Tag: Building Trust

Last year, the ABIM Foundation and AcademyHealth announced a collaborative effort focused on rebuilding trust in health care. Part of the Foundation’s Building Trust initiative, the effort aims to advance research about what creates or inhibits trust among various health care stakeholders and which strategies are effective to build and rebuild trust.

The Foundation and AcademyHealth spent much of last year exploring the evidence base for building trust in health care. We first needed to find out where gaps in trust research existed. We led a stakeholder meeting on trust research attended by approximately 70 researchers, clinicians, patients, and funders. Following the meeting we outlined 10 key areas of interest for research on advancing trust at the organizational, clinician, and patient and community levels. We also reviewed recently funded grants to further identify areas of current research. This marked the beginning of our efforts to build a research community.

Now, we hope to coordinate disparate efforts, facilitate learning, and spur new research on building trust in health care by officially establishing such a multidisciplinary community.

The Research Community on Trust will bring together researchers and other stakeholders – clinicians, patients, health system leaders, payers, policymakers, and funders – who are interested in trust and trust-related issues. It will also enable researchers to connect and share with each other, and with other stakeholders who are critical to research development, dissemination and implementation.

If you are interested in learning more about the Research Community on Trust, please email info@buildingtrust.org.

February 15, 2022 | 4PM ET

Dr. Prochaska is an Assistant Professor of Medicine at the University of Chicago. He is a clinical investigator and hospitalist clinician, and is supported by grants from the National Heart, Lung, and Blood Institute (NHLBI) to study how red blood cell transfusion for hospitalized patients with anemia affects their fatigue, activity, and fatigability levels after they have been discharged from the hospital. Dr. Prochaska is also the Associate Director and Co-Investigator of the University of Chicago Hospitalist Project research infrastructure, and involved in the integration of the Chicago Area Patient Centered Outcomes Research Network (CAPriCORN) into clinical research at the University of Chicago. He is Co-Investigator of the University of Chicago Translational Medicine Program (CTMP), and the Cultivating Health & Aging Researchers by Integrating Science, Medicine, & Aging (CHARISMA) Program, both of which train undergraduate students in clinical and translational research. Dr. Prochaska is an Assistant Director of the MacLean center for Clinical and Medical Ethics and a Healthcare Delivery Science and Innovation Scholar, both at the University of Chicago.

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Two weeks before the pandemic shut down New York City, I was in a windowless basement endoscopy center on the east side of Manhattan. It was 12:30 in the afternoon, and I hadn’t eaten or had a drink of water since the night before. I was uncaffeinated, missing a day of work, and wondering if this diagnostic procedure was worth the roughly $1100 it seemed likely to cost me out of pocket, roughly one-third of the median amount that Americans have in their savings accounts. 

The administrator was friendly and efficient, and as she was running my credit card, she asked, “Will your wife be picking you up after the procedure?”

Was it worth the trouble to explain that no, in fact, my husband would be picking me up? Did I really need to come out to someone who I did not know and would probably never see again? I let it go, and figured she’d have the pleasant surprise of meeting him after the procedure.

Half an hour later, as I was getting situated in the pre-op area, a nurse was running through a series of questions:

“When was the last time you ate anything?” she asked.

“Last night at around ten o’clock,” I told her.

“When was the last time you drank anything, including water?” she asked.

“Probably around midnight,” I responded.

“Have you been pushed, shoved, slapped, hit, kicked, choked or otherwise physically hurt by your partner or by someone in your home?” she asked.

I knew why she was asking. I had only recently finished research on screening for social needs in pediatric primary care. Thankfully, the answer was no and that’s what I told her. That screening may be worthwhile if it picks up just one person who needs help. But I wondered how many people would feel comfortable telling a pre-op nurse in an endoscopy center about domestic violence – especially after having to decide whether or not it was worth coming out.  

The anesthesiologist opened the curtain around the bed, and asked if I had any questions for her before she got started.

“Just one question for you,” I asked. “Are you in-network?” 

She was flustered. I knew she would be. Maybe I was even kibitzing a little. But asking doctors about prices has become a bit of a habit for me.

