All healthcare leaders aspire to build and sustain ethically aligned organizations that engender trust with those they serve. They want their patients and families to trust that care delivered will be safe and of high quality, that services will be available when needed and that the organization’s business objectives consider the needs of those served. Those who work within healthcare organizations wish to work in safe, secure and respectful environments, and they want honest, routine and understandable communication from leaders about performance and achievement of the organization’s objectives. Transparency—the sharing of key data, information and decision-making—is considered a means to achieving these desirable ends.
A full commitment to transparency often requires a leader’s discernment, commitment and courage to share “the good, the bad and the ugly.” And, often, this requires keen ethical judgment and decision-making that helps leaders determine how and when information is best shared and when sharing can do more harm than good.
Defining Transparency
In his book, The Speed of Trust, Stephen M.R. Covey describes transparency as being based on the principles of openness, honesty, integrity and vulnerability: “telling the truth in a way that others can verify.” Covey describes the opposite of transparency as hiding, covering, obscuring and secret-keeping, as well as having hidden objectives, agendas and meanings.
In these descriptions, one can easily grasp the relationship between transparency and trust, with transparency being seen as critical to establishing and sustaining a high-trust organization. Everyone appreciates being dealt with honestly and in a way they can understand. Conversely, no one likes the sense that leaders or organizations are not “being straight” with them or are spinning data and information in a way that obscures reality.
Appreciating this and genuinely wishing to nurture trust with their patients, their staff and their communities, healthcare leaders often have important decisions to make. Such decisions include whether information can and should be shared, the timing of information sharing, the depth and complexity of information to share, and the proper communication mechanisms that best convey the information for greatest understandability. Following are several examples that highlight these considerations.
Balanced Transparency
In the 1990s, as the quality improvement wave came to healthcare, there was mounting pressure for hospitals to publicly disclose their performance outcomes with respect to indicators such as mortality rates, complication rates for specific procedures, readmission rates and other such data. The initial pushback on this notion was strong, and concerns about the public’s ability to interpret this complex data were high. Many worried that the disclosures would, in fact, have the opposite effect of building trust and instead erode public confidence in the healthcare system and its providers.
For example, if a higher mortality rate was attributed to one hospital in a region versus another, one might be tempted to believe that one organization was safer to receive care at than the other. Of course, those of us who lead healthcare organizations know myriad factors that have nothing to do with care quality or clinician expertise can contribute to a higher mortality rate. But the complexity of explaining these factors to the uninitiated (not just the public but, importantly, our employees) is daunting and certainly not suited to a paragraph in a local newspaper.
In the early 2000s, I remember thinking that one of our physicians, the leader of our bone marrow transplant program, was practically a pioneer for agreeing to publicly disclose multiple quality and patient outcome indicators for his program, particularly because some were not in the “excellent” category. I remember this physician’s passion for moving toward greater transparency, as he believed it made the program better and more accountable to those served. He was right. Colleague and patient responses were positive. Many of his colleagues decided to follow suit.
One of the resulting positive effects was the learning that ensued among colleagues who wanted to know how to improve their personal and their clinical program’s performance. As we all know, these and similar efforts began a push for greater accountability from the healthcare field. Today, healthcare organizational performance and quality data are not only publicly reportable and available, they are also accessible to anyone via simple internet searches.
Responsible Transparency
Covey and The Speed of Trust contributor Rebecca R. Merrill are quick to point out that there must be a responsible balance with transparency. Obviously, information that is confidential, highly sensitive or private should not be disclosed. Nor should transparency be performed irresponsibly, with information being disclosed in ways that are “too much or too fast.” Two examples come to mind.
A healthcare organization’s recent restructuring led to about 100 people losing their jobs. There was a lot of pressure placed on leaders to publish a listing of those individuals. This pressure came from an altruistic place: People wanted to reach out and support those affected and to understand who might now be taking those employees’ places so that various workflows could continue. In this instance, the leaders did not succumb to the pressure for transparency. They decided that it was more important to protect the affected employees’ confidentiality and did not publish the list.
Another example of transparency’s role in healthcare is related to the COVID-19 pandemic. There was a time during the pandemic’s height when healthcare organizations were scrambling to create their crisis standards of care, the policies and procedures for how hospitals would make decisions regarding rationing of scarce resources should it become necessary. The plans were elaborate and complicated, comprising special triage committees, scoring instruments and decision-making algorithms.
Once the crisis standards of care were completed, leaders in my organization began to receive calls to publish these documents to the entire organization as well as the public. Several spirited discussions ensued. On one side, strong opinions noted the need for full transparency as well as people’s “right” to have this information. On the other side was concern about placing additional (and potentially unwarranted) stress on the already anxious organization and community, particularly given how unlikely it was that the crisis standards would ever need to be implemented.
There was grave concern that publishing the standards might cause people to forgo urgent and emergent care out of fear that hospitals would not provide it. Both the organizational and clinical ethics committees wrestled with this transparency dilemma. In the end, a decision was reached that the crisis standards would not be released in full form. Instead, the hospital provided employees and the community assurance that a plan existed and outlined what was included, demonstrating responsible transparency.
The Power of Transparency
The push for greater transparency in healthcare is ever-increasing. For example, calls for price and cost transparency headline healthcare news outlets, as do demands from the public for disclosure about adverse events and their remediation.
When deployed responsibly, transparency has the power to enhance trust in our organizations. It makes us more accountable to all we serve—our patients, our communities and our people. As leaders, we need to make sure to carefully consider all the motivations for and potential effects of transparency and be prepared to respond to the outcome.
Susan A. Reeves, EdD, RN, CENP, is system chief nurse executive for Dartmouth Health, headquartered in Lebanon, N.H. (Susan.A.Reeves@hitchcock.org).