There are concrete steps you can take to ensure your quality improvement efforts are successful.
“The number one problem in poor hospital-physician alignment is the physicians’ lack of trust in administration.” — Quint Studer, former health care consultant and hospital CEO
Today’s health care literature is replete with articles stressing the importance of engaging physicians, aligning incentives and integrating initiatives. Indeed, the rapidly changing environment has clearly indicated that the past “you do your thing and I’ll do mine” relationships between physicians and health care organizations (HCOs) will no longer be sufficient.
The current transition from volume to value will require much stronger and more genuine alliances than have been the case in the past and, not too surprisingly, all kinds of relationship-building activities are now taking place with a wide range of differing approaches.1
Perhaps because individual situations are, in themselves, so unique, there has yet to emerge much in the way of a best practice for accomplishing this now-widely pursued objective. In the absence of established guidelines, many of the relationship-building processes have not been well-managed, nor have their outcomes always met intended expectations. Failed attempts have unfortunately become commonplace.2
The health care industry seems to have its problems with a consistent use of such common yet equally important terms as alignment, engagement and integration. All three are often used interchangeably throughout academic and professional literature, with considerable variations in what they represent or mean.
Although it takes great deal of time and effort to strengthen the bonds of trust, it can take only a few seconds to unravel them.
In one consulting engagement, the president of a major firm asked 35 physicians and administrators what the term “alignment” meant to them, receiving no less than 17 different interpretations.3
Compounding the problem of definitions has been an absence of agreement around just how the terms should be sequenced. Does alignment precede engagement, or vice versa? How are the terms interpreted by the various key stakeholders, and can such potential ambiguity run the risk of serious miscommunications when it comes to actualizing what was a presumably agreed-upon corporate strategy? How can there be reasonable assurance that everyone is on the same page?
Current use of these terms seems to depend more on the subjective interpretations of authors and consultants than on any established procedures or uniform definitions. Authoritative research in this area is still far from adequate, and an unfortunate consequence is that, given the rapid pace of change, HCO leaders find themselves in the uncomfortable position of having to take quick action in attempting to establish effective relationship management programs or similar partnership initiatives, without having much in the way of standardized nomenclature or research-tested guidelines.
“Leadership without mutual trust is a contradiction in terms.” — Warren Bennis, leadership expert, professor and author
Trust Is Essential
Faced with the absence of established guidelines, a comprehensive literature review is one of the few practical options at hand for obtaining useful insights from credible sources. In one such review presented here, several major themes seem to be consistently present:
- Closer HCO-physician relationships will be essential for future success.
- Such relationships take time and are not easily achieved.
- Mutual trust is the key precondition for success.
- Each relationship-building situation is unique.
- Deliberate ongoing care, attention and commitment is required.
Given these observations, one rational approach involves viewing the relationship-building process as part of an iterative continuum, along which each element is treated as a necessary precondition for the one that follows.
The more complete each element is, the more favorable is the likelihood of achieving the next step. Less-than-adequate completion of an element, or skipping one entirely, markedly reduces the chances for a successful outcome.
The model, along with its associated definitions, looks like this:
TRUST → MOTIVATION → ENGAGEMENT → ALIGNMENT → INTEGRATION
Trust: Firm belief and confidence in the reliability, integrity and ability of another.
Motivate: To provide a compelling reason to act in a particular way.
Engage: To attract and maintain focused interests and commitments.
Align: To arrange separate elements in such a way that their positions are compatible.
Integrate: To combine separate elements in such a way that they become a whole.
The important thing to note here is that the first and most essential element is trust — irrespective of how the others eventually end up being defined or sequenced.
According to most experts in this area, trust is the foundational bedrock upon which everything else is built. It’s the sine qua non of creating genuine HCO-physician relationships, ones that will be durable enough to withstand the difficult challenges ahead. If this element is weak, it is all but certain that most of what follows will have neither the necessary substance nor sufficient staying power.
What you’re more likely to end up with is a deceptively appealing “sandcastle” relationship, at best, or simply an untenable nonstarter situation, at worst. Yet despite numerous cautions from a host of experienced sources, time and time again serious attempts are made at strengthening HCO-physician relationships without first having developed a rock-solid foundation of mutual trust.
“You cannot be an effective leader without trust.” — Stephen Covey, businessman, author and educator
Build a Foundation
The need for developing trustful relationships among key players in an organization encompasses much more than simply having a pleasant working environment. There is also a fundamental business aspect.
Covey, the late author of The 7 Habits of Highly Effective People, referred to trust as a “soft” relationship factor — one that is intangible, ethereal and unquantifiable. At the same time, he stressed that “it is trust that makes the world go ’round, and that right now we are in a crisis of trust.”