“Um, I’m really not sure…” She was stalling.

Luckily for us both, the gastroenterologist who would be doing the procedure happened to walk by at that moment. “I’m in your network,” she said, “and all the anesthesiologists here bill through me, so she’s in network.” It took the anesthesiologist three tries to get the line into the back of my hand.

As I woke up from the procedure – groggy, hungry and very thirsty – the gastroenterologist launched into a long explanation of what she had found. Mostly nothing, a little something, and maybe it could be this but it’s probably that.

Despite being only half awake, I pressed her to try to understand what she meant. I know from my own research that listening is the top priority when people with Medicaid are asked how doctors can earn their trust – and I bet it’s a top priority for people with employer-sponsored insurance like myself.  Clearly in a rush, she said “I have another procedure – call the office and make an appointment.”

My husband picked me up, and brought a bagel. My Flexible Spending Account thankfully covered the bill. And I found a new gastroenterologist.

David Schleifer is Vice President and Director of Research at Public Agenda. He manages and executes Public Agenda’s research, including projects in health care, K-12 education, higher education and civic participation. Along with the rest of the research team at Public Agenda, David’s work elevates the views and voices of members of the public and other stakeholders through focus groups, surveys, in-depth interviewing and media analysis.  

The ABIM Foundation has launched a Misinformation Challenge Grant program designed to enhance or expand existing practices designed to build trust in the health care system by identifying and countering misinformation in health care and public health. We are seeking to support practices that are focused on improving the quality of communication by providing or ensuring accurate information to the public. This can include practices related to creating accurate content and/or innovative approaches to delivering content more effectively.

We are open to a variety of proposals, and note (1) our particular interest in practices that are tailored to discrete groups/communities, particularly populations made vulnerable by misinformation and (2) that our interest goes beyond practices that are specifically focused on COVID-19, although we are open to such practices.

Selection Process & Funding

An independent panel of judges will select two winners, who will receive 2-year grants of $80,000 (first place) or $30,000 (second place). The first-place winner will have the opportunity to present at the 2022 ABIM Foundation Forum, which brings together leaders from across health care and which will be devoted to the topic of misinformation.

How to Apply

Please submit a proposal by 11:59 pm ET on February 15, 2022 to Tim Lynch, the Foundation’s Senior Director of Programs. For information about proposal formatting, download the RFP (pdf). 

Information Sessions

Foundation staff will host informational webinars on January 11 at 1pm ET and January 19 at 3pm ET. These sessions offer potential applicants the chance to ask any questions they may have. You can access those sessions at https://abim.zoom.us/j/81743769978.

Black Americans attempting to gain access to transplants face significant disparities. These include lower rates of referral to specialty care (nephrology, hepatology); referrals at advanced stages of disease; lower rates of referral for transplant evaluation; lower likelihood to make it through the evaluation process and be listed as a transplant candidate; higher likelihood to be delisted once listed; and lower likelihood to actually receive a transplant.

The African American Transplant Access Program (AATAP) at Northwestern Medicine seeks to earn the trust of Black patients who need transplant surgery. Each patient meets with Dinee Simpson, MD, the project’s leader and Illinois’ first Black female transplant surgeon, and a social worker to explore and address the myths and misconceptions that exacerbate their distrust of the health care system. Following the intake visit, regular check-ins with both Dr. Simpson and the social worker help to answer questions, provide support, and shepherd the patient toward listing and transplantation.

The program was implemented in early 2019; between 2017 and 2019, Northwestern saw a 55 percent increase in evaluations of Black patients, and an 18 percent increase in the number of Black patients listed for transplants.

AATAP builds trust through:

• Provider-patient racial concordance
• Patient-centered communication
• Use of lay language
• Removing time constraints on the visit
• Cultural competency (Knowledge of common vernacular used, food preferences, and religious beliefs)
• Demonstration of care and increased patient comfort with this potentially life-saving process

Learn more about Northwestern Medicine’s AATAP program.

