s needed. So we need that partnership there.
Christine Sinsky: I’m curious about the name.
Melinda Ashton: Yes.
Christine Sinsky: I love the name. And I think if you just had a comment box and ask people to put in comments, you probably wouldn’t have gotten as much engagement.
Melinda Ashton: Right, right.
Christine Sinsky: But I’ve also heard a little bit of pushback about stupid.
Melinda Ashton: I agree.
Christine Sinsky: And yet I think if you didn’t have stupid, it wouldn’t have worked. That stupid just resonates with us and know that’s what spending, what’s taking up so much time.
Melinda Ashton: It does. We actually had some serious conversation at the executive team level about whether we were going to call it stupid. And at first, it was, you know, I just, when I was presenting the examples that we don’t covered, I basically throw up my hands and said, this is just plain stupid. And then we talked about we would have a program for administrative simplification, and I think the system goal actually had that terminology in it, but then we looked at each other and we said, no, we need to go out there and tell people this is, we really want to get rid of this stuff that’s totally stupid.
Christine Sinsky: In fact, I think by saying getting rid of stupid stuff, you actually engender trust because you were able to tell it like it was.
Melinda Ashton: Right.
Christine Sinsky: Right. You weren’t sugarcoating it. You weren’t saying it’s optimization. We really weren’t wrong at the beginning, you know, we’re just optimizing. No, we’re saying, you know, there’s a lot of stupid stuff here. To me, that just resonated so clearly.
Melinda Ashton: It was interesting as I went out to present this as a new program to our managers, directors’ meetings, across the system. We have four hospitals, four of those meetings Plus one at the system level. Every time I put the title up and started to talk about it, the room—there was just a ripple of kind of sheepish laughter that went through the room each time. And I had one of the people that reports to me tell me that if I hadn’t been up there standing them telling them that that’s what we were truly thinking about doing, that somehow it wouldn’t have been as trusted, I guess.
Christine Sinsky: I would say there’s a leader who understands something about my life if I heard you speaking that. I want to tell you, I had the chance to visit another organization, another academic medical center or unacademic medical center, and they had just called someone from your department and were reinstated. They were going to replay that initiative or copy that initiative and they were really enthused about it. They had gotten, I believe, 450 suggestions in the first three weeks.
Melinda Ashton: Wow. That’s great.
Christine Sinsky: Yes.
Melinda Ashton: I just love the fact that other people have decided there’s something here that they want to kind of replicate or I’d love to see it just ripple. I think it’s great.
Christine Sinsky: Yes. And I want to thank you because you’re helping us make that ripple. You’re helping us write a toolkit online at the American Medical Association on getting rid of stupid stuff so others can be inspired.
Melinda Ashton: We’re happy to talk to anybody and help anybody do this. I think it’s so exciting that others want to do it.
Christine Sinsky: I think we learn by example, and you’ve just given us a great example.
Melinda Ashton: That’s good.
Christine Sinsky: So I’m really pleased that you’ve made the trek all the way from Hawaii to come and share what you’ve learned with the larger organization, the larger group here at the forum.
Melinda Ashton: And I’m really pleased that I was invited to come in and do that. I’m absolutely excited to be part of this.
Christine Sinsky: Great. Well, thanks. I think you started a movement.
Melinda Ashton: Thank you.
Narrator: Visit buildingtrust.org to learn more.
No posts found.
Transparency in health care
The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in health care.
Chris Queram, a healthcare policy leader, and Beth McGlynn, a healthcare researcher, focused on efforts to build trust through transparency.
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Chris Queram, a healthcare policy leader, and Beth McGlynn healthcare researcher, focused on efforts to build trust through transparency.
Chris Queram: I’m Chris Queram, the president and CEO of the Wisconsin Collaborative for Healthcare Quality.
Beth McGlynn: And I’m Beth McGlynn. I’m the vice president for Kaiser Permanente Research and also the immediate past chair of the board of the American Board of Internal Medicine Foundation.
Chris Queram: It’s a pleasure to be with you.
Beth McGlynn: It’s great to be with you, Chris. I’ve wondered if you could just tell a little bit about how the collaborative, that Wisconsin Collaborative for Healthcare Quality got started, what the motivation was, what brought you together?
Chris Queram: It the story goes back about 20, 20 or maybe even a little bit more than that years. The late 1990s, the early 2000s, there was a lot of restlessness among the business community and many of the stakeholders aligned with the employers’ labor unions, consumer groups, individual employers, business coalitions, who had been pushing for more information for quite some time. And the primary strategy was to go the legislative route and persuade the then governor to sign a bill that mandated physician groups to submit claims data to a state data agency. And about that same time, public file of hospital discharge data was used to develop a hospital report that was catalytic in the sense that I think it really changed the conversation with some of the health systems. And many of those health systems owned a health plan. So they were familiar with performance measurement through HEDIS, the clinical relevance, the pertinent of the specifications. But we’re frustrated with the fact that the HEDIS results were tied to an individual health plan.
