Dr. Sunita Mutha, Director of Healthforce Center at UCSF: Bridging Cultural Gaps to Provide Better Care

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, healthcare and workforce development explore new education to work approaches and innovations. I’m your host, Van Ton-Quinlivan CEO of Futuro Health. Naturally, we focus a lot on this show on training workers, but with our guest today, we’re going to spend some time talking about training leaders. Dr. Sunita Mutha is a clinician, professor of medicine and researcher with more than a decade of experience preparing leaders to improve health in their communities and beyond. But that’s just one focus for her. As director of Healthforce Center at the University of California San Francisco, Dr. Mutha partners with organizations nationwide to research critical issues from nurse staffing ratios to underrepresented minority dentists to the use of electronic health records. Her own research has focused on the intersection between quality improvement and healthcare disparities. She’s also a nationally recognized expert in culturally competent curriculum development, a topic I’m looking forward to exploring with her. Dr. Mutha, thanks so much for joining us today.

Dr. Sunita Mutha: It is my pleasure to be here. I’m excited to have this conversation with you.

Van Ton-Quinlivan: We would love an overview of Healthforce Center at UCSF. Can you talk about the organization’s focus on the health workforce and how the work has been changing in the last few years?

Dr. Sunita Mutha: My pleasure. So, a simple way to think about Healthforce Center is it’s your resource for everything that’s connected to the people in healthcare and their champions. Well, who do I mean when I say people? I mean providers of all types — dentists, physicians, nurses, community health workers, allied health professionals, and ultimately the students who will fill these roles in the future. And we connect them to champions, and champions are people like you. They are people who are influencers, they’re advocates, they are researchers they are other healthcare organizations, foundations, community-based organizations…really anyone that is interested and looking at understanding the workforce and thinking about how to change its capacity.

So really what we do at Healthforce is we are focused on both illuminating the issues by doing research that describes what’s working and what are we working towards, and then what could be. What does that future state look like? Our research focuses on who’s in the workforce, where are they located, what preparation do they have for their roles? What’s the demand for their roles and how will that change over time? One of the things that’s really unique about Healthforce Center is that we take that knowledge production that we do and we work relentlessly towards making care better by investing in people and identifying solutions. And for us, we know that without a workforce, there is no healthcare, so we take the information that we have and we turn it into solutions around capacity-building programs of different types, which we can talk about a little bit more.

Van Ton-Quinlivan: Dr. Mutha, you engage a lot with leaders and research, and I wonder if you could share with us what you think are the greatest healthcare workforce issues, gaps and trends right now?

Dr. Sunita Mutha: Yes, so there are several and I think this last year with the pandemic has really brought some of these longstanding issues to light and raised some new ones of concern. So, some of the things are that workforce is foundational. Without the workforce, we can’t really deliver care. It’s what makes access real. It’s what’s necessary for high quality outcomes. One of the things that’s really been clear, and it’s a longstanding issue, is that the workforce is not as diverse as our communities and that matters for many reasons that maybe we’ll touch on a little bit. We also have learned that our information about workforce is not perfect, that we don’t always have the data systems that we want to collect information or to connect it to outcomes.

I think other trends are that who we talk about when we talk about workforce has greatly expanded, as it rightly should. We’re talking about a larger team of individuals who are coming together to work to provide care. We’re talking about people that are not narrowly defined by geography or by where they practice or deliver services, so they’re outside the bounds of our usual clinics and hospitals. We’re talking about different categories of workers. And then probably one last thing I’ll add in terms of a trend is this whole issue around burnout and wellness of our workers.

Van Ton-Quinlivan: Can I ask a clarifying question? When you say the information on workforce is not perfect and we can’t connect it to outcomes, are you talking about health outcomes or you’re talking about other outcomes?

Dr. Sunita Mutha: I’m talking about that we have many different types of workers, and we don’t actually have very good information necessarily about how many there are of certain types of workers. We don’t track or capture all of that information as well as we’d like to be thoughtful and systematic about matching where the workforce is and who’s available to where the need is. So, some of it’s data systems to describe who’s in the workforce and the other is to utilize it to deliver good care. In some cases, we can connect it to the quality of care, but not always.

Van Ton-Quinlivan: I see. So, this topic of burnout. I have heard about it alluded to by doctors from Kaiser Permanente who serve on my board, and it’s all in the context of bringing joy to the work as a way to prevent burnout. Could you give us a little bit more detail on what is happening?

