Physicians Leading | Leading Physicians

How Can You Tell If Trust and Respect Are Problems Among Clinicians and Non-Clinicians?

Interview · August 7, 2017

Laura Forese and Tom Lee

Read or listen to our interview with Laura Forese, MD, MPH, Executive Vice President and Chief Operating Officer for NewYork-Presbyterian.


Tom Lee: This is Tom Lee from NEJM Catalyst, and we are talking today with Laura Forese, a physician and orthopedic surgeon who is the Executive Vice President and Chief Operating Officer at NewYork-Presbyterian. I have learned in the last year or two that she and her colleagues, but she in particular, are doing very important work trying to build trust and respect among the clinicians and non-clinicians who work together to take care of patients at one of the biggest hospitals in one of the biggest cities in the world. You’re an orthopedic surgeon in a tough environment. What moves these issues to the top of your priority list?

Laura Forese: We have big aspirations at NewYork-Presbyterian, and we are not going to be able to achieve all of these unless we have everybody together, that concept of everyone growing in the same direction.

So we talk then about teamwork. It becomes very obvious that teams can’t be high performing at any level unless there is tremendous trust among the team members, and so it was starting to think about that that got us moving. Then we talked to our team members at all levels, in particular Steve Corwin, our CEO, and I spent a lot of time with our front line. We asked people what would really make a difference, and the word “respect” came up over and over and over again. That’s when it started to click for us that we needed to take that on and make that a priority in everything that we do.

Lee: In abstract, yes, of course, trust and respect are good things to have. But how can you tell if trust and respect are problems among your personnel? How can other leaders tell if they have a problem? How can you tell if you are making progress?

Forese: We just asked people, “How are we doing?” It was particularly important to get a sense of this notion around trust and respect because we have been growing very rapidly. For us at NewYork-Presbyterian, we’ve acquired additional hospitals and additional doctors now that we [had been] working with, and we started to talk a lot about culture, and it became very obvious that we needed to define what we meant by that.

So we heard people talking about respect and said maybe we have to define this in a very specific way. And so, for us, it became then about a concept of a culture of respect. Respect might mean something very different to me than it does to you. We went on to then define it. Our notion is, again, sort of credo now, which is something that we learned about as a best practice from other institutions — including your former institution, Tom — where we decided it starts out right at top.

“At NewYork-Presbyterian, every person in every role counts. We will treat everyone as a valued human being, considering his or her feelings, needs, ideas, and preferences, and we will honor everyone’s contribution to creating a healing environment for our patients and families.” Once we spelled that out, we put it in writing and we asked people, “Are we living up to that? Does that make sense?” We got a lot of interesting feedback, and it has allowed us to grow and define who we are, which has been important as we’ve taken that out to other institutions and other members of now our system.

You asked about how we know how it’s going. Well, we are tracking progress. As recently as a couple of months ago, we did a little pulse check, a little survey that we sent out to 20,000 people. We had more than a 30% response rate, and one of the things we asked was, “Are you seeing signs of this?” What the question was specifically [was], “I have seen efforts to build a culture of respect.” We had 75% of people who responded to the survey, so obviously not all, but 75% said they either agreed or strongly agreed with that. That was our notion that we have to keep checking on how this is going.

Lee: I agree completely [about] having your CEO, Steve Corwin, and the rest of your C-suite team make it very clear that it is really important to them. That’s definitely a critical first step. But how are you going about it right down at the front line, at the patient care unit level? What happens there?

Forese: Again, I will go back to our concept of a credo, which spells out very simple language: “these are things we will do and things we won’t do”, and, “I will not speak or act disrespectfully toward anyone.” This is posted everywhere now in the organization, and at the individual unit level and at every management level, people are talking about how they are using that, and it’s become a framework for saying, “Here’s where we’re not meeting that.” So it allowed us now to put teams together and say, “Well, look, our credo says that every person, every role counts.” So when we have now our huddles, we’re making sure to include the housekeeper in that. We’re making sure to include the transporter and the person who is delivering the food, and they’re actually being asked questions about that.

