Building Trust: Focus on Measuring Change in Health Care Institutions

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership
Health Equity

Patient trust in their physicians, health care staff, and medical institutions they’re affiliated is built — or not — at every point of patient contact with health care systems.

Dr. Andrew Anderson

That reality is at the core of an analysis by researchers Andrew Anderson, a Tulane University health policy and management professor, and Derek Griffith, professor of health management and policy and founding co-director of the Racial Justice Institute at Georgetown University. In “Measuring the Trustworthiness of Health Care Organizations and Systems,” published in The Milbank Quarterly, Anderson and Griffith explore how implicit and systemic bias in health care systems helps perpetuate longstanding skepticism among Blacks and other historically marginalized groups about the quality of care they receive.

Dr. Derek Griffith

In the article, they also offer a conceptual model for trust-building that aims to result in better health outcomes. A fundamental barrier, however, is that strong, empirical, real-time measures that would enable patients to judge the trustworthiness of health providers, and health care organizations to improve, are largely non-existent.

Griffith and Anderson discussed their research and proposed remedies to improve trust in health systems with health journalist Katti Gray. This is an abridged version of their conversation:

What’s the genesis, the real starting point of this research?

Derek Griffith: I came to this research out of frustration. We were hearing people’s concerns about their providers and realized there was an egregious lack of good measures reflecting what’s happening for certain people in the health care system.

Certain measures seem to put the onus and responsibility on the patient to trust clinicians, without looking at whether there are legitimate reasons that patients don’t trust physicians or health care institutions. The framework for measuring trust has largely and wrongly focused on how to get patients, potential patients, their loved ones to trust a system that, too often, isn’t trustworthy rather than asking physicians and health care institutions to demonstrate why their patients should trust them.

Today, at what point of contact with health care is patient trust built or eroded?

Anderson: Immediately. As soon as the patient interacts with the system for the first time. That might even be a website where pictures, aesthetics also convey a message. At the doctor’s office, it could be the person at the front desk. Organizations must make sure they are considering every part of the health care encounter.

How are those seemingly minute, collateral aspects of the medical consumer’s experience and the actual clinical parts of this being cemented as policies aimed at building trust? And, as a result, better health outcomes?

Griffith: The Affordable Care Act (ACA) requires institutions to conduct a community needs assessment. Rather than just documenting demographic and disease patterns, part of that assessment should be a perception of trustworthiness from a community’s point of view.  There could be paid community advisory boards for hospitals and other health systems to not really oversee the needs assessment or work of the health system, but to provide feedback on what the health system is doing and could be doing better.

Sort of like what happens with the oversight, if you will, of an Institutional Review Board, ensuring the ethics, humanity, and do-no-harm medical research on real people?

Griffith: Exactly. What’s important to the community? The community’s safety and confidence in their providers and health system must be part of the framework, the policy.

And this isn’t creating a new structure. The community needs assessment is built in the ACA. The big question is “Who’s overseeing that review and what are they doing with the findings?”

What else is on your wish list of policies and methods that will yield more accurate gauges of patient trust?

Anderson: Right now, we have some measures of patient experiences but it doesn’t really go beyond, for example, annual surveys. We must go beyond annual surveys. There must be a way for institutions to respond and act on what patients say more quickly.

One of the best ways to measure some of this is through real-time feedback systems. You might rate your visit, on different dimensions, on a scale of one to five. Kaiser Permanente and Geisinger do this kind of work. There are health care systems that do consumer surveys during or after a visit. But where many of those surveys fall short is in not having a bi-directional follow-up. Systems are just collecting information, negative or positive, from the patient but not going any further.

What will help create these changes?

Anderson: The research makes far too many comparisons between Black and White people, Hispanics and White people … We’ve got to look at diversity within communities of color. There are Black people who trust health care. We need to understand better what structures are helping to facilitate that.

Our work, in part, is about helping policymakers rethink what kinds of policies generate trust from the patients who, in the past, have trusted them the least.

Additional Policy Priorities for Creating and Measuring Trust

  • Make equity a strategic priority and develop structures and processes to support work to advance health equity as advised in the Institute for Health Care Improvement Health Equity Guide.
  • Develop and require regular use and public reporting of measures that document trust in health systems and organizations along with measures of health care experiences and satisfaction.
  • Provide incentives for providers to develop long-term relationships with patients and health systems to make investments in improving social determinants of health in the communities that they serve.
  • Increase transparency and public literacy around the quality and cost of health care services, the cost-sharing associated with it, and disclosures around adverse events as endorsed by the Agency for Healthcare Research and Quality Communication and Optimal Response (CANDOR) Process.