The responses to the coronavirus pandemic of 2020 have many lessons for health equity and the need for health systems to demonstrate a commitment to trustworthy processes and outcomes for people. I would like to dedicate this post to the memory of Dr. Francisco Marty, who embodied the values and behaviors that are needed to achieve equity within health systems.

An infectious disease physician at Brigham and Women’s Hospital, Dr. Marty led the trial for the anti-viral medication Remdesivir at our hospital, which was one of the few options for treatment that existed at the start of the pandemic. Dr. Marty spent hours upon hours working with a multicultural, diverse team to make sure that all hospitalized people had access to accurate information and an opportunity to participate in the trial at our hospital, regardless of their race, ethnicity, age, disability status, or their languages spoken.

After reviewing the data for participation after the conclusion of the trial, we found that Dr. Marty succeeded in enrolling a diverse group of people to receive this important care. Without his commitment to ensuring that trial participants were represented fairly and equally, many may not have had the chance to participate simply because of the color of their skin or their age.

As we reflect on what is needed to build trustworthy health systems, it is important to note that structural changes are needed, including better systems for data collection and addressing social determinants of health. The work of incredible individuals like Dr. Marty also demonstrate that diversity, equity, and inclusion in health systems is deeply impactful and an important strategy for achieving trustworthy care.

Cheryl R. Clark MD, ScD is a hospitalist and health equity researcher at Brigham and Women’s Hospital. Dr. Clark’s research focuses on social determinants of health as contributors to health status and utilization in the U.S..

The organizations will use an evidence-driven approach to identify behaviors and practices that make health care providers and organizations more worthy of trust, with the goal of replication nationwide

PHILADELPHIA and BOSTON, November 22, 2021 – Trust at all levels of the health care system is at historic lows, affecting quality of care and equity among patients and communities. According to a survey released by the ABIM Foundation in May 2021, about one in every eight adults say they have been discriminated against by a US health care facility or office, with Black individuals being twice as likely to experience discrimination in a health care facility compared to white counterparts. That’s why the ABIM Foundation and the Institute for Healthcare Improvement (IHI) are partnering to identify and promote practices, policies, and behaviors for rebuilding trust in US health care systems.

IHI will spearhead an effort to assess the current landscape of trust in health care, including reviewing existing literature and conducting interviews with leaders and clinicians at health systems that have achieved high levels of clinician-patient trust. The findings will enable IHI to develop a clear set of actions health care systems can take to enhance trust between providers and the patients they serve, with a particular focus on strengthening relationships with communities of color.

This theory of change will incorporate and build on the system-level drivers of clinician-patient trust that the ABIM Foundation has identified as part of its work in this area: Competency, caring, compassion, comfort/equity, and cost.

“We launched the Building Trust initiative to elevate the importance of trust as an essential organizing principle to guide operations and improvements in health care, including promoting health equity,” said Richard J. Baron, MD, President and CEO of ABIM and the ABIM Foundation. “We’re well on our way of creating a vanguard community of organizations interested in addressing trust, and now is the time to build on this work and move toward deriving a specific set of trust-enhancing practices that can easily be spread across health care systems.”

“Rebuilding trust is critically important to our efforts to improve health and health care worldwide, and to addressing health equity in particular,” said Kedar Mate, MD, President and CEO of IHI. “Our hope is to build on this work by pilot-testing trust-building practices with a small group of US health care organizations, and eventually scale the effort across the country.”

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About the ABIM Foundation 
The ABIM Foundation’s mission is to advance medical professionalism to improve the health care system by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org, connect on Facebook or follow on Twitter. 

About the Institute for Healthcare Improvement (IHI)
The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization based in Boston, Massachusetts, USA. For 30 years, IHI has used improvement science to advance and sustain better outcomes in health and health systems across the world. IHI brings awareness of safety and quality to millions, catalyzes learning and the systematic improvement of care, develops solutions to previously intractable challenges, and mobilizes health systems, communities, regions, and nations to reduce harm and deaths. IHI collaborates with a growing community to spark bold, inventive ways to improve the health of individuals and populations. IHI generates optimism, harvests fresh ideas, and supports anyone, anywhere who wants to profoundly change health and health care for the better. Learn more at ihi.org.