He concluded that “significant distrust doubles the cost of doing business and triples the time it takes to get things done.” He further noted an extensive Watson Wyatt study that showed that high-trust companies outperformed low- trust companies by nearly 300 percent.
According to Covey, “The ability to establish, grow, extend, and (where needed) restore trust among stakeholders is the critical competency of leadership needed today. It is needed more than any other competency. Engendering trust is, in fact, a competency that can be learned, applied and understood. It is something you can get good at, something you can measure and improve, something for which you can move the needle.” 4
Despite much cautionary advice from experienced leaders about taking the time to do the necessary interpersonal groundwork before attempts at alignment and integration, insufficient attention is often the norm.
Massachusetts Institute of Technology lecturer Jim Dougherty is another of the many senior executives who has observed the frequent disconnect between recognizing the importance of building trust and lacking the follow-through to actually make it happen.
“In leading various companies over the years, one of the most valuable lessons I’ve learned is that establishing trust is the top priority. Whether you are taking over a small department, an entire division, a company or even a Boy Scout troop, the first thing you must get is the trust of the members of that entity. When asked, most leaders will agree to this notion, but few do anything to act on it.”4
“Trust is the core quality — the cornerstone, if you will — of any collaborative partnership.” — Jeanette Comment
It’s a common mistake to think of trust in binary terms, i.e., either it’s there or it isn’t. Like most psychosocial phenomena, trust includes a complicated array of interacting, individualized constructs that, as of yet, are not fully understood.
What is known, however, is that there are varying degrees of trust, that some individuals are more receptive to trust than others and that there are various levels of trust. Degrees of trust can run from extreme distrust all the way to implicit or complete trust. It can be built upon over time through continual acts of reinforcement, each of which requires demonstrated evidence, as well as some form of personal acknowledgement.
Depending on such things as personal characteristics, prior trusting experiences, and how high the stakes and risk of breaching trust are in a given situation, individuals can vary widely in their willingness to participate in trust-building relationships.
In terms of levels of trust, individual-to-individual (I do/don’t trust Dr. Jones/Mr. Smith) is the most up close and personal. Individual-to-group (I do/don’t trust those surgeons/administrators) tends to be the most pervasive, and possibly symptomatic of “group think” or stereotyping. Individual-to-organization (I do/don’t trust the medical staff/management) can be an even more widespread and divisive generalization.5
The latter two tend to be the most common because they are the farthest removed from personalization and emotionally “safer” because they involve the least chance of potential individual-to-individual confrontation.
It should also be noted that although there are subtle differences between the terms distrust (based on prior experience with a party in question) and mistrust (a general feeling of unease, but without prior experience), most individuals fail to make the distinction and might well use the wrong term or use the terms interchangeably, either of which can run the risk of being misinterpreted.
Another way of looking at trust is to distinguish between the personal and the impersonal perspectives. The former has more to do with adherence to ethical values and is concerned with whether another individual will do the right thing,” while the latter has more to do with a person having an acceptable level of competence and focuses more on whether the individual will “do the thing right.” One is based on integrity, the other on competence.
In building trusting relationships between physicians and managers, both elements need to be present. Physicians need to have confidence that there will be a culture of “organizational justice” and that the managers are indeed competent at what they do.
By the same token, managers need assurance that the physicians they are dealing with are ethical and professionally competent. Anything short of this likely will become a barrier in terms of achieving a genuine trusting relationship.
“Trustworthiness is the most noble and powerful of all the attributes of leadership.” — John Hamm, investor, CEO and leadership expert
Why Trust Is Lost
Most physicians are highly action-oriented. They have been trained and practice in a world where time is of the essence. In a matter of a 15-minute office visit, they focus in on a particular problem, make an assessment and render a decision.
By the very nature of what they do, they are faced with expectations of being expedient, results-oriented and unilaterally responsible. This they do up to 20 times a day — day in and day out.
Managers on the other hand are typically dealing simultaneously with a host of much more general problems. Of practical necessity, their attention has to move back and forth from one operational issue to another, most of which go on to further discussions at one or more multidisciplinary meetings in which yet additional input takes place — all of which can take days, weeks and sometimes months. Given these marked differences in how problems are routinely addressed, it’s not too surprising that time frame expectations often turn out to be one of the major bones of contention.
Physicians also see themselves as being immediately responsible for the care of their patients, whereas managers typically see themselves as being responsible for the most efficient use of hospital resources.
Although the two perspectives are not mutually exclusive, problems are too often viewed through decidedly different lenses, neither of which presents a complete picture.
- “Physicians and managers have different socialization, training, value orientation and expectations resulting in important gaps in beliefs and attitudes. These factors have led to serious problems of physician distrust, skepticism and disengagement.”6
- “In brief, managers and physicians represent different ‘tribes,’ each with its language, values, culture, thought patterns and rules of the game.”7
Health care consultant Joseph Bujak, MD, further describes executives as speaking the language of business, framing all issues from that perspective and applying business metrics to define success while physicians speak the language of medicine, view things through a clinical lens and apply clinical metrics.
