Private Healthcare Providers In Poland

Published Date: 02 Nov 2017

Faculty of Production Engineering

Przemys�aw Szabelski

Building customer trust in private healthcare providers in Poland

Master's thesis

Supervisor:

dr hab. in�. Anna Sankowska

Institute of Organization of Production Systems, Faculty of Production Engineering,

Warsaw University of Technology

Warsaw, January 2013

Tu b�d� podzi�kowania

Abstract

Tu b�dzie streszczenie

Table of contents

1. Introduction 7

1.1. Objective and structure of the thesis 8

1.2. General overview of the research 8

2. Theoretical framework for trust management 9

2.1. Characteristics of trust 9

2.1.1. Definition of trust 11

2.1.2. Trust dimensions 12

2.1.3. Patient trust 16

2.1.4. Economics of trust 18

2.1.5. Measuring trust 21

2.2. Main assumptions and principles in building trust systems 22

2.2.1. Principles of trust building 22

2.2.2. The trust development model: competence 23

2.2.3. The trust development model: conscience 26

2.2.4. The consumer's response 28

2.3. Healthcare marketing � chosen aspects 29

2.3.1. Introduction to healthcare marketing 29

2.3.2. The specificity of health services 30

2.3.3. Healthcare market deficiencies 31

2.3.4. Healthcare consumers and consumer behavior 32

2.3.4.1. The healthcare consumer 32

2.3.4.2. Consumer behavior 34

2.3.4.3. Consumer decision making 36

2.3.5. Branding as a strategy 38

2.3.6. Integrated marketing communications 40

2.3.7. The changing marketing paradigm 43

2.3.7.1. Corporate social responsibility in healthcare sector 48

2.4. Introduction to private healthcare market in Poland 51

2.4.1. Characteristics of private healthcare market in Poland 51

2.4.2. Polish medical subscriptions market 51

2.4.3. Private health insurance market 52

2.4.4. Private hospitals 52

2.4.5. Diagnostic imaging facilities 53

2.4.6. Prospects for the private healthcare market 54

2.4.7. Public opinion on healthcare system in Poland 57

2.4.7.1. General opinions on healthcare system 57

2.4.7.2. Poles about public and private healthcare 60

2.5. Building trust and a trusted reputation 63

2.5.1. The power brand 63

2.5.2. Understanding branding 64

2.5.3. Positioning: the brand promise 65

2.5.4. The brand hierarchy 66

2.5.5. The situation in healthcare 68

2.5.5.1. Building a brand for a medical facility � focus on identity 69

2.5.5.2. The importance of the image for the functioning of a healthcare facility 70

2.5.6. Developing a brand around trust 73

2.5.7. What reputation is and why it matters? 74

2.5.8. Establishing reputation 75

2.5.9. A reputation based on trust 76

2.5.10. The brand tool kit 77

2.6. Trust-based marketing 79

2.6.1. R1: Raison d'?tre: Mission, Vision, and Values 79

2.6.2. R2: Reputation and brand development 83

2.6.3. R3: Reputation management (relevancy to the brand) 83

2.6.4. R4: Recognition 85

2.6.5. R5: Repetition 88

2.6.6. Assessing brand equity 88

3. Research methodology 89

3.1. Objectives 89

3.2. Outline of the study 89

3.2.1. Literature review 89

3.2.2. Definition of research questions 89

3.2.3. Case studies for three main players in private healthcare industry in Poland 89

3.2.4. Analysis of patients trust and attitude towards private healthcare providers 89

3.2.5. Comparison and conclusions 89

4. Case studies 89

4.1. Background 89

4.2. ENEL-MED 90

4.2.1. Introduction 90

4.2.2. History 91

4.2.3. Strategy 94

4.2.4. Situation 96

4.2.5. Awards and distinctions 97

4.2.6. Quality Management System 98

4.3. LUX MED 99

4.3.1. Introduction 100

4.3.2. History 102

4.3.3. Strategy and situation 103

4.3.4. Awards and distinctions 105

4.3.5. Quality Management System 108

4.3.6. Information Security Management System 109

4.4. MEDICOVER 109

4.4.1. Introduction 110

4.4.2. History 111

4.4.3. Strategy 113

4.4.4. Patient-centered care 113

4.4.5. Awards and distinctions 115

4.4.6. Quality Management System 117

4.5. Comparisons 118

4.5.1. Social responsibility 118

5. Data analysis 120

6. Discussion 121

7. Conclusions 123

1. Introduction

To be trusted is a greater compliment than to be loved.

