As part of our shared work to advance research on trust, AcademyHealth in collaboration with ABIM Foundation developed a series of blog interviews to showcase successful efforts and lessons learned in the effort to build trust and trustworthiness in our health systems.
In our first of three interviews, AcademyHealth’s Vice President of Health Systems Improvement, Elizabeth Cope, Ph.D., M.P.H., speaks with Fred Cerise, M.D., M.P.H., President and Chief Executive Officer of Parkland Health, to discuss their latest approaches to restore trust between communities and clinicians.
Elizabeth Cope: What made you decide to focus on trust as a specific area of focus, given the many competing priorities that health systems face?
Fred Cerise: As Dallas County’s public health care system, Parkland has had a longstanding commitment to health equity. It is our origin story and is recognized in our vision and values today. In a state that still has not expanded Medicaid and has the highest uninsured rate in the country, it is understandable for people to be cynical regarding health care and mistrustful that any health care system is operating in their best interests. About 45 percent of our patients are uninsured and another 25 percent are low income and on Medicaid. Lower income groups have been shown to have less trust in their doctors and hospitals than higher income groups.
Texas has a large immigrant community that has reason to be distrustful given the current divisive political rhetoric and the public charge policies promoted in recent years. The literature is replete with high profile examples of mistreatment of Black individuals by the health system such as the U.S. Public Health Service Untreated Syphilis Study at Tuskegee and the gynecologic surgeries conducted on slaves by Marion Sims. Sixty two percent of our patients are Hispanic or Latino and 24 percent are Black.
Among the competing demands involving access, quality, and finances is an issue that transcends all priorities – trust. Lack of trust will deter patients from seeking appropriate care and is correlated with poorer clinical outcomes. We care for a population that is predisposed to mistrust the health system. The importance was reinforced by findings from our 2022 Community Health Needs Assessment in which focus group participants identified trust as the most important driver of a positive experience between themselves and health care workers.
If we are going to improve the health of the community, it is essential to earn the community’s trust as a foundational starting point.
Elizabeth Cope: How are you focusing on addressing issues of trust within your health system, e.g., related to clinicians, patients, or the broader community?
Fred Cerise: To be successful in improving the health of the population, we must go beyond traditional hospital strategies and operations, and we do that by listening, showing up consistently, and telling stories.
1. Listen.
One example involves our financial assistance program. We have found that a significant number of patients are not eligible for free or low-cost care simply because they have not completed the required application – a group traditionally deemed “noncompliant.” We conducted a series of focus groups to understand why some do not complete applications and are using that information to develop interventions including developing an automated process to draw from existing public data sources to eliminate the application process for many. By reducing barriers to accessing care, we hope that patients will gain trust and engage more readily in accessing necessary care.
2. Show up.
We invest in a community relations team, led by people with deep roots in the community. We push programming and respond to community requests for Parkland to bring health information and screening services to community events on a weekly basis. For example, each year we partner with the local school districts on a large event to provide free comprehensive physical exams to over a thousand high schoolers. This physical exam is required for participation and can be a barrier for children lacking access to a regular provider.
3. Tell stories.
We use storytelling to raise awareness and create learnings that may be replicated. Inspired by the ABIM Foundation’s “Building Trust” initiative, we conducted our own “Building Trust Challenge” in which we received over forty submissions highlighting for others specific practices likely to engender trust.
Elizabeth Cope: What have you learned from your work in focusing on issues of trust that you think would be helpful to share with others working in this area, e.g., related to strategies for assessing or measuring trust, or for addressing or improving trust?
Fred Cerise: We participated in an Institute for Healthcare Improvement (IHI) collaborative sponsored by the ABIM Foundation entitled, “Organizational Trustworthiness in Healthcare Prototyping Network” to test the implementation of a framework that emphasizes acknowledging past breaches of trust; closing present trust gaps; and building systems to strengthen trust for the future. In the many discussions with staff and community members, we recognized that our assumptions of areas of mistrust and actions to address those were often off-target and time and again experienced the value of showing up to listen and commit to follow-up on issues important to the staff and community.
Still, measuring trust continues to be elusive. One approach we have taken is to infer from standardized surveys that many health systems undertake. We have a goal of improving trust as expressed through annual staff engagement survey questions like, “I feel free to raise workforce safety concerns.” We attempt to capture patient trust through our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey general category of "likelihood to recommend."
Perhaps the best way I have found so far to assess and engender trust is by listening and incorporating that input into planning and decision-making over time. For instance, this sentiment came from a community member during a focus group we conducted as part of our Community Health Needs Assessment process: “People need to feel that they can identify with the providers. If I saw a doctor with tattoos, it would make me feel safer.” That is an important message for the 60-year-old hospital administrator who may imagine just the opposite and reflect that conflicting view in the hospital’s dress code.
Another tactic we adopted is the inclusion of a panel of frontline staff at our semiannual leadership planning sessions. These sessions give our senior executives a chance to hear directly from our staff and they invariably provide new insights to inform our decision making.