“Each of these groups can evaluate the same data set, and using different perspectives, metrics and languages come to diametrically opposed conclusions. To each the conclusion is imminently clear. That the other disagrees must mean that the other either doesn’t or chooses not to get it. In either case, each group assumes that the other cannot be trusted.”8
Leadership expert Philip Betbeze suggests that the differences can engender suspicions and operational dysfunctions as well: “Physician relationships with executive leadership have always been important at hospitals and health systems, but there has been a history of distrust on both sides, to put it mildly.
Executives often view physicians as a huge impediment to many important initiatives within the hospital, from cost-cutting to process reengineering. Meanwhile, physicians habitually distrust senior executives who are looking out for what’s best for the hospital or health system — or maybe just the bottom line and the executives’ own bonuses — but not the physicians and not even necessarily patients, in the worst case.”9
“Among all the attributes of great leaders, one stands above the rest: They are all highly trusted.” — David Horsager, CEO of Trust Edge Leadership Institute
Trust is not a frequent topic of conversation between physicians and managers, perhaps because of the highly charged nature of its violation consequences. When trust is fractured, words such as betrayed, backstabbed and double-crossed typically come to mind with serious implications for possibly irreparable damage.
The most serious implications are ones involving breaches in integrity that tend to arouse deeper feelings of resentment, along with more permanent relationship scars. So it’s not that unusual for parties to avoid putting the issue of trust squarely on the table as a topic for candid discussion.
Instead, the focus tends to be more on the psychologically safer, less personal elements such as financial incentives, shared resources or more general agreements about a common purpose. Although all of these are important, they either ignore or mistakenly take for granted the glue that will be needed to bind together what have been traditionally disparate interests.
Given the immediacy of need along with long-standing cultural differences, who is in the best position to lead the trust-building initiative? It is this author’s contention, along with many others, that the physician executive is by far and away in the best position to take on this difficult but essential task.
No other leadership position can more fully appreciate the differing perspectives while at the same time identifying essential commonalities and areas of mutual benefit, areas as fundamental as improving the coordination of patient care or as strategic as developing dramatically new health care delivery systems.
“Physician leaders are viewed as more important than ever to closing the divide between clinicians and administration as they try to create accountable care organizations, reduce readmissions, improve care and implement electronic medical records.”10
“It is crucial for managers to develop a better understanding of trust and how to manage it.” — Robert Hurley, professor with Fordham University’s Gabelli School of Business
Most of the management, motivation and leadership studies conducted in the past have gradually moved from a “one best way” approach to more contingent or “it depends” models in which the most effective courses of action have not been a “one size fits all,” but rather depend, in part, on various characteristics of the individuals involved as well as on the nature of the situations at hand.
One such theory has been developed by Hurley, whose research notes a number of concerning findings, including one in which nearly 70 percent of the respondents in the organizations under study agreed with the statement: “I don’t know who to trust anymore.” 11
During the course of conducting executive seminars, Hurley asked participants what it was like to work in environments in which there were low levels of trust. Typical responses included terms like tense, unproductive, stressful and divisive. When asked the same question about working in environments where there were high levels of trust, descriptions included decidedly more positive descriptions such as productive, comfortable, supportive and motivating.
Hurley has published widely on this subject, including the development and testing of a “Model of Trust” that can be used to help assess whether an individual will choose to trust or distrust another in a given situation.
He denotes the terms truster (the one making the decision to trust) and trustee (the one asking for trust). With staff physicians and senior management, each would become a truster and a trustee during the course of trust-building relationships, since it’s essential that both end up with a strong sense of mutual trust.
His model includes 10 decision-making factors, each of which should warrant careful consideration.
- How risk tolerant is he/she?
- How well adjusted is he/she?
- How much relative power does he/she have?
- How secure do the parties feel?
- How many similarities do they have between them?
- How well-aligned are their interests?
- Does the trustee show benevolent concern?
- Is the trustee capable?
- Has the trustee shown predictability and integrity?
- Do the parties have good communication?
Citing evidence from more than 50 years of research, he notes that when choosing to trust, a person goes through a definite decision-making process that involves a number of major factors that can be identified, analyzed and influenced.
He concludes that having a greater awareness of these factors can help leaders avoid making the mistake of costly misjudgments: “By understanding the mental calculations behind the decision whether or not to trust, managers can create an environment in which trust flourishes.”
As mentioned earlier, the importance of intra-organizational trust has received considerable attention in the past. However, there has yet to emerge much in the way of a recognized “best practice.” On the other hand, the literature on this topic has included the reasonably consistent presence of certain critical success factors along with a number of associated trust-building behaviors. The following were observed to be among the most common:
Critical success factors:
- A shared sense of purpose.