George MacDonald

Trust influences almost every interaction in our lives. In some way, every communication is shaped by the trust and reputation that we grant to the people and organizations that we deal with. Both trust and reputation can't be, however, created overnight � they are created and nurtured through a series of experiences which can be treated as a foundation for people's evaluation and placement of a person or institution in their minds - on a specific trust scale. In this process, each action can add value to a positive reputation and make it stronger or destroy it in a day. Building an image of a company or an individual as trustworthy might take ages � destroying it might take a heartbeat. Thus, the need for trust management in organizations seems to be natural.

Trust has always been an essential category of management � especially in healthcare. People who work in this specific industry know in their mind and heart that trust is a key element of their enterprise. Too often, unfortunately, they all know that they and their organizations are not trusted as much as they might be. They understand what it would mean to enjoy a trusted reputation, but they are not sure how to go about building and maintaining one. [1,�2]

Healthcare leaders ask often the same question: �How can we become more trustworthy?� and �How can our organization become known for being trusted�.

In this thesis, I will try to prove, that healthcare providers can learn to build trust and create a reputation that is based on trust. I will suggest some strategies, tools and techniques that healthcare providers may need to remake their enterprises into the ones with the reputation that people really know and trust. [2]

I will also investigate, how three main players in Polish private healthcare industry: ENEL-MED, LUXMED and MEDICOVER are building their �trust capacity� and how their individual customers are affected by these strategies.

1.1. Objective and structure of the thesis

This study attempts to present the theoretical and practical aspects of building customer trust in the healthcare industry. In its practical part, it is aimed to investigate the strategies of building trust-based reputation in private healthcare providers in Poland: ENEL-MED, LUXMED and MEDICOVER.

The first part of Chapter 2 describes what trust is and why trust management is so important. The second part of this chapter is about principles in building trust systems. Part 3 of the same chapter is about marketing of healthcare services � mainly about consumer behavior, branding and integrated marketing communications. Part 4 describes a private healthcare industry in Poland and its specificity. Part 5 is about building trust and a trusted reputation and part 6 describes trust-based marketing: a practical implementation of strategies of building trust-based reputation and gaining customer trust.

Chapter 3 describes the chosen research methodology; Chapter 4 - case studies for three main players in private healthcare industry in Poland and Chapter 5 - analysis of research outputs, which are then discussed in Chapter 6.

1.2. General overview of the research

Research consisted of four parts and it aimed to check, how different strategies applied by chosen providers work.:

1) content analysis in terms of building a reputation based on trust;

2) �Trust Leader� - a rank based on the most important touch points enhancing building organizational trust;

3) subjective analysis of CSR actions and media relations;

4) survey focused on measuring both organizational and interpersonal trust, satisfaction and brand reputation.

The results of the research will help to present the strategies in building the companies' reputation based on trust.

2. Theoretical framework for trust management

2.1. Characteristics of trust

The concept of trust has been studied in disciplines ranging from psychology, medicine to business. It has been broken, abused, misplaced, shaken and violated. Sometimes it is repaired and rebuilt. Trust is a vulnerable commodity, prominent in the marketplace, acknowledged in every profession, yet very difficult to quantify. Marketing managers measure its value in sales, brand loyalty, customer satisfaction and retention. Business relationships would be nonexistent without trust, which is expressed in various business contexts such as contracts and regulations, as well as in company policy and personal reputations, and long-term relationships. [29, 31]

Trust is a Mission Driver

In healthcare, the presence or absence of trust in patient � provider relations can have life-changing consequences. Patients who trust their providers are more likely to seek care, to follow treatment protocols, to succeed in their efforts to change their behavior (for example giving up smoking) and also more likely to return for follow-up care than a patients who have little trust in a specific provider. Data shows clearly that trust improves medical outcomes and it is the number one predictor of loyalty to a physician. If the organization�s patients (customers) do not trust it, why would they use its products and services? Alternatively, if they trust it, why would they look anywhere else? The trusted organization is the one that people turn to when they are in need. And what is the most important, in healthcare, the customers are people who are in need. [2, 29]