And so there was this bringing together of these diverse groups to see if there could be some sort of a balance struck between the urgency that the demand side of the market wanted to bring to this issue and the desire of the provider organizations to measure in a way that would support their efforts to improve. And after a long series of discussions about how to balance those interests, the idea was to form a collaborative in a multi-stakeholder fashion and work together to make measurement meaningful and sustainable.
Beth McGlynn: That’s great. So one of the things I take from what you’re talking about was not a lot of trust going into the development of the collaborative. Can you talk a little bit about how you were able to build trust amongst those multiple stakeholders?
Chris Queram: I give a lot of the credit. The time I was running one of the business coalitions in the state and I give tremendous credit to the physician leaders who had the idea to bring everybody together and see if there was some way to work together. I have to confess, I was skeptical initially given the resistance that we had encountered and the obstacles that had been erected. But at each critical moment when there was a decision to be made, the clinical leaders would stop and ask those of us from the employer and labor union and consumer communities if what we were talking about made sense. Was it relevant to us? Would we use it? And really, took extra effort to reflect our perspectives in the design of the model. And gradually, trust was established through that process. And we’ve thought it was a better way and we gave the benefit of the doubt to the provider organizations and within a year of the sort of the penultimate decision to do this, the first performance measurement was released, and we’ve gone on from there.
Beth McGlynn: That’s pretty fast. So as a result of this transparency and reporting initiative, do you feel like you’ve seen real improvements in quality in Wisconsin?
Chris Queram: We have. Wisconsin consistently ranks very high among the 50 states on meta measures of clinical quality. We know anecdotally, talking with the leaders, both lay leadership, but also clinical leaders from our member organizations, that the measures are valid, they’re reliable, they’re actionable, they are making a difference in how quality is improved within the organizations. Observationally, we’ve begun to track our measures over time and the steady trend is upward, improving almost all of the measures. A good example is three years ago, we debuted a clinical depression screening measure and the initial results were very low. In aggregate, after one year, there was a 6% improvement and in the three years that we’ve been reporting in that measure now, there’s a 20% improvement. And then last but not least, as esteemed health services researcher, you may appreciate we wanted to contribute to the evidence base. And so we, with funding from the Commonwealth Fund, undertook to empirical evaluations of our work. One qualitative, one quantitative. And as a result of that, we’ve sort of taken the old aphorism that what gets measured gets improved, what gets measured and reported publicly improves faster.
Beth McGlynn: So you’ve talked a little bit about the business community and the provider community in this. What’s the level of engagement with the public or do you have a sense of how the public in Wisconsin has responded to the transparency in reporting?
Chris Queram: It’s been a struggle, to be perfectly candid about that. We’ve experimented with different approaches to try to make our measures and the results more accessible to the public. But the best we can tell through Google Analytics and some of the other tools that we have available, the primary users of our website are the provider organizations and the payers who use it for benchmarking and for different payment incentives. We’ve had some success partnering with consumer reports a few years ago. We repurposed some of our data, and as an insert into an issue of consumer reports, we saw a dramatic spike up in visits to our website after that. But that was unfortunately an experiment that was not repeated by consumer reports and we thought, you know, this is great. We’ll just, those organizations that have dedicated readers and dedicated followers who are really into data and into a numbers, that’s exactly the audience we want to reach. But they’ve moved in a different direction since then. And so that’s been our experience.
Beth McGlynn: That’s great.
Chris Queram: I would love to hear from your vantage point at Kaiser Permanente how transparency drives improvement within such a large complex organization?
Beth McGlynn: Well, it’s an interesting question. I think, in many ways, the transparency particularly in terms of public reporting is almost more important for our organization because we sit in a model that’s a largely prepaid model. And I think that there is, there are concerns, perhaps a lack of trust about whether the organization is withholding care. And so I think that the transparency provides a balancing perspective in terms of really looking at are you doing the best for us that you could possibly do. It has definitely driven pretty significant interventions or pretty significant campaigns, particularly, it’s in the area of management of chronic disease. And I was just talking to someone the other day about our journey with hypertension control, you know, heart disease is major reason for premature loss of life, and we have really seen dramatic improvements in our control of blood pressure.
And I think that started by getting these public reports and saying, wow, we really aren’t doing as well as we thought we could, as we think we should. And so really doubling down on what is at stake. And I think it’s important in our organization to note that, you know, it hasn’t been, it’s not easy. I mean, even with a big organization that has resources to bring to bear to help everybody achieve the kind of performance that we would hope to achieve. It took us a good ten years to get to the levels we’re at, which are some of the best in the country.