- A compelling collective vision.
- A mutual commitment to building a culture of trust.
- A clear and accepted definition of what is meant by trust.
- Physician and management leaders who will champion the initiative.
- Give physicians a voice in decisions that will affect them.
- Convey a rational sense of urgency.
- Demonstrate clinical and managerial competence.
- Be fair, nonaccusative and team-oriented.
- Empower physician colleagues whenever appropriate.
- Communicate often using multiple modalities.
- Promote transparency and share information.
- Demonstrate understanding and empathy.
- Develop clinical leadership among colleagues.
- Be friendly and personable.
- Provide timely and meaningful feedback.
- Demonstrate emotional intelligence.
- Exclude physicians from the strategic planning process.
- Stress cost-control at the expense of clinical quality.
- Underestimate the personal importance of income and call schedule.
- Confuse administrative authority with personal power.
- Be unavailable, evasive or “spin” or “sugarcoat” the facts.
- Appear overly egotistical and/or self-centered.
- Be indecisive, inconsistent or disrespectful.
- Go back on your word or commitments.
- Be unresponsive or slow to respond.
- Fail to give credit when and where it is due.
- Ignore disruptive physician behavior.
- Breach expected confidentiality.
“The best leaders focus on making the creation of trust an explicit objective.”— Covey
Trust Is Good
Today’s HCO leaders must be courageous enough to be the first to extend trust. Not necessarily a blind trust, but more of a “smart trust,” with clearly articulated expectations and specific measures of accountability. Some have referred to this kind of initial gesture as being “consciously naïve” — giving the recipient of trust the benefit of the doubt that professional integrity, if given a fair chance, will win out and that an initial, workable element of trust that can then be built upon will eventually be reciprocated.
This proactive move is much more than merely a magnanimous gesture. It’s an invitation to a collaborative future. Without it, underlying issues of trust are too often avoided and are seldom addressed or articulated, even though they are at the core of developing essential relationships.
With it, the door is opened for constructive dialogue around the clarification of uncertainties and the identification of future opportunities for mutual support. From there, it’s a matter of each party earning higher levels of trust, realizing at the same time that although it takes great deal of time and effort to strengthen the bonds of trust, it can take only a few seconds to unravel them.
Talking the talk is pretty much as easy as it sounds. Actually walking the walk, however, is an entirely different matter, requiring exceptional courage, wisdom and sometimes even sacrifice. Trust between professionals should never be a matter of guessing. The stakes are simply too high.
Sincere and candid communication will let each person know just where they stand on the trust continuum and why. Each can then identify what if any barriers still exist, work out what, if anything, to do about them and then get on with taking care of the business at hand. Valuable time will be saved, irrespective of the final outcome.
There will always be a certain degree of risk involved as there are with most highly personal engagements of this kind, but the potential rewards can be enormous and well worth the effort.
In the words of Hurley, “Trust as a foundation for high performance means just that: Trust comes first. When we try to make the plan before the trust issue is resolved, we deal with symptoms rather than causes and repeating problems just change names.”
Les MacLeod, EdD, MPH, FACHE, is a professor of health management and policy at the University of New Hampshire.
- Pizzo JJ, Grube ME. Keys to lasting partnerships – Experts offer six tips for sustainable physician integration. Trustee 64(7):23-6, Jul-Aug 2011.
- Burroughs JH. Physician engagement must-dos. Hospital Impact, July 2013.
- Huff C. Physician alignment. Trustee 66(8):8-12, Sep 2013.
- Covey, SM. How the best leaders build trust, Leadership Now. http://www.leadershipnow.com/CoveyOnTrust.html.
- Dougherty J. The best way for new leaders to build trust. Harvard Business Review blog network. December 2013. http://blogs.hbr.org/2013/12/the-best-way-for-new-leaders-to-build-trust/.
- Galford R, Drapeau AS. The enemies of trust. Harvard Business Review. Feb 2003.
- Kaissi A. A roadmap for trust: enhancing physician engagement. Regina Qu’Appelle Health Region. https://pdfs.semanticscholar.org/b9a1/9f415e24b3462537499d7a11c3b0c0226bb9.pdf.
- Kaissi A. Manager-physician relationships: an organizational theory perspective. Health Care Management. 24(2):165-76, Apr-Jun 2005.
- Birk S. Creating a culture of “we” — investing in physician leaders. Healthcare Executive 29(1):10-8, Jan-Feb 2014.
- Betbeze P. The end of them vs. us. HealthLeaders 15(4):10-22, 2012.
- Elliott VS. Hospitals’ new physician leaders: Doctors wear multiple medical hats. American Medical News. April 4, 2011.
- Hurley RF. The decision to trust. Harvard Business Review, Sep 2006.