The Business of Trust


Novelist George McDonald wrote, “To be trusted is a greater compliment than being loved,” And although he was no scholar in the business of healthcare, his words ring as true in the boardroom as they did in the Scottish hills of his homeland.

Imagine a world in which physicians and patients trusted each other enough to become high-performing collaborators in the practice of healthcare-where patients advocated for their own health and physicians welcomed them as partners. Or consider a scenario where physicians became integral to the decisions that drive the administration and governance of their healthcare system.

Farfetched? Maybe. But the forces shaping the future of healthcare are putting increasing pressure on all players in the medical community to forge more effective partnerships and collaborations if they are to achieve quality patient outcomes at reduced cost.

The foundation of successful partnerships and collaborations is trust. Trust isn’t just a fluffy concept; it’s an outcome based on repeated interactions characterized by specific behaviors that drives high performance. It’s not synonymous with skill, as in “I’m a skilled physician, therefore I should be trusted.” Abundant research now shows that even in the doctor-patient relationship, trust isn’t a given; it has to be earned. And physicians who succeed at earning trust are rewarded with better patient outcomes. In our experience, the same holds for physician-leaders and their all-important relationship with hospital administrators: more trust leads to better business results.


The administration of a leading healthcare system decided to establish clinics for their employees. Their intent was to create a “customer pleaser” for employees by providing convenient care. Just prior to the opening of the clinic, the administration made the physician community aware that this business decision had been made. Can you guess what happened next?

If you guessed commotion, confusion and mistrust, you would be right. The physicians were caught off guard and felt left out of the decision-making on an initiative that directly impacted them. The administrators, who had carefully considered the benefits of the clinics for the physician community, were at first surprised by the reaction of the physicians. They quickly realized however, that while their intentions were well-placed, they had neglected to adequately involve and communicate with their physician stakeholders.

A timeout was called. The administration opened a dialogue with the physicians that was designed to both explain the benefits of the program, and, very importantly, to get valuable input from the physicians on how best to implement this “customer pleaser.” The goal was to provide physicians with the necessary information to help them identify their benefits in this new model of service delivery.

Whether you’re trying to demonstrate and reinforce your own trustworthiness or make the leap to trust others, you know that every interaction either enhances or diminishes the trust relationship. Once compromised, trust is not easily restored. So, what does it take to trust and be trusted?

Four Ways To Build Trust

Trust is an outcome of the use of four specific practices:

  1. Straightforwardness
  2. Openness
  3. Acceptance
  4. Reliability

In the case study above, the level of trust between administrators and physicians was strengthened in each of these four ways: straightforwardness was achieved when administrators communicated their intentions directly; openness was apparent as clinician-stakeholders were invited to participate in influencing and shaping the outcome; acceptance was evident when administrators moved beyond rigid roles of clinician versus decision-maker; and reliability was reinforced in the partnership through respect for the interests of all the parties involved.


Here’s a closer look at each of the trust-building practices.

  1. STRAIGHTFORWARDNESS: Saying what you mean and meaning what you say.

We all know people who are candid. There is no mistaking what they think, feel, or believe. They’re aware of their thoughts, values and beliefs, and are willing to act on them. Straightforward people speak frankly, without hesitation or confusion. We value people like this because they bring decisiveness and direction to situations where it’s needed.

Straightforwardness is essential when, for example, clinicians are giving a diagnosis, prescribing a treatment plan, or offering a team member feedback. It is a key trait whenever critical business decisions need to be made, standards upheld, or policies enforced. It is essential for the governance of healthcare systems, which must rely on the strength of the relationship between physicians and administrators. Straightforwardness is no coward’s game, especially at times when you are called upon to speak truth to power, express an unpopular opinion, or say something that you know will make others uncomfortable.

When straightforwardness is absent, breakdowns occur in the form of confusion, lack of clarity, and ultimately poor performance. Ever hear these telltale remarks that signal the absence of straightforwardness?

I can never understand where he’s coming from.”   “She says one thing and does another.”   “Why doesn’t he just say what he really means?”

Trust grows when your actions are aligned with your thoughts, values and beliefs. In other words, when you’re straightforward with people, their trust increases because they never have to guess what your intentions are.

Straightforwardness can be learned. It’s a practice that relies on our ability to counter breakdowns in communication and trust by:

  • Making clear requests: stating what you want, from whom, by when
  • Declining requests with respect and dignity
  • Making declarations of your intent and following through
  • Clearly distinguishing between subjective assessments and fact-based assertions


  1. OPENNESS: How willing are you to risk being changed?

Transitioning to a leadership role in any organization is fraught with pitfalls. This is especially true for physicians ascending to leadership in the governance of a hospital or healthcare system. The independent, authoritative approach that often works well for physician practitioners falls flat when it comes to leading high-level organizations. To succeed in this more complex kind of leadership, physicians need to cultivate a quality of openness.

The practice of openness is comprised of:

  • Curiosity: A genuine interest in “finding out,” an eagerness to learn
  • Willingness to be influenced, to prioritize “getting it right” versus “being right”
  • Listening and dialogue; communication flowing freely in both directions
  • Development of a feedback network of people who are willing to tell you what you need to hear when you need to hear it

Do you have the self-confidence to seek out the views of others, especially those who see things differently than you do? Are you inclined to include others in decision-making or, are you a “my way or the highway” autocrat? Do you have the courage to seek feedback and incorporate new ideas into your work? Honest answers to these questions are a great starting point for change.