Chris Queram: That’s right. That’s wonderful. And is there a link with financial incentives or as is the primary use of the information more intrinsically motivated as opposed to the extrinsic motivators?
Beth McGlynn: I would say it’s primarily intrinsic motivation, although interestingly, for a number of quality measures, the executives in our organization have in their variable comp plans performance on quality measures. I’m not out there getting people’s flu shots or making sure their blood pressure is controlled and yet a part of my compensation is tied to how well we do in those areas. So I think it makes it clear that this is a top priority for the organization. The physicians similarly get a relatively small part of their compensation that’s attached to their quality performance. So I think, but I think when I talk to our docs, they are really clear on what they think is important. And I think this, what this has helped with, is to organize the kind of support systems around them that make it easier for them to do the right thing. And that’s kind of one of our mottoes. You talk about some of yours, which is make the right thing easy to do. And that’s really been many of the changes that we’ve been, that we’ve implemented have been kind of with that in that spirit.
Chris Queram: The other question I have is a lot of the focus that we’ve had over the first 15 or 16 years of our work has been clinical quality. We want to broaden beyond that to begin looking at cost, per capita cost and appropriateness of care. Do you have much experience and lessons that we can learn from how your organization has taken on the cost and the appropriateness of care issue?
Beth McGlynn: Well, appropriateness and costs are drivers for us. It’s interesting. The vision of our organization has had the term affordability in it since for… 75 years. We’ve almost been—yeah. So, you know, our mission is to provide high quality, affordable healthcare and that’s been there long before it was as popular as it is today. And actually, our current CEO has affordability as one of his absolute top drivers. And we’ve made commitments as an organization to not only look at the trajectory in the cost of care, to try to keep it at the level of inflation, but over time, to actually try to start making it lower than inflation. And I think the sense with what he says is, you know, if we’re a terrific health plan and nobody can afford us, what does it matter?
Chris Queram: Exactly.
Beth McGlynn: And so this is a huge part of our journey and really taking a look at where are the opportunities are. The nice thing in our system is because of the prepayment and the nature of our integrated system, the incentives between the health plan and the providers are very aligned. When we all do well, you know, we all do well. And so I think that that helps with the conversation. Tell people when I first got to Kaiser Permanente had this very interesting conversation with some of our vascular surgeons who said, you know, we’re seeing patients that we shouldn’t be seeing because they have preventable conditions and we really think we should be investing in some work earlier on. So that these patients never get to us. And I thought, are you really vascular surgeons? I mean, I’ve never had this conversation with a surgeon and. you know, and indeed we have been on the journey that they identified as being important.
And so that kind of is an example of what we’re able to do. And I think there are a lot of lessons to learn. It’s not easy. I mean, I wouldn’t at all pretend that this is easy, but I think it’s… and so we’re looking at a lot of how technology for instance, can be improved the patient experience, making it easier for them to get the care they need and in ways that may be less expensive to deliver. So it’s kind of an everybody wins type situation. So I think it’s opening people to think about a lot of different innovative approaches to healthcare delivery.
Chris Queram: Very nice.
Beth McGlynn: So as you think about the journey ahead for the collaborative, what do you think are the most critical issues you’re taking on? And talk a little bit about the role of trust in continuing to be able to execute on your vision and mission.
Chris Queram: Well, one other element of trust that I didn’t mention is when we were back in those conversations about doing something together to balance that urgency with a desire to be sustainable in this work. There was another commitment made by the health systems to not use the measures that would be developed and reported publicly for competitive advantage instead to use them to support the development of learning collaboratives with the goal of improving care across the state. And I think that sometimes gets referred to as sort of upper Midwest nice. Everybody likes to be nice to one another, say good morning and say goodbye when you’re leaving and work together. But one of our physician leaders put it this way. He said when he was in medical school, it was always his understanding, the way he was taught is that if he found a better way or an effective way to manage a particular condition or procedure, he had a professional obligation to share that with his colleagues.
And there is, I think this belief that best practices are should be shared. It’s the execution and the implementation of them that’s going to be a differentiator as opposed to hoarding that and keeping that. And one of the things that I’ve observed over the last 15 or more years is the environment has changed fairly significantly. And I think a lot of those values still hold. But I think sometimes the tendency is for leadership to focus internally as opposed to what they can do as part of a larger ecosystem. And so I think that’s one of our both challenges and opportunities going forward.
Beth McGlynn: It strikes me in this situation that maybe it doesn’t matter so much if patients are going to the website if they can trust that all of the rest of the system is working on delivering the best possible care to them. So to me, it could be a sign of faith, not just a centrist.
Chris Queram: Absolutely. Well, thank you for the opportunity to visit.
Beth McGlynn: Thanks.
Narrator: Visit buildingtrust.org to learn more.
No posts found.