Trust is a Margin Driver

It is as true in any kind of business that trusted organizations attract and keep customers. In an environment in which everyone assumes all parties are trustworthy everything goes much more smoothly and efficiently. Organizations that care about trust experience less bureaucracy, paperwork, and transaction costs due to lower monitoring and surveillance costs. Trust is also important in promoting organizational efficiency, team working and job satisfaction. Trusted organizations attract the best managers and employees; they appeal to the best business partners. They can raise capital more easily than their competitors. They are even forgiven their mistakes. According to Covey reports, high � trust organizations have increased value, accelerated growth, enhanced innovation, improved collaboration, stronger partnering, better execution, and heightened loyalty. A 2002 Watson Wyatt study showed that high - trust organizations outperformed low - trust organizations by 286 percent in total return to shareholders (stock price plus dividends). [2,�78,�80]

Why is it worth to consider trust?

Mission and margin are the twin goals of any healthcare organization, and a strategy of building trustworthiness and a trusted reputation necessarily involves stakeholders from both the clinical and administrative fields. But there are two other reasons why healthcare leaders should consider trust. One is strategic, the other personal. [2]

On a strategic level, trust sets the organization apart. Healthcare has been changing rapidly: the traditional doctor�s office has given place to the large group practice, big hospital and medical center. Technologically complex and costly new treatments have become more and more available every year. Patients find it all completely stunning. These are all factors in the trust crisis - today consumers no longer know whom they can trust. According to a February 2002 Golin/Harris Poll, nearly 70% of Americans agree with the statement, "I don't know whom to trust anymore".

In this situation, the organization that is trusted stands apart from the main pack. Building a reputation based on trust can not only give the market what it desperately wants and needs but can also help to establish a unique and sustainable value proposition for an organization. This thesis helps to show the way how to get there - how to build a reputation for trust just as Volvo has built a reputation for safety. As Volvo owns the �safe car niche�, the organization that owns the trust niche will own its marketplace. [2,�81]

On a personal level � for a medical director, chief executive officer or a unit head what can be better than helping to create an organization that is trusted? Trust is much more than just a self-congratulatory adjective to be sticked to a company's press releases. Trust is not the latest, fashionable management concept. It is an evergreen concern, which will be as relevant in 20 years as it is at this moment. Trust is also the gold standard of an organization. Patients, employees, board members, third-party payers, suppliers, referring physicians, and everybody else who comes into contact with a trusted organization feel good about being associated with it. This feeling can be intangible, but it is priceless. The leaders who build a trusted organization can know that they have made a contribution not just to healthcare but to a better society. Trust is at once good medicine, good business, and excellent leadership. [2,�81]

Like I have mentioned before, there is a trust crisis in healthcare. But crises give opportunities to those who can respond. Now is a good time for companies to embark on a trust-based marketing strategy. Imagine that you are not only a business leader but also a trust leader, and that your organization operates not only in the healthcare business but also in the trust business. Imagine the organization that consumers immediately trust and that this trustworthiness is what distinguish it from the crowd. Imagine that it owns a reputation and a brand that people automatically associate with trust - and feel that they can trust. [2,�81]

How to build and maintain such a reputation is the subject of this thesis.

2.1.1. Definition of trust

A position of trust is the single most powerful position in any customer's mind. For that reason, earning the customer's trust almost always becomes one of the most important goals in any effort to build a long-term relationship with a customer. In a permanently changing world, a relationship founded on trust seems to be the only genuinely sustainable competitive edge. [21]

Trust was defined by Hall M. A. as �the optimistic acceptance of a vulnerable situation in which the truster believes the trustee will care for the truster�s interests�. Trust involves an element of risk, where the intentions, motives and future actions of other individual are uncertain, and an individual must depend on another. There is no perfect guarantee that ensures that trustee will live up to the truster's expectations. Trust plays an important role in healthcare because healthcare providers know more about the treatment options, costs and effectiveness of treatment, whereas patients know more about their medical history, financial capacity and personal preferences. While patients are vulnerable to and dependent on decisions made by healthcare providers, trust can also strengthen the patient � provider relationship by encouraging personal exposure and cooperation in treatment. Trust is important to healthcare because it supports the cooperation throughout the sector that is required for health production. [31, 32]