Dr. Sunita Mutha: You know, what’s interesting is that this has actually probably been a topic of conversation in the background, and it really started out looking at physician workforce. But what’s really important to keep in mind is that it involves actually much of the workforce beyond physicians. It includes nurses and other groups, not all of them are as well studied. So, in the background, we’ve been hearing for a while that physicians are burnt out and trying to understand what the forces are. Is it the electronic health record and some of those demands? Is it the demands about other things in the way our system operates? Is it productivity demands? All of those things. What’s really changed is a recognition, particularly in this era of a pandemic, that the issues are much broader than burnout among physicians, that the issues matter because they matter for health outcomes for patients.

They also matter because people have poor outcomes themselves: increased rates of suicide in populations with higher rates of burnout; more people who are projecting that they will leave the workforce or contemplating leaving the workforce earlier than they might expect. As the data starts to get more robust, we start to realize this isn’t one group that’s affected, it’s many of the workers. Nurses experience burnout. There are burnout reports internationally around other types of health workers such as dentists and physical therapists. So, there are things going on in our systems and the way we deliver care that are contributing to this. I think we have a pretty good definition now. It matters. It’s not just people who are unhappy or complaining. It’s involving larger groups of people. We have some ideas of interventions that seem to be beneficial and helpful at an individual level, and now we’re trying to understand what does that actually mean at a systems level or for other levers that we can use to improve this issue?

Van Ton-Quinlivan: Well, this is very distressing news because of the wide and large gap that we have in the workforce. The allied health workforce has a need for 500,000 more workers in California alone, and we had this issue where the pandemic stopped the next generation from actually getting clinical hours as required for licensure. So now, if we also have this burnout phenomenon, we really need to focus on developing our workforce development pipeline.

Dr. Sunita Mutha: Absolutely.

Van Ton-Quinlivan: Dr. Mutha, tell us about the capacity work that you’re doing within Healthforce and what is the range of health workers involved in your experiential leadership programs? How are you developing them?

Dr. Sunita Mutha: So there’s three types of capacity building work that Healthforce Center does. We train individual leaders to be more effective. They’re better at leading within their organizations and outside their organizations. The second way we do it is we connect leaders and organizations so they can come together for collective change. The third way is we consult to organizations to help them identify strategies to enact changes that increase their capacity to understand the landscape and by collecting and synthesizing information that informs solutions. So, there are three really big buckets.

One really important one to us is the one that you highlighted. It’s around leadership training. In our leadership training programs, we focus on the gamut. We focus on proven leaders who are looking to get to the next stage of impact. They want to lead at a larger scale, bigger, with different kinds of risks, or perhaps really pivot from a delivery system to working in a place where they might be directing policy. We also focus on emerging leaders, and we think both are really important. For us, an example of an emerging leader would be managers, first time managers. They’re the glue that keeps an organization functioning and effective. They mobilize the frontline teams. So, we instill in them both confidence and skills so they can be really effective.

Van Ton-Quinlivan: When I talk about workforce development, I think about technical skills but also what has traditionally been called the soft skills. Some people call it employability skills. Some people call it human plus skills. They’re the transferable skills, and very important in the provision of care. It’s interesting that even at the higher level, at the managerial and administrative level, the development continues — not only building your technical acumen but also your leadership acumen. As a matter of fact, last year we underwrote 153 individuals from the public health clinics to go learn how to lift the telehealth function in their organizations. So. that’s developing the technical skills, but the changing of workflows requires a lot of the leadership skills that you’re talking about. Maybe we should nominate them to go to your program here!

Dr. Sunita Mutha: (laughs) Well, we would love to have them. We agree with you. There are technical skills for every one of our roles and any one of our leadership roles. If you’re the chief financial officer, you have to understand the flow of money and funds and all of those things — and you can say that for any one of the roles — but what we realize in any leadership role is that failure is not because of a lack of technical skills. Usually, it’s from a lack of leadership skills, people management skills, how you mobilize a group. We focus a lot on the skills that you’ve described that we call the people-relational, and we also just call them leadership skills, that deal with how you get groups to move in a similar or same direction.

Van Ton-Quinlivan: Wisely stated. Now, I’ve been dying to get to this set of questions. Dr. Mutha, you served on multiple panels and boards, including the Joint Commission, to develop standards for culturally competent care. Can you help us understand what cultural competency means and why it’s so important to health equity?