Media Contacts

ABIM Foundation
Jaime McClennen, 609-703-6909
jmcclennen@abim.org

Institute for Healthcare Improvement
Joanna Clark, CXO Communication, 207-712-1404
joanna@cxocommunication.com

My son K.C., 14, is creative and funny. His room is a riot of color and texture, filled with rainbow pride flags, stickers, collectables, bright stuffed animals, string lights, and superhero posters.

Colorful as he is, sometimes people see in him only one of those colors: brown. He is Hispanic. He has beautiful brown skin, thick brown hair, and chocolate brown eyes. The rest of our family is Caucasian; we adopted K.C. upon his birth to Mexican-American parents.

When K.C. was 7, at a suburban science fair for grade schoolers, K.C. made a beeline for one display, a Rube Goldberg contraption created by two college engineering students. It mesmerized K.C., who stood at the front of the exhibit while six other kids, all white, crowded behind him. The college students hosting the exhibit began engaging the kids, asking questions and offering freebie trinkets.

K.C. had a question, but the exhibitors didn’t respond, even as they answered question after question from kids standing behind him. K.C. wanted a trinket, but exhibitors distributed them to other kids behind him, somehow missing K.C.. Exhibitors posed challenge questions but ignored K.C.’s efforts to answer. My child was quite literally overlooked as the exhibitors peered over his head to engage the white kids.

I don’t believe this was intentional on the part of the student exhibitors. But I was seized with outrage. I made my way to the table and demanded the exhibitors pay attention to my child. They looked at me blankly with eyebrows raised.

When I got home I burst into tears. This really hurt. It was the first time I truly felt the impact of racism from the perspective of a victim—the wincing pain of your child being dismissed and ignored and the frustration of being treated as a crazy lady for pointing it out.

At work the next day, I recounted the story with a colleague I trust, Angela, an African American mother of two kids around the same age as K.C. “Welcome to my world,” she said.

I asked her about that world. She gave an example: a traffic dispute when a white woman called her the N-word.

Angela is misunderstanding me, I thought. What happened to K.C. wasn’t like that. Nobody aimed a racist slur at my child; that would be “real” racism. But my story and hers are both real racism from Angela’s perspective. That’s when I realized that, for Black or brown people, being ignored and being insulted are different in form but identical in function. They are acts that reinforce bias and disdain.  

I asked Angela how she picked physicians for her kids. To begin with, she picked an African American doctor. That doctor was part of a practice with white physicians, and as her kids grew older she had to occasionally to see some of them when her chosen doctor was unavailable. Now, years later, she trusts all the physicians in the practice to see her kids. But it took years.

I asked her what they did to earn to her trust. She recounted that they looked her and her kids in the eye and listened. They didn’t rush through the appointments as if they had something better to do. They got on the phone when Angela called with a concern. They didn’t make her languish pointlessly in the waiting room.

Many clinicians would see these as small things. But the weight of history tells Angela—and K.C.—that small things are big signals of the true level of respect doctors have for their patients. Lapses in the small things trigger memories of mistreatment, invisibility, disdain, and indignity. They are as insulting as a slur.

I’d love to think I’m free of the bias that so enraged me at the science fair. But ever so gently, Angela reminded me of the time I excluded her from meetings on a project she was involved in. I thought it was a small oversight, not in any way racially motivated, yet I overlooked her in the same way those college students overlooked my son. Intentionally or not, I caused her harm, which is not a small thing at all.     

Building an equitable and inclusive delivery system will require the trust of patients who are accustomed to being overlooked and treated as inferior. They may view routine lapses and errors as disrespectful to them on a profoundly personal level. Their trust will be earned only with respect for a different worldview.

Leah heads The Leapfrog Group, a national nonprofit founded in 2000 by employers aiming for giant “leaps” forward in patient safety and quality. She has advocated to put patients first over a 30-year career spanning a rural hospital network, the New York City Mayor’s Office, and the National League for Nursing. She grew up in Maine though she dislikes lobster and winter sports, and she lives in the Washington, DC, area with her husband Sam and two sons.