Whilst trust is frequently closely linked with quality of care, it rather focuses on the relational nature of exchanges between two parties. Trust captures the latent relationships and exchanges among different individuals in a health system, while quality of care explains the actual events and observed behaviors of individuals. Quality of care is a more tangible concept and it includes some observed and measurable features such as availability of medical equipment and frequency of service provision. What is more, quality of care is not defined by a relationship or existence of risk. Trust, on the other hand, is found in interactions where the truster is vulnerable to the trustees� uncertain actions. Trust captures the relational nature of interactions between two individuals that can reveal communication obstacles and people�s beliefs in a system. [32]

Trust can take two forms: interpersonal and impersonal/organizational. While trust in friends describes a form of interpersonal trust, trust in strangers, social systems or institutions illustrates a form of impersonal/organizational trust. Both forms of trust may be present simultaneously. In healthcare, customers may trust providers because of their personal relationships and interactions with physicians, or because of their trust in the health system in general or just in a specific healthcare organization. According to M. Hall, people typically have stronger trust in individuals than in professional systems or organizations. [32, 77]

2.1.2. Trust dimensions

Gaining customer trust involves consideration of its two main components: competence trust, which emerges from an economic foundation, and a conscience trust, which emerges from an empathy foundation.

The competence is the ability of the organization through its leadership, strategy, decisions, quality, and capabilities to meet the challenges of its environment. Competence relates to the overall efficiency of the organization as well as to the quality of its products or services. Competence comes from the capabilities of employees at all organizational levels. Finally, competence is measured by an organization's ability to achieve its objectives.

Organizational commitments are reliable only if its employees are capable of doing what an organization says they will do. They must have the skills, equipment, experience, and whatever else may be necessary to execute organizational intentions. [2,�81]

Even if an organization is capable, will its employees do a good job and charge a reasonable price? Will they give an honest advice? Can anyone trust them? All of these questions depend not on a organization's competence but on its employees' conscience. To trust other people, we must believe in their good intentions, their benevolence toward us. Conscience is the most important element of trust, because we can usually take competence for granted. The most important questions about trust revolve around benevolence and good intentions. Will people act with our best interests, or their own best interest? Will they try to cheat us?

Conscience trust (often defined as goodwill or intentional trust) relates to the trust one has in the intentions of the partner to refrain from opportunistic behavior.

Trust has other components, but there are not so important as conscience and competence. Let's apply these definitions to healthcare. [2,�83]

Healthcare provider's competence

Usually we do not try to making judgments about a physician�s skills. Instead, we use substitute attributes that we can assess, for instance: medical school he graduated, her manner or how much time she has to talk to us. There are two problems with dependance on such simple attributes. For one, they can be misleading. A good education received 20 years ago or a pleasant manner is no guarantee of competence in diagnosing and treating medical conditions. The more unusual the illness is, the more questionable may be the doctor�s competence. Has he seen anything like this before? Has she treated this condition with success? The other problem is the very high stakes involved. If a physician makes a serious error, a patient can end up disabled or dead. It would be nice to be sure - rather than just hope - that the physician and a medical team know exactly what they are doing.

The need for trust in technical competence is not limited to the patient-doctor relationship: a hospital administrator depends on the competence of her staff; a surgeon depends hugely on the competence of his nurses and support personnel. Everyone who works with a third-party payer depends on timely claims processing without any errors. The more complex the situation, the greater is the reliance on trust. [2]

Healthcare provider's conscience

Issues of competence are usually overshadowed by issues of conscience. Fukuyama writes: �We trust a doctor not to do us deliberate injury. We expect him or her to live by the Hippocratic oath and the standards of the medical profession.� In other words, we hold an presumed trust in the physician�s benevolence. But how far does this extend? We have to trust him to not only care for us well but also to not order unnecessary tests in hopes of filling his own wallet or that of his employer.