Dr. Sunita Mutha: Now you’re touching on something that is a passion for me. So, what I’ll describe is first to acknowledge there are disparities and inequities in health and it’s the recognition of that which has been long coming. We have measured it in probably every way possible. We realize, yes, it happens. As a response, the focus has been to identify what was then termed culturally competent care, which is how do you provide tailored care to meet the needs of an individual? Whether it’s that they speak a language other than English, they have a cultural belief that shapes how they access care or interact with healthcare settings, or more. A great example currently is the vaccine hesitancy that we’ve been talking about. Why is it that people have it? How do we meet them where they are? Many would say that culturally competent care is really responsive care. It is tailored to the individual and their set of unique issues, and we can predict what a lot of those are.

What’s interesting, though, about this is that one really important thing has changed: most of us are now willing to recognize — because of the way our world has changed — and vocalize that an important issue in these disparities in care is structural racism. It’s not about individual patients with individual vulnerabilities. It’s about the predictable ways in which systems advantage or disadvantage some groups. And the advantages might be small. They might be advantaging people who have flexibility in their work hours by the time at which we provide services. So, if I have more flexibility in when I can get that mammogram, I might just do a better job of being able to get the mammogram because I can accommodate that in my work schedule. Whereas if a service is designed differently and it requires me to take time off from work and is only offered during certain times, I might not be able to get access to care that I might actually believe in and want, and so I’m going to show up with a differential health outcome.

All of this work with the Joint Commission and others was really designed to say let’s get rid of the predictable things that influence these inequities in care. Let’s try to provide interpreters for patients who have language barriers and be consistent about it and say this is how we’re going to do it and this is how we’re going to measure how well we did it. In other cases, we’re going to actually just really think about our processes differently and be mindful of who’s coming in for care and how are we providing care in the way that they can best access it.

Van Ton-Quinlivan: What about lived experience? How important is lived experience in the provision of care?

Dr. Sunita Mutha: I think it’s really important. I think as our understanding has really improved and our thinking and our expansiveness about who is in the workforce, that has been a great example. So, two great examples that I know you are very familiar with are community health workers and recognizing the lived experience of understanding what the beliefs might be of a group, what the barriers might be to accessing care or achieving those outcomes. In another case around substance use disorders, it’s peer providers — people who have lived experience and can understand and help meet patients and clients where they are in order to help them get to better care when they can’t really get the full benefits of all the systems and therapeutic options and things we do now have. So, it’s really, really important to be able to have that when it’s possible.

Van Ton-Quinlivan: I’m curious, on the point of cultural competence, can you train that or does someone have to come with that?

Dr. Sunita Mutha: We believe that everyone can and should be trained in it. None of us is culturally competent for everything or for every group of individuals. When we did a lot of our training, we just said, “You know what, there are predictable things around the way we communicate that we can actually train people in.”  And I’ll use the example of when people go to professional school or any kind of clinical training or certificate program we are trained to be able to do that job well, and the same is true for cultural competency. I might be highly culturally competent for a particular group that I have a lot of familiarity with, I have a lot of experience with and maybe I have lived experience with. But the next patient might be somebody that I actually know very little about. And so in this work around developing capacity and training people is giving people the tools to actually fill those gaps and saying it’s not by chance and it’s not by whether or not you look like the people that you are helping to take care of and provide services for, but that you can bridge those gaps.

Van Ton-Quinlivan: Is this something that you can actually measure and evaluate in a person? How would I select somebody or screen somebody in an interviewing process on whether or not they would perform well on cultural competency?

Dr. Sunita Mutha: Well, there’s different ways, I think, that you could try to do that. We focus on the skill base piece. So, getting back to the earlier part of our conversation, we focus on communication skills. If you did a training and you allowed people to have better tools to be culturally competent, who better to ask than patients as to whether or not they actually are able to perform? Do they connect with you in an effective way? Are they able to communicate with you in a way that you understand and can follow directions? So, yes, you can train to it. You can do process measures to see how effective a training might be. The Holy Grail is always, “Did this lead to better care?”

We have some evidence that that can be the case. Is it as strong as we’d like? No, but I think we’ve also realized that as with every complex problem that we are solving in our healthcare systems, we have to use multiple strategies to get to a solution. Training alone isn’t enough. We need a diverse workforce. We need systems that reinforce good access.  Like access to interpreters. That’s been, I think, a game changer for us in the last 20 years in terms of getting rid of barriers that have been problematic to getting good and high-quality care.

Van Ton-Quinlivan: Maybe you could close the loop on this, Dr. Mutha. What’s an example of how health outcomes do differ when you have a culturally competent workforce?