Senior Investigator Michael Parchman, MD, MPH, of the MacColl Center for Health Care Innovation, part of Kaiser Permanente Washington, is a nationally recognized expert on applying implementation science to primary care. As both a family practitioner and health services researcher, he has more than 25 years of experience as a clinician and medical educator.

Building Trust team: Can you tell me why you think trust is important in improving health care and what interests you in the topic?

Dr. Parchman: This work began several years ago, when the Robert Wood Johnson Foundation approached us about the issue of engaging clinicians and other health care professionals in addressing overuse and promoting high value care. The more we explored this issue, the more we became aware of how trust is woven deeply into the fabric of every aspect of delivering high value care. It came up over and over again, and also came up repeatedly in our opioid work, where we are supporting primary care clinics in redesigning their care systems for patients who are on long-term opioids for chronic pain.

BT: You’re now working on a project that’s focused on medical management for dementia patients in ACOs. Can you tell us more about that project and how trust factors into the work?

Dr. Parchman: We’re currently funded by the IMPACT Collaboratory, which is a National Institute of Aging-funded initiative, to work with ACOs on prescribing potentially inappropriate medications for patients with dementia. This raises clear issues of trust with both patients and their family members or caregivers. For example, they may ask, “Why was I started on this medicine in the first place?” So, there’s a trust in the medical profession issue that arises.

Clinicians may also not trust data that’s presented to them about how often they prescribe these medications. Clinicians may not trust patients to follow through on replacement services that might be safer and sometimes more effective than some of the medications. And then there’s the issue of clinician and patient trust in the evidence behind the potential harm from these medications. Many clinicians say, “I know these studies show there’s potential for harm from these medications but they’re not like my patients.” Finally, as a clinician there’s trust in  your organization to support you in decreasing the use of a service for which the potential for harm is greater than the benefit, and trusting your peers not to prescribe these potentially inappropriate medications.

BT: What do you hope to measure around trust with this project?

Dr. Parchman: We’re training 30 clinicians across two ACOs to become clinician champions. Through a curriculum and a project workbook, we’re going to partner with these clinicians to look at how they implement this work in their own setting and use the data they enter in the project workbook to discover how often issues of trust come up, what kinds of trust issues come up, and how they address them. (Find the workbook and curriculum at Taking Action on Overuse.)

BT: What have you learned about trust from your work on de-prescribing opioids and older adults?

Dr. Parchman: Our work focuses on six building blocks for opiate medication management. When clinics engage with our team, coaches or facilitators help them look at how they are managing opioid medications. Clinics sometimes come to us when they unexpectedly find themselves inheriting patients who have legacy opioid prescription from a retiring provider. When those patients come in for refills, there’s that difficult conversation about why they are on the medication and the potential for harm. Then they ask why they were started on the medication in the first place. It entails having what I call a “sense-making conversation” with patients, and we worked to develop scripts for those conversations. We suggest saying things like, “Well you know we used to think these medications were safe. We now know they are not. There’s new evidence that these medications probably are not as safe as we thought.” So, you blame the medication and don’t blame the retiring provider.

BT: Historically, older patients are reluctant to have these shared decision-making conversations. Do you have any tips on engaging older adults in such conversations?

Dr. Parchman: It usually requires several visits. You have to build a relationship and frequently you find yourself in a position of saying, “OK, let’s not upset the apple cart today. We will give you enough to last you for another month or two. But, I need to see you back, and we need to continue this conversation. In the meantime, I want to give you some materials for you to read and think about and then we can talk about some options for your care.” The number one message is “I am never going to abandon you as a patient. I just want to make sure that you’re safe.”

BT: Can you share any insights from your practice facilitators, who need to convince clinicians to take the time to have those conversations?

Dr. Parchman: To have a conversation with the patient, you don’t have to go into a 20-minute long conversation. The other thing is, not to put it all on the shoulder of the prescriber. We train medical assistants and nurses on how to have these conversations with patients so everybody on the team is on the same page. (Find these tools here.)