The lack of trust in conscience constantly makes itself felt. Patients sue doctors and hospitals not so much for making a mistake � (people realize that everybody makes mistakes) - but for not being straight with them, for refusing to acknowledge the error and apologize for it. [2]

Other elements

One of the other elements of trust is vulnerability. People who deal with the healthcare system are by definition vulnerable: they are often sick or injured, and they usually do not know as much about their condition as do the professionals they are seeing. Trust obviously reduces the fear that accompanies vulnerability.

Similarly, consumers are firmly concerned with minimizing risk, because those risks (illness, infection, bankruptcy, death) are otherwise so high. They want to know that the surgeon to whom they are entrusting their bodies has done the same procedure a hundred times before. They want to know that the drugs they are taking will actually help them. Trust appears to be necessary where there is uncertainty, and this element of risk appears to be derived from a patient�s uncertainty regarding the motives, intentions and future actions of another on whom he or she is dependent. [2,�82]

Patients (customers) use the same trust cues to assess the physician or healthcare staff as they do with anybody else. Does the physician look you straight in the eyes? Does he seem rushed or distracted? So it is with nurses, receptionists or magnetic resonance technicians as well as with the representatives of healthcare providers whom patients must talk to on the telephone. With organizations, too, patients make judgments about trust based on how they feel about them in addition to what they know. Where trust is concerned, the brain is important, but if the emotions do not go along, there is no trust. [2]

The change of trust paradigm in healthcare

Traditionally, healthcare was the most intimate of relationships - and one of the most trusting. People knew their family doctor for years and knew if they can trust him on that face-to-face basis and have placed high levels of trust in them. Such interpersonal trust relations have been characterized by a type of blind, embodied trust that developed as a result of a patient�s knowledge of and relationship with their personal doctor. Institutional trust in healthcare organizations and systems have also tended to be high. [2, 78]

Today, the intimacy of the relationship has been threatened, and trust along with it. Typically, the patient-doctor encounter takes seven minutes or less. Even the physician you see may not be �your� doctor; he or she may be your doctor�s partner in a group practice or one of the many specialists to whom internists frequently refer patients. The face-to-face intimacy is gone. There is no well-known human being whom you can trust. Is it any wonder that alternative medicine has begun to catch on? Its practitioners specialize in high-intimacy healing, the kind that we feel we have lost. [2]

Patients attitudes towards medical professionals and their authority as medical experts are changing, reflecting a more general decline in respect to authority and trust in experts and institutions, together with increasing reliance on personal evaluation of risk. The days of blind trust in a physician have been consigned to history. These broader social processes that have encouraged change in interpersonal trust relations have also stimulated changes in organizational trust. Beliefs about the limits of medical expertize together with concerns about the effectiveness of professional regulatory systems, highlighted by the media news about medical errors, have eroded trust in healthcare organizations, in the medical professions in general, and in health systems as a whole. According to Urban, increasing customer power will drive a new paradigm for marketing, a paradigm based on advocating for the customer by providing open, honest information and advice. At the same time, this customer power is reducing the effectiveness of old-style push-based marketing. Thus, the shift to trust-based marketing may be a necessity rather than an optional opportunity. [78,�81]

Principals and agents

There is one more important element of healthcare that affects trust and that makes trust even more essential in this area than in most others. Many interactions in the healthcare sector involve so called principal-agent relationships. An agent is someone whose objectives are (or are supposed to be) the same as those of the principal. If I own a business and you manage it for me, you are my agent. If I am a patient and you are my doctor, you are my agent. Caregivers are supposed to work with their patients� best interests at heart. [2]

But agency relationships in healthcare are always complicated. For example, the hospital that employs a physician or the NZOZ that contracts with him also expects that he will work in their best interests. The physician�s spouse expects that he will work in the family�s best interests (for example, by earning good money and by not taking calls during the vacation time). Agents' motives are not always aligned with the interests of the patient. Doctors are often accused of ordering more tests than necessary and thus earning some extra income. On the other hand, they are often accused of ordering fewer than necessary, thereby saving their employer some money. In effect, healthcare providers play multiple roles: they can induce purchases on the one hand, and they can act as a gatekeeper on the other hand, denying care or drugs that may be indicated. Clinical mistrust arises when patients feel that doctors are not acting primarily as their agents. [2]

