Cheryl Martin (Host): Coming up next, the sixth episode in a series of conversations with Dr. Marcelle Davis, Vice President and Chief Inclusive Excellence Officer at VCU Health, and team members throughout our health care system about their commitment to inclusive excellence and its impact on health. Today, along with Dr. Davis, we're pleased to welcome Nathan Cunningham, Associate Vice President of Patient Experience. He'll discuss how the focus on patient services impacts our patients and the community as a whole.

This is Healthy with VCU Health. I'm Cheryl Martin. Dr. Davis, it's great to have you back on Healthy with VCU Health.

You have been very strategic when it comes to inviting experts from your organization based on their experience to speak on the topic of inclusive excellence. Share your thought process with us and what led you to our guest this episode.

Marcelle Davis, DSL: Cheryl, thank you so much for having us back today. It's always a pleasure to be here to share the incredible work that's happening across the health system and really our leader's commitment to advancing health outcomes. And Nathan's role has a large scope in that he oversees key areas like the language services department, patient relations and patient experience.

And those areas are patient-facing and connect directly with our diverse patient population. And his team's commitment to inclusive excellence ensures that as a health system, we can effectively advance health outcomes. And that's really why I thought he would be fantastic to hear from today.

Host: So, Mr. Cunningham, let me say we're delighted that you're a guest on this sixth episode, and now that you've heard why you are here, tell us a bit about yourself and your role.

Nathan Cunningham, MPH: Well, thank you, Cheryl, and thank you both very dearly for inviting me today. I've been a listener of the prior conversations with their fascinating insights, and I greatly appreciate the opportunity to now join that esteemed group of podcast alumni. So, I actually started my career with the Philadelphia Eagles and the Philadelphia Phillies in the stadium operations realm, really overseeing concourse operations during events.

Then with my dual undergraduate minors in public health and disability studies, healthcare policy has always really been a passion of mine. In fact, when the Affordable Care Act, nicknamed Obamacare, when that legislation was first released to the public, I actually downloaded it and began spending my evenings reading through it.

Um, I know what you're thinking, I have some quite exhilarating downtime hobbies, but really my fascination with that groundbreaking piece of legislation is what led me into healthcare. It led me to Tennessee for graduate school focusing in healthcare management and policy. That kick started my first healthcare career, again in East Tennessee for a health system, Wellmont Health, now named Ballard Health.

I was working in performance improvement. Then I moved to Texas. I joined Houston Methodist Hospital, solely focusing on patient experience. And then finally to my home, VCU Health. And I've been with VCU Health for just over eight years now, and in my current role, I am responsible for the Department of Arts and Healthcare, Department of Language Services, Department of Volunteer Services, Gift Shop, Retail Space, and of course, our Patient Experience Departments and the general programs that fall under Patient Centered Services.

So, among all of those departments is of course, a unified mission. We're here to improve not just how we deliver that care, but how do we communicate that care for all of our patient population, our entire patient population. And aligned with our health system mission, as it states, we preserve and restore health for all people of Virginia and beyond through innovation, service, research, and education. And I just absolutely love the inclusion of the phrase for all people in that mission statement. They really aren't just words here.

Host: Thank you so much for sharing, and it's clear that you have a passion for what you do. Dr. Davis, what does inclusive excellence mean for the patients Mr. Cunningham's team serves?

Marcelle Davis, DSL: Yeah. So, thank you so much for that question, but let me start by saying now, I hope it's clear why Nathan is one of my favorite people. I knew a lot about your background, Nathan, but I had no idea the connection to the Philadelphia Eagles. So, you know, growing up in Brooklyn, there was a significant rivalry between the Giants and the Eagles, but that's another conversation for another day.

Inclusive excellence really is a strategic enabler to safe quality care. In other words, when we apply the principles of inclusive excellence, we are better able to support all patients by expanding our efforts related to diversity, equity, and inclusion. And Nathan shared, pieces of our mission, but that really is about supporting all patients. And this particular body of work in terms of inclusive excellence; this really is critical for the patients that Mr. Cunningham's team serves.

Host: Mr. Cunningham, as most of our listeners are aware, our communities are becoming more and more diverse in every aspect we can think of, and of course, most notably, are the various languages we speak. So how has your organization pivoted to meet the needs of your patients to provide the language services they need?

Nathan Cunningham, MPH: Well, first and foremost, I'm very proud of this organization being an early adopter and recognizing and embracing that diversity is a strength. Period. End of sentence. And language has always been incredibly fascinating to me. In the United States, for example, 21 percent of citizens 5 years or older, are speaking a language other than English at home.

And of that 21%, 62 percent are speaking Spanish, a considerable majority, of course. So, VCU Health's patient population, very interestingly, represents that diversity in language. Our language services team monitors, on average, over 140,000 appointments and clinical encounters annually, that has spanned over 150 languages in the last two years alone. So, the sheer magnitude of those figures are astounding to conceptualize, and the predominant majority of those appointments are Spanish speaking patients and families. And early into my time here, we noticed our Spanish speaking volumes increase by about 10,000, or really by at least 10,000 appointments and encounters year after year. So, recognizing that we have this growing patient population in our community, especially in pediatrics, the organization has committed to the growth of our in-person interpreter team and really the advancement of our remote interpretation technologies that include video interpretation and audio only interpretations.