BT: Is there any additional advice you’d like to offer?

Dr. Parchman: Be patient. This work takes time.

Last fall, my mother stopped being able to walk independently. She had multiple myeloma, and because she also had Alzheimer’s disease, she had no idea that she could no longer walk on her own. When she tried to stand up, a home health aide would lunge towards her, panicked, trying to prevent her from falling. My mother perceived the aide’s concern as an effort to control her, and it infuriated her. She so much wanted to maintain her independence.

Years before, she had mentioned a file folder with information about the assisted living home where my stepfather spent the end of his life. He had been treated exceptionally well there, and my mother had told me that she kept the information in case she ever needed that level of care. Unfortunately, she now did.

My sister and I quickly moved her to one of the assisted living organization’s small, 8-resident houses. The next morning, before I could even really exhale, I received an email: “Mom had a small fall this morning. No injury! She is doing fine.” Minutes later, the staff person explained by phone that my mother’s fall didn’t constitute a true fall, because an aide was there and broke her fall. When I visited later that day, though, the story had changed. There had been no staff person by my mother’s side.

When I sat with my mother that afternoon, she complained of back pain. The pain had become constant with the myeloma, and it was surely exacerbated by the fall. When I asked for my mother’s pain medication, the response was that they could not give it to her. There was no order for it.

That is when I started to get frustrated. I had brought her Tramadol to the house, and her pain was being managed by the same hospice organization as before the move. The hospice nurse had even visited earlier in the day. My mother had been without pain medication for over 24 hours (for the first time in weeks), and no one had let me know. I had, though, gotten an email asking me to bring over a remote control for her television.

I tried reminding myself that we had moved her in very quickly and maybe the rocky start would ease as she settled in. The problems, though, unfortunately continued.

Several days later, my daughter visited and reported that my mother was struggling to take her medication with water; apparently the staff had not read the form where I had indicated that medications should be given with apple sauce or yogurt. Ten days in, I learned that they had not given her any laxatives despite her not having had a bowel movement.

On a drive home after she had been there almost two weeks, I had a realization that was so obvious that it was embarrassing. For years I had been interviewing people to explore what built their trust in doctors and other health care providers. The assisted living home, I realized, was lacking the exact three attributes that I had found in my research builds patient trust: competence, communication, and caring. The staff had repeatedly made mistakes, they did not communicate with me, and I realized I had seen only one staff person smile or laugh since mother had arrived. As a result, I had no trust in the assisted living home.

Without trust, I needed to move my mother out. I reached out to the assisted living organization’s lead nurse, whom I did trust. We had spoken extensively during my mother’s time there, and she too was disappointed by the care my mother received. I told her that I was going to move my mother to my house. She asked me to please give another of their homes a try. She told me that the mistakes my mother had experienced are not consistent with the culture of the larger organization (which was confirmed by the hospice nurse and by my stepfather’s prior experience). She said she would make sure my mother had a good experience at the new house and would work to improve the culture at the house where my mother currently was. She promised that they would communicate with me so much that I would get sick of hearing from them.

We decided to give a different home a try and, remarkably, they were able to rebuild our trust. When I first visited I sat down with the house manager and explained my mother’s desire for agency. She listened. And she described having worked with many similar residents. Once my mother moved in, I received multiple daily emails with updates and photos, and I did quickly get sick of so much communication. On my visits, there was laughter. One week the house manager told me that my mother, instead of eating her green beans, put them in her water glass. I explained that my mother never really did like vegetables.

The next week, my mother fell into a deep sleep. The house manager told me that green beans had been served again the day before. She said that to humor my mother, she threw a couple green beans onto the floor, and my mother smiled.

My mother never woke up. I will forever be appreciative of the house manager giving my mother a final moment of happiness.

Jessica Greene is a Professor and the Luciano Chair of Health Care Policy at the Marxe School of Public and International Affairs, Baruch College, City University of New York. Her research focuses on patients’ interactions with the health care system, from what builds patient trust in health care institutions to patient awareness of state Medicaid policies. Her mother, Stefanie Greene, died December 16, 2020.