2.1.3. Patient trust

The crucial role of trust in medical relationships has been recognized for a long time. Trust is seen as a global attribute of treatment relationships, one that embraces subsidiary features such as satisfaction, communication, competency, and privacy. Following D. Shore, patient trust is �trust in the clinical skills and knowledge of the physicians, the other professionals, and the service organizations with whom the patient comes into contact. It is confidence in the integrity of all these clinicians and organizations. And it is confidence that, whatever else they may do, they will fulfill their role as the patient�s agent�. [2, 30]

Changeability

Evidence from qualitative studies suggests that patient trust is a subject to change. In focus groups and interviews, patients easily recall situations that they felt greatly increased or decreased their trust in a doctor. Patient trust also seems to be specific to the particular physician, correlating weakly with patients� trust in people in general. What is more, there is much variation in the mean level of trust stated by patients of different physicians. This is an evidence for the view that trust is influenced by patients� experience with their doctor and that patients can have different levels of trust in different doctors. [29]

Physicians� behavior and trust

Research has identified doctors' behavior associated with increased or decreased trust, based on patient focus groups, interviews and patient surveys. Doctors' behavior identified as increasing patients trust commonly falls into the categories of competency, communication, caring, honesty, and partnership. Identified factors that promote interpersonal trust include (1) greater perceived mutual interests; (2) clear communication; (3) a history of fulfilled trust; (4) less perceived difference in power with the person being trusted; (5) acceptance of personal disclosures; and (6) an expectation of a longer-term relationship. All of these factors suggest some approaches that could increase patient trust, such as emphasizing mutual interests (the patient�s health); checking patients� understanding of messages; taking opportunities to fulfill trust (calling with test results); reducing power differences (sharing information); responding to patients� self-disclosures in a supportive and nonjudgmental way; and promoting continuity of care. [29]

Impact of organizational factors

Organizational factors are also important in building patient trust. They include allowing and encouraging patients to choose their physician; giving patients sufficient continuity with the same physician to allow for the establishment of a long-term relationship; and ensuring that physicians are not under economic or other pressures to act other than in their patients� best interests. In addition, organizational structures that allow better communication between physicians and patients - for instance reporting test results outside of the office visit - may help build trust as well. [29]

Trust versus satisfaction

Over the past few decades, patient satisfaction has taken a remarkable position in the healthcare research literature. Patient trust is related to - but conceptually distinct from - satisfaction with the physician. Patient satisfaction can be defined as a response that results from patients� post-treatment evaluation of medical service performance given pre-treatment expectation. Satisfaction looks backward and is based on past experience, while trust looks forward, and is kind of an expectation of future behavior. Although satisfaction refers to the patient�s judgment of the physician�s actions, trust refers to the relationship between the physician and patient that is based mainly on perceptions about the physician�s motivations. Trust also has a strong emotional component not present in satisfaction. [29,30]

In focus groups, patients easily differentiate trust from satisfaction, describing trust as a reflection of a commitment to an ongoing relationship. Patients may report being satisfied with each visit in their physician's office, but still not feeling they have established a sense of trust. Vice versa, trust in a physician may be maintained even if a particular visit is not satisfactory.[29]

2.1.4. Economics of trust

Trust is both a mission driver and a margin driver. The healthcare provider that leads its market and that operates effectively and efficiently will be a successful organization. It will also successfully accomplish its mission and generate the margin it needs to operate in a competitive market. One way of analyzing why trust matters so much to an organization�s success is to estimate its return on investment (ROI). Because trust is an intangible asset, the ROI may be difficult to quantify, but there is no doubt that it is large. Even the most skeptical of CFOs can be convinced of the importance of a focus on trust. [2]

Fig. 1 presents the transition from old economy to the new one according to Grudzewski et�al. As we can see, for a modern organization, trust is seen as a capital even more important that brand or reputation. [79]

Across all industries, 56 percent of consumers say they will decide to purchase something just because it was made by a company they trust (Macrae and Uncles 1997). In one recent industry study by a large consumer healthcare company, a solid 94 percent of consumers and 95 percent of healthcare professionals said that trust is �extremely� or �very� important. If someone runs a trusted organization, he will attract and keep his customers, which, after all, is the first job of any organization.