Leaders who internalize the concept of openness have the psychological hardiness to show their warts, and to interact with others in ways that make them want to open up too. So when problems arise in the trenches, when timelines slip or mistakes are made, the probability that their colleagues will share relevant information before it becomes a crisis is raised. Time and money are saved, objectives met, trusting relationships solidified-everybody wins.


  1. ACCEPTANCE: Do you respect yourself as you are – good and bad qualities included – and do you grant the same respect to others?

Mistakes happen. People forget, drop the ball, and break agreements. Leaders encounter any or all of these situations in the space of a day, sometimes within themselves. How they respond reflects their level of acceptance: the ability to attack the problem and not the person; to consciously work to uphold the dignity of others even when justifiably unhappy with them.

Acceptance requires the courage to resist stereotyping, bias, and objectifying. Administrators are not all money-hungry bureaucrats. Physicians are not all egotistical autocrats. And people who make mistakes, voice resentments, dig in their heels, and otherwise make a leader’s job difficult are just that – people. Bias can be subtle and insidious, but its counterpart – acceptance – is a skill that can be learned. The payoff is psychological safety, the absence of fear, which makes it possible for people to engage in all of the other trust-building practices.


At a prominent medical university on the East coast, a female anesthesiologist was made head of the department. Extremely competent as a healthcare professional and a scholar in her own right, she struggled to be successful as a leader among her colleagues. Two barriers plagued the early days of her tenure: many of her colleagues felt they were more deserving of the post, and some had difficulty accepting a female as their leader. She was suddenly in the position of having to figure out how to turn adversaries into colleagues and collaborators again. Instrumental to the turnaround was coaching that capitalized on openness and facilitated acceptance. Her openness was exhibited by her willingness to recognize that she needed the coaching individually and that she needed help in developing her team. The team development work resulted in the team’s acceptance of her as their leader. They stopped judging and attacking her personally, and began to focus their attentions on the work that needed to be done.

  1. RELIABILITY: What are your promises worth?

Have you ever stopped to count the number of deals, agreements, and promises you make in the space of just one day? Do you keep track of how many you follow through on? Making and keeping promises is the foundation of reliability and it is essential to good leadership and good business. The absence of reliability leads to breakdowns in the form of conflict and loss of credibility.

Reliability is a practice that distinguishes the “go-to” people – those who are always busy, yet always have the energy to take on the next thing. They are counted on because they inspire confidence that they will come through again and again on the promises they make.

The “Cycle of a Promise” requires that you and others:

  • Are on the same page about the result you want
  • Negotiate clear agreements to reach the result
  • Perform the actions prescribed in the agreement
  • Evaluate outcomes, learn from them, and improve

Ben Franklin understood the practical importance of reliability when he said: “Promises may fit the friends, but non-performance will turn them into enemies.”

Trust grows when you make and keep your promises.


Too Much Trust?

Is it possible to trust too much? In a word, yes. For example, the near enemy of straightforwardness – bluntness – can signal insensitivity, which undermines acceptance. Overplaying openness (i.e., being naive or gullible) can leave you too easily influenced, which undermines your confidence and squelches straightforwardness. Too much acceptance (a bleeding heart) can set you up to be so concerned about relationships that you sacrifice results, and reliability takes a holiday. Excessive emphasis on reliability (obsession) can close you off to the input of others. The more closed you appear, the more openness is stifled and the less input you receive.

Trustworthiness is the foundation underlying the sound governance of our healthcare systems, the relationships among clinicians and administrators and the partnership between healthcare practitioners and patients. The four trust practices are essential to making these relationships work and to ensuring the overall health of our healthcare delivery system.


Take this quick test to determine your Trust Profile. To add some objectivity, you can also have a colleague take it on your behalf and compare your two viewpoints.

1. I invite feedback. (O) 1 2 3 4 5
2. I make clear promises. (R) 1 2 3 4 5
3. I attack problems, rather than people. (A) 1 2 3 4 5
4. When I believe in my position, I fearlessly take a stand. (S) 1 2 3 4 5
5. I am clear about my values and beliefs. (S) 1 2 3 4 5
6. Others know that I respect them. (A) 1 2 3 4 5
7. Given good information, I am willing to change my mind. (O) 1 2 3 4 5
8. I follow through on my promises. (R) 1 2 3 4 5
9. I am a “go-to” person. (R) 1 2 3 4 5
10. I am frank with people. (S) 1 2 3 4 5
11. I approach conflict with curiosity. (O) 1 2 3 4 5
12. I refrain from stereotyping people. (A) 1 2 3 4 5
13. I willingly speak truth to power. (S) 1 2 3 4 5
14. I am a good listener. (O) 1 2 3 4 5
15. When necessary, I make promises even when I’m afraid.(R) 1 2 3 4 5
16. People feel safe with me. (A) 1 2 3 4 5


S=Straightforwardness: 4, 5, 10, 13 Score:  
O=Openness: 1, 7, 11, 14 Score:  
A=Acceptance: 3, 6, 12, 16 Score:  
R=Reliability: 2, 8, 9, 15 Score:  

A score of less than 12 on any of the Trust components suggests that you and your organization could benefit from cultivating trust skills. An overall score of 48 or less signals a strong need for enhancement of trust skills.