We round on staff, not on patients, as executives, and I was rounding in one of our emergency departments and asking some of our frontline team members how things were going. We would talk about, “Are you seeing this? Are you feeling it? What’s an example of using the credo and the culture of respect?” One of our housekeepers in the emergency department said to me, “The chief of the department asked me what I thought about how we interacted with this particular patient, and he cared about my discussing this because he knew that I had watched this patient throughout the day.” She was so proud of being part of that team, that little interaction. That is how we are driving it throughout that organization. I’ve told that story now, of course, many times, because it’s those opportunities that we have to demonstrate that in action that are really meaningful for the team.

Lee: Now, I hate to be trading stereotypes, but do you think it is extra tough to do this in New York City?

Forese: It’s funny you ask that, because one of the things we’re talking about is culture of respect. It’s really greeting people and making sure that team members all know each other’s names. It seems so obvious and self-evident. But in part, when you get on the subway in New York, you don’t necessarily greet everyone by name in that setting, and so we laugh and say we have to be explicit about some of our expectations and making sure that everybody understands what this means. That we’re in a diverse, multicultural city, and so it is important.

This has been a framework to allow us to say team norms will matter and how people are treating each other, and why it is important to talk about these things, but we do expect you to talk about them and make sure that everyone is on the same page. I don’t think it’s necessarily harder in New York, but it may be that we need to acknowledge everything that goes into this kind of multicultural framework.

Lee: Let me go into another stereotype. You’re a surgeon. Are there special approaches that are necessary or helpful among your surgical colleagues?

Forese: No, I don’t think it’s surgeon versus non-surgeon or specialist or even the different types of colleagues that we have throughout the hospital or in the health care system. But I do think it’s important for us all to be coming back to, what does this mean in our individual jobs? I mean, it’s easy for a surgeon to be brought back to “Hey, I can’t do the work of a surgeon if I don’t have a terrific team around me” — that notion of a high-functioning team. One of the things I always talk about [is] that during my clinical days, it [didn’t] matter how great my plan was, but if I wasn’t communicating it to everyone, then we weren’t going to be a team. So making sure everybody’s understanding that notion around communication, figuring out everyone’s role, here’s why every role counts. That brings it back to everyone no matter what the discipline.

Lee: I know that you and the rest of your colleagues in leadership at NYP have been thinking [about] and pushing on this now for at least a year or two. I’m sure at the beginning you must have had some people roll their eyes when you brought it up. How do you think it’s going?

Forese: For us, I think it’s going well, but we’re not satisfied that we’re done. Maybe we’re never done on something like this, that it’s always about reinforcing the culture. We’ve done important work, and you feel it and see it in terms of the employees. Part of it is that we have insisted that we’re talking about it all the time. I never am in front of a group of people where I’m not raising it, constantly connecting the dots. I think we do have more work to do, Tom, in terms of our work with physicians, and we didn’t do as good of a job as we should have over the course of this last year.

It went back to connecting the dots and make sure everyone sees it and feels it. One of the things we recommitted to ourselves is that we’re going to relaunch again with our physicians to make sure we’re getting to everyone. I started it with the orientation for our new residents and got very specific when I was describing to them our expectations around this culture of respect, what it would mean, and how they each would have a part to play as we go forward. So, more work to do but we’re excited about what we’ve achieved so far.

Lee: I’ll just close by saying that I think this work is really important, not just for NewYork-Presbyterian but for all of health care, because the team dynamic issues that you bring up are important for everyone. And as they say in that [Frank Sinatra] song, “If you can make it there, you can make it anywhere.” I think what you find that works in your culture at NewYork-Presbyterian is going to be very helpful for the rest of health care.

Thanks very much for joining us today, but thanks [especially] for doing this work. You can be sure that we’ll be tuning in and paying attention for years to come.

Forese: Terrific. Thanks so much for having me.


This interview originally appeared in NEJM Catalyst on July 11, 2017.

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