Dr. Sunita Mutha: There’s a couple of great studies that have actually tried to crosswalk that for us. I’ll give you two examples. A more recent example is birth outcomes for black women. We know that infant mortality rates are much higher for black women, but that can change when we have care that is delivered by culturally competent workforce. A recent study showed that women whose care providers also share their background — they’re black — do better. They have better health outcomes, and we think that that gap is that cultural competence piece. We have really robust data around diabetes care, that when there is cultural concordance or language concordance between the patient and the clinician, then diabetes care is better. So, I think there’s really good data that helps demonstrate that this thing that seems like the right thing to do and a good thing to do for engagement, actually leads to better care.

Van Ton-Quinlivan: Those are great examples of the imperative of getting a diverse workforce. How do you approach training culturally competent skills and what have you found to be the biggest challenges?

Dr. Sunita Mutha: How we approach it, is we have always said it’s both head work, heart work and hand work. Head work is, you have to have better awareness. You have to understand that there is a problem currently. That creates a willingness and a desire to change, to have different behaviors. The heart work is empathy. It’s recognition and humility that you may not know everything that there is to know about a particular group, that there may be a gap that is beyond a clinical knowledge gap in really understanding and meeting the needs of a population. And the hand work is, in cultural competency, a lot of the skills are around communication skills. But there are also systems skills around quality improvement and things like that.

I think the biggest challenge for a long time was the willingness to connect the dots between recognizing we have decades of work that showed us that there were differences in outcomes among populations. And then I think we finally just said, “We can’t just accept that that’s OK.” So, it was overcoming that acceptance to say it can be different, it should be different so now let’s try strategies to improve it. We’ve talked about some of those strategies: training the workforce; getting better diversity of our who’s in our workforce; expanding who our teams are to deliver that care in translation or interpreter services. So, I think it requires actors at every different level. There’s that individual change you have to make, you have to have the humility to recognize you don’t know. Then there are supporting structures.

Van Ton-Quinlivan: Can you give me an example of a supporting structure that you would love to improve?

Dr. Sunita Mutha: Oh, there’s so many. (laughs) If I could choose one improvement, it would be that our awareness is integrated in everything we do. So let me give you a really pragmatic example. Our vaccine rollout has been challenging for so many reasons and we think we understand some of the reasons. It might be around knowledge, it might be around hesitancy, it might be experience, it might be questioning the science.  But when we look at it from a systems side, one of the barriers for us is we are trying to do two really hard tasks at one time.

We want to get the vaccine out quickly and we want to get it to as many people as we can and do it efficiently. One strategy we’ve all used is, “Let’s reach out to our patients electronically, get them signed on, get them signed up, get them connected to places where they can go for vaccines.” Who does that leave out? It leaves out people who don’t have online access, who might be monolingual, who might be elderly and they might be isolated. In that way, you could look at it and say, “You could have predicted who you would leave out by the strategies we chose to use.” And so that that’s my example of how I would like to have this embedded in all of our work at all times, and maybe we should be asking ourselves the question frequently, if not always, “Who does this advantage and who does this disadvantage?”

Van Ton-Quinlivan: In a way, I would imagine your leadership students would be asking these questions of themselves as they think about all sorts of policy decisions and programmatic decisions. What’s predictable? Who would be advantaged and who would be disadvantaged? That’s a great critical thinking skill. I am learning so much from you during this conversation, and I want to end by asking you the question, what are you working on now that excites you the most?

Dr. Sunita Mutha: I am working on two things, because I can never choose one. I’m working on really trying to better understand this issue we discussed about health worker wellness, how that’s changed with COVID and what are the systems solutions that we can think of to improve wellness for workers? Is it better pay? Is it mental health support? The reality is, I don’t think there is one solution, but just really looking thoughtfully at those and then how do we try them and how do we demonstrate what works well so that we can do it?

The other one, and the part that I think is a passion project for a very long time, is a piece that you’ve touched on several times. We have some really terrific leaders we have worked with and what’s been really heartening and inspiring to see is in this era of a pandemic, when there were so many things that needed to happen and change, those groups came together collectively to be advocates for change and to think ahead about the change that was needed and how to work across silos to help move in the right direction. So, that leadership piece and watching leaders in action and watching leaders really be able to use a full range of tools in their suite of skills, has just been fantastic to do. I think there’s just so many opportunities now in healthcare to see more of it and we need it. We have really complex problems to solve and we need everyone working together to do it.

Van Ton-Quinlivan: We do have complex problems. Thank you so much for being focused on wellness and burnout, as well as building capacity for future leaders. I’m Van Ton-Quinlivan with Futuro Health. Thank you, Dr. Mutha, for being with us today.

Dr. Sunita Mutha: My pleasure. Thank you so much.

Van Ton-Quinlivan: Thank you to the audience for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.