Healthcare won’t work if neither patients nor clinicians trust in the system, and that’s the focus of an initiative by the American Board of Internal Medicine (ABIM).
For the last few year, ABIM has been struggling with attacks on its own credibility, especially concerning the way it administers its maintenance of certification (MOC) program. “Quite frankly, we were mystified,” said Richard Baron, MD, the ABIM’s president and CEO. “The attack came on MOC but it became a more generic attack on the integrity and legitimacy of the organization itself.”
“As we tried to understand how that could have happened, we came to realize that we had lost the trust of our diplomates; we had been distant from them,” he continued. “We didn’t think about the importance of being connected to the community we served.”
A Challenge to Rebuild Trust
So the ABIM foundation — the board’s philanthropic arm — started an initiative aimed at rebuilding trust in the medical profession. “We came to realize that many healthcare organizations were relying on their expertise and thinking that would give them their legitimacy, and that something had changed in the world — it wasn’t just ABIM — in the way people thought about expertise and the way they thought about legitimacy,” said Baron. “We said, ‘You know, if we can help create models for organizations to think explicitly about trust before they wind up losing it, we could help people get ahead of something that could wind up being damaging to healthcare and to patients.”
The ABIM initiative, known as the Trust Practice Challenge, tries to “identify and promote existing practices that have helped build or rebuild trust in various aspects of the health care system.” The challenge gives awards to organizations that have implemented projects to rebuild trust between the organization itself and different constituencies, such as:
- Hospitals/health systems/medical groups administrators
- Commercial insurers/HMOs
The board selected its first round of awardees last May; winners presented their projects at the ABIM’s Foundation Forum.
How much money did the board spend on this project? “I don’t have a precise number on that,” said Baron. However, he added, “we’ve made it the focus of what we do, and we give a large annual conference every year … and for the last 2 years, that’s been focused on building trust and starting to create a vanguard community of other people who care about this and want to work on this.” He added that ABIM is a $70 million foundation “give or take,” and it spends 4.5% to 5% of its endowment — $3 million to $3.5 million — each year, “and pretty much all the work we’re doing now is focused on trust.”
Mayo Clinic’s Leadership Index
One of the challenge winners was the Mayo Clinic’s Leader Index project, overseen by Stephen Swensen, MD, who worked at Mayo for 35 years. “For each of our 242 physician leaders, we wanted to make sure they were the best leaders they could possibly be,” he said in a phone interview. “That makes a huge difference for patients — in outcomes, safety, and costs. We wanted to evaluate incumbent leaders and those in the succession pool.”
“We were looking for good way to evaluate leaders related to how well staff worked and the well-being of staff,” he explained. “We know the well-being of staff has a rock-solid relationship to better patient care.” Mayo started evaluating the 242 leaders on five criteria based on the perceptions of their direct reports, and that worked so well “that we scaled it to all 3,300 front-line leaders, including nurse managers and the people in our journalism, marketing, and press areas.”
Swensen said the five Leader Index behaviors used by effective leaders “are not rocket science:”
- Show appreciation. “I appreciate you; thank you for your work today with patient and this family.” Effective leaders give appreciation and recognition in the form of intrinsic motivators and rewards, said Swensen.
- Communicate transparently. “Does he or she open the books and share everything that’s not confidential, so the team can work together?” Swensen said.
- Welcome everyone’s ideas. Effective leaders say, “‘I am interested in your ideas. What do you think we should do? Let’s figure this out together,'” said Swensen.
- Express interest in employees’ careers. Effective leaders ask, “What do you want to be doing five years from now at Mayo, and how can we help your dream come true?” he said.
- Promote genuine inclusion. “Does the leader of your group or team make sure everybody feels welcome, included and respected regardless of gender, ethnicity, or culture?” Swensen said.
The Leadership Index evaluation is part of an anonymous survey all employees get every fall that asks about Mayo’s culture, quality, leaders, and morale. There are 12 questions on the survey that relate to those five behaviors, and each has a 5-point scale, for a total high score of 60 points, he explained. “For each point upwards on that 60-point scale, there was a 9% improvement in satisfaction, fulfillment, and camaraderie of the staff in that work unit.”
Importance of Trust Among Clinicians
When the survey results came back, Swensen would sit down with the leaders individually to discuss the results. “They were consistently able to improve their behaviors, and their scores went up,” he said, adding that occasionally there were “those that didn’t get it or didn’t care, and we found a different role for them.” Even though Swensen is no longer at Mayo, the Leader Index still continues to be used.
This idea of cultivating trust among a health system’s employees squares with comments Baron and his team heard as they were developing the challenge. “One of the first things we heard in conversations with leaders in healthcare around the country — ‘Boy, if you think there’s a problem with trust between patients and the healthcare system. Yes there is, but one of the first problems we’re seeing is the way in which front-line clinicians — many of whom used to be in independent practice and now may have become employees — how deep the lack of trust they have for the institutions in which they work,'” Baron said. “We heard that a lot.”
The foundation also learned about the importance of having the right messenger. For example, in trying to combat vaccine hesitancy — another indicator of lack of trust in the healthcare system — it’s great to have researchers telling people that vaccines work well, “but having an organized parents’ group from Chicago doing this was a more persuasive strategy,” he said.