Increasing Trust in Health Care

ABSTRACT

Trust in American health care and in the people running medical institutions is in decline, which poses a threat to the physician-patient relationship. In response, the ABIM Foundation has established the Building Trust initiative, which includes the Trust Practices Network, advancing research in trust, leadership convening, and various communications vehicles. The Trust Practices Network includes hospitals and health systems, specialty societies, health plans, consumer organizations, employers, and others who are working to reaffirm and strengthen trust as a pillar in their own missions. Participants offer examples of how they have built trust, and their contributions have illuminated 4 dimensions of trust: competency, caring, communication, and comfort. This commentary discusses an exemplary practice for each of these dimensions and describes the “positive deviance” strategy that underlies the Trust Practices Network. It also offers an overview of the other elements of Building Trust, such as a grant program to promote trust as well as diversity, equity, and inclusion in internal medicine education, and an effort to spur additional research on trust.

Am J Manag Care. 2021;27(12):520-522. https://doi.org/10.37765/ajmc.2021.88790

Takeaway Points

This commentary describes the kinds of behaviors that build trust among patients and employees, which the authors group into 4 dimensions:

• competency, in which organizations and their employees provide evidence-based services effectively, reliably, and consistently, delivering on what they promise;
• caring, in which organizations demonstrate compassion, empathy, and concern for their patients’ welfare;
• communication, in which the way that organizations communicate shows respect and an understanding of those they serve; and
• comfort, in which organizations make their constituents feel safe; treat them fairly and equitably, with a particular emphasis on historically marginalized communities; and provide a sense of belonging.

The work of building trust is critical to improving American health care. The patient-physician relationship depends on patients’ trust that physicians have their best interest at heart, especially during times when patients are particularly vulnerable. Similarly, trust between clinicians and the institutions with and for which they work is essential to the efficient working of our health care system.

However, surveys show that many Americans are skeptical of the motives of our health care system and its leaders. Indeed, confidence in the medical system fell from 80% in 1975 to 38% in 2019, and confidence in the people running medical institutions dropped from 61% in 1974 to 37% in 2018.¹

This discrepancy between the centrality of trust to the foundations of health care and the evidence of its erosion prompted the ABIM Foundation to adopt “enhancing trust as a core operating principle” as its strategic focus and to establish the Building Trust initiative, which is focused on increasing organizational trust, addressing medical misinformation, and increasing equity and includes programmatic, research, and communications activities. As part of Building Trust, the ABIM Foundation has created a Trust Practices Network of organizations from across the health care system that includes hospitals and health systems, specialty societies, health plans, consumer organizations, employers, and others, all of which are working to reaffirm and strengthen trust as a pillar in their own missions. Network members contribute examples of how they have built trust, and we are publicizing these practices through our Building Trust website.²

As we have learned through this work, trust is a multidimensional concept. Indeed, the academic literature includes many potential drivers of trust and many useful ways to think about what builds it. The submissions we have received from our network partners affirm 4 dimensions of trust that can be thought of as the “4 Cs,” which we have defined as:

• competency: the practice/organization and the individuals who work within it provide evidence-based services effectively, reliably, and consistently, delivering on what they promise;
• caring: the organization’s efforts demonstrate compassion, empathy, and concern for its patients’ welfare;
• communication: the organization’s communication shows respect and an understanding of those it serves; and
• comfort: the organization makes its constituents feel safe; treats them fairly and equitably, with a particular emphasis on historically marginalized communities; and provides a sense of belonging.

An exemplary submission from each category will further define the scope of these dimensions.

Competency. Through its Refund Promise program, Pennsylvania’s Geisinger Health provides refunds of co-pays, deductibles, and coinsurance payments for unsatisfactory patient experience outcomes. This program demonstrates an ethical commitment to the system’s patients that poor service is unacceptable, reinforced by the system’s acceptance of financial responsibility for failing to deliver satisfactory service. The program’s guiding purpose is to put the patient at the center of their interaction with the system and to demonstrate responsibility for the totality of the experience that patients and families encounter. The Refund Promise makes the system accountable for its hospitality and for consistently and competently delivering services to the community.

Caring. SCAN Health Plan, a nonprofit Medicare Advantage plan in California, operates the Member2Member Program, a telephonic outreach initiative that encourages members to become more physically active and assists members who are experiencing common geriatric conditions such as urinary incontinence, depression, and issues with mobility, balance, or falls. Peer advocates reach out to members with whom they have something in common to build trust, develop relationships, provide education, and share personal experiences. Advocates encourage members to talk with their physicians about their health, and they use motivational interviewing to guide behavioral change. This program emphasizes the importance of caring, empathic relationships to encourage patients to receive the care they need, as well as clear communication. SCAN reports that these peer advocate interventions increased the number of members seeking care for urinary incontinence by 25% in 2018, the last year for which it has formal data.