In healthcare, trust is a strong predictor of continuity with providers. For example, the 1999 study by Thom and colleagues found that after six months, only 3 percent of patients in the highest trust quartile had left their physician, compared with 24 percent of patients in the lowest quartile. Other studies have found a similar, strong association between trust and actual or intended change in providers.

Just as trust is the top predictor of loyalty to a physician�s practice, it is also likely to be the top predictor of loyalty to any organization in the business of healthcare. [2, 29]

A good way of understanding the power of trust in the marketplace is to consider the concept of brand dependency (Fig. 2).

When had to make any choice, consumers have more or less knowledge about what they are buying. If it is a motorcycle, they may talk to a friend who owns one, look for a related topic on the internet or test-drive several models. If it is a flat, they will walk through it several times and have it inspected by a professional inspector. If what they are buying is something more intangible, like legal services, they may know less about it. So knowledge can be plotted on one axis of the graph. Meanwhile, the importance of the purchase varies. A fast-food meal or a box of laundry detergent are likely to be on the �not so important� end of the range. Legal services, a home, and an expensive watch are all up on the �important� end.

Healthcare is usually high on importance and low on knowledge � exactly where consumers are most dependent on a trusted brand. That is why the healthcare organization that owns trust will own its marketplace. [2]

But trust has favorable effects on an organization that go beyond this powerful attraction. According to David A. Shore, among them are the following:

Trust allows the organization to establish itself as an employer of choice - to attract the best managers, clinicians and employees.

Trust gives an organization easier access to capital. The trusted healthcare institution, whether for-profit or not-for-profit, is one that people want to invest in or support.

Trust appeals to key stakeholders. Because healthcare is such a complex business, all organizations have additional key stakeholders other than customers and employees. For a hospital, one key stakeholder group is referring physicians. Trusted organizations find it easier to partner with these stakeholders.

Trust affects the attitude of regulators. Healthcare is one of the most strictly regulated industries. Regulators always have a choice as to where to put their resources: they can be aggressive in their enforcement, or they can put their faith in the good word of a given organization. When an organization enjoys a reputation for trust, which is more likely?

Trust allows people in organizations to work together effectively. In healthcare, many different kinds of people are asked to collaborate in a difficult and demanding enterprise. The unpleasant relationships that often characterize the business - nurses versus physicians, patients versus insurance companies, administrators versus clinicians�reflect an absence of trust. How much easier would it be for everyone if they knew that their organization, at least, could be trusted?

Trust reduces transaction costs. Rules and regulations, due diligence, forms, and verifications all create extra costs for everybody, and many of them exist because not everybody can be trusted. No single organization can eliminate these transaction costs, but every organization can minimize them by building an internal culture of trust.

Finally, trust allows organizations to take on challenging projects: a new product or service, a new wing for a hospital, etc. Healthcare professionals everywhere thrive on the difficult challenge, but only if they truly believe that the organization taking it on can be trusted to see it through and to manage it effectively. [2]

2.1.5. Measuring trust

As Mark Hall noted in his papers, most of the work relating to trust in healthcare has focused on patients� trust in health professionals. Hall suggests that this reflects the importance that people attach to choosing and establishing relationships with their own physicians. However, the trust that patients express and place in healthcare teams, healthcare provider organizations and health care professions may also warrant more attention than researchers have been paid to date. [77]

The cost of failing to recognize the importance of trust could be substantial: economically, politically, and most important, in terms of health outcomes. Measuring levels of trust between patient and provider can reveal system failures or individual communication hurdles. Low levels of trust can be changed, and improved trust might reduce disagreements and improve health outcomes. [29, 78]

Measuring trust would also be an important supplement to market forces. It could help focus market forces on maintaining or improving trust as an aspect of healthcare quality. Trust is often implicitly or explicitly used in marketing hospitals and other healthcare organizations. However, if it is not measured, it is rather unlikely to be valued sufficiently to balance the economic forces believed to reduce the strength and quality of medical relationships. Measures of patients� trust in particular physicians can be aggregated to create a measure of patients� trust in their healthcare providers within a medical center. Such a measure would allow provider to monitor and provide an incentive to change organizational and physician behavior to promote patient trust. [29]