Communication. Through the Respect for People program at Virginia Mason Medical Center in Washington state, staff receive mandatory training in listening and collaborative behaviors; patient and team member experience efforts; diversity, equity, and inclusion strategy; and process improvement work. The program builds trust by striving for an inclusive, psychologically safe workplace climate in which team members foster respectful behavior during interactions with patients and each other. Virginia Mason believes that enabling team members to communicate freely with one another—by asking for help, discussing problems, and admitting errors—is critical to achieving its goals of being a quality leader and transforming health care. In a survey conducted after the training, 76% of staff reported experiencing improvements in at least 1 “respect behavior” in their teams, and the percentage of staff who reported that staff members treated one another with respect rose from 76% to 84.5%.³

Comfort. Northwestern Medicine seeks to earn the trust of Black patients who need transplant surgery through its African American Transplant Access Program. Each patient meets with a Black physician and a Black social worker throughout the process to explore and address the reasons why they may distrust the health care system. This program builds trust through the racial concordance between physicians and patients, the use of lay language, and removing time constraints on the initial clinical visit with a physician and social worker, which is devoted to exploring and debunking myths and misconceptions about transplantation. These steps demonstrate care and increase patients’ comfort with this potentially lifesaving process. Dinee Simpson, MD, the project leader, reports that there has been a 55% increase in evaluations of Black patients and an 18% increase in the number of Black patients who were included on transplant waiting lists from 2017 to 2019.

The Trust Practices Network illustrates the ABIM Foundation’s theory of change in building trust. We will employ a “positive deviance” strategy that highlights specific examples of how organizations are enhancing trust. We hope to inspire other organizations to focus on trust as an essential organizing principle to guide operations and improvements in health care and to provide ideas for how they can do so.

The Trust Practices Network is just 1 component of our Building Trust work. Other highlights of our trust activities include:

• cosponsoring a grant program to support projects to promote trust as well as diversity, equity, and inclusion in internal medicine training, together with the Alliance for Academic Internal Medicine, the American Board of Internal Medicine, the American College of Physicians, and the Josiah Macy Jr. Foundation;
• increasing the profile of research about trust through a synthesis of peer-reviewed literature on trust at multiple layers in the health care system, and hosting a meeting to discuss the findings and help shape a research strategy that aims to develop and inform best practices; and
• sponsoring opinion surveys to learn more about views held by physicians and the public on trust-related issues.

We also are seeking opportunities to elevate science and address medical misinformation, which interferes with the physician-patient relationship and threatens public health. The importance of this issue is demonstrated by the resistance to COVID-19 vaccination among certain population groups, such as members of Generation Z and political conservatives.^4,5 Indeed, the pandemic has highlighted the skepticism that many Americans feel about the advice of medical experts and the widespread public willingness to place trust in information received from sources who lack expertise, particularly through social media. Developing successful approaches to address this skepticism could be central to achieving herd immunity for COVID-19 and preparing for future health crises.

We are eager to partner with other organizations that would like to work with us to achieve our goal of building trust. In particular, the Trust Practices Network is open to organizations throughout health care that are interested in sharing their experiences in enhancing trust. For more information, please visit our Building Trust website.²

Author Affiliations: ABIM Foundation (DBW, TJL), Philadelphia, PA.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DBW, TJL); analysis and interpretation of data (DBW, TJL); drafting of the manuscript (DBW, TJL); and critical revision of the manuscript for important intellectual content (DBW, TJL).

Address Correspondence to: Timothy J. Lynch, JD, ABIM Foundation, 510 Walnut St, Ste 1700, Philadelphia, PA 19106. Email: tlynch@abim.org.

REFERENCES

1. Baron RJ, Berinsky AJ. Mistrust in science—a threat to the patient-physician relationship. N Engl J Med. 2019;381(2):182-185. doi:10.1056/NEJMms1813043

2. Building Trust: an initiative of the ABIM Foundation. ABIM Foundation. Accessed April 21, 2021. https://buildingtrust.org/

3. Chafetz LA, Forsythe AM, Kirby N, Blackmore CC, Kaplan GS. Building a culture of respect for people. NEJM Catalyst. 2020;1(6). doi:10.1056/CAT.19.1110

4. Ao B. Vaccine hesitancy is increasing among Gen Z. targeted public health messaging can help, experts say. Philadelphia Inquirer. April 19, 2021. Accessed April 21, 2021. https://www.inquirer.com/health/coronavirus/gen-z-tiktok-covid-vaccine-coronavirus-20210419.html

5. Ivory D, Leatherby L, Gebeloff R. Least vaccinated U.S. counties have something in common: Trump voters. New York Times. April 17, 2021. Accessed April 21, 2021. https://www.nytimes.com/interactive/2021/04/17/us/vaccine-hesitancy-politics.html