Our language services team is now 27 members strong. We have interpreters, we have document translation specialists, all serving our Virginia communities and beyond. And I fervently believe that VCU Health System has the strongest language access across the Commonwealth.

Host: Wow. What have you seen as the biggest impact or benefit of providing these language services to your patients?

Nathan Cunningham, MPH: It's a great question, and you may have noticed that in that last sentence, I used the term language access. Improving language access really is the ultimate goal, and it's a goal truly rooted in equity. No patient or family should have a healthcare experience any different than an English-speaking patient or family. And I think we, as well as our listeners, would agree that all patients and families should receive effective communication in the healthcare setting. I think we believe that all patients and families should understand what is happening and should feel welcome to ask those clarifying questions.

Now replace that word should. Replace it with deserve in those statements. And that, Cheryl, is our impact. Simply put, improving health equity for these community groups really ensures that our health system has pathways that are easy to navigate for patients from all backgrounds and from all different languages.

And we know that we're effective in meeting that goal of improving our language access because we see our volumes continually grow. In healthcare, reputation is very heavily carried by word of mouth, and it's very valuable in our patient communities. A brief tangent on that point if I may. I recall a few years ago in 2022, we had a Romanian patient start coming to a very specific specialty that I won't publicly name to protect the privacy, but we recognized that this was a language that we traditionally did not see very often. So, we worked to provide strong interpretation services for that patient.

Host: I love the fact that you all are so committed to being there and assisting these particular groups and they know that. I love the example you gave of the Romanian patient. So, this is wonderful. So, are there any challenges you've encountered that you would like to share with us?

Nathan Cunningham, MPH: The first challenge that we often encounter is, of course, our increasing patient volumes. In response to the growing language access needs, we've developed an internal prioritization guide or ladder on how we assign in-person interpreting versus those remote interpreting services.

Another challenge that I think we often come up against is differentiating language spoken versus preferred language for healthcare communication. Medical terminology is obviously very difficult and it's very difficult in English as well because we have so many words for the same thing. We have so many synonyms across our beautiful language. And just because a patient checks in at the front desk and can answer basic demographic or insurance questions in English, does not mean that that patient prefers English for the remainder of their clinical conversations with providers. And this misnomer is an important tactic that we teach to our team members to make sure that we're honoring our patients' individual preferences and really ensuring that the patient is understanding what's happening to them there for their health.

Health is so sensitive and so intimate, and we want to make sure that all of our patients have a full understanding and we're going to do whatever we can to make sure that that happens. Healthcare communication is not a one size fits all model, and we fully recognize that. And I'd say the last challenge that we often come up against is patients fear of asking for an interpreter or for a translated document.

And something I really hope all of your listeners can walk away today knowing, is that healthcare interpretation is free. No healthcare organization in the United States can ever charge a patient or an inpatient's insurance for use of an interpreter or translator.

Host: That's good to know. Thanks for sharing that. Let's switch gears a bit. Now, you mentioned that you provide the best or strongest language access in healthcare in Virginia. So, how do you prepare your team, including the language services team, to ensure patients have an optimal experience?

Nathan Cunningham, MPH: That's really where the rubber meets the road, right? You can bring in the resources, you can bring in the infrastructure, but how do your processes make sure that that is a fluid and efficient model for delivering care? The first is cohesion. It's cohesion among our clinical teams. How do we integrate our interpreters into a clinical team? We fully believe at VCU Health that, interpreters are part of the clinical team, but it's not a traditional model that's taught out of medical schools. So really working with our provider teams and our nursing colleagues and our social work and care coordinators and ORs and making sure that they fully understand the value and also necessity of having an in-person interpreter or an interpreter through remote services involved in every step of that care. And we help with that by embedding our in-person interpreters through various very high utilization areas on a rotating basis. So, we will always have an interpreter for example, on our labor and delivery and mother infant units because we have a very high utilization rate. So, if you're here, you're guaranteed during a week, to have in-person interpreters for that entire care. Then we really focus a lot with the team on continuing education.

You know, we are an academic health system. Academia is part of our mission. And so, we really want to promote and even compensate our team members for completing annual trainings and additional certifications. You know, you can get language certifications in various specialties, like oncology, for example, which has extraordinarily complex language, especially when interpreting.

Whether it's just that certification or a very specific two-day course. We actually sent a team member to Alabama for a four-day course in a very, very specialized and high degree of difficulty American Sign Language course. We really pride our team, at least I'm proud of our team for their unquenchable thirst for really growing that interpretation repertoire and skill set.

And I think the third reason that we are as strong as we are, it's because we do such a good job communicating to patients about the availability and the free cost of our services.

Host: Well, it looks like you are definitely on the right road, and you've accomplished so much so far. Dr. Davis, I want to bring you in here. What is your ultimate goal in ensuring that patients feel that they have a safe space when seeking services?

Marcelle Davis, DSL: Nathan shared three reasons why his team is a key part of ensuring optimal patient experience. But really, I'd like to add a fourth. And that last one really is his leadership. His advocacy for patients truly is bar none, because in order to support our patients and ensure that they receive safe, quality care, it means that he advocates significantly for his team.

Which, based on everything he's shared, we can clearly see. And so here at VCU Health, we strive to be a healthcare provider of choice for every single person that we come into contact with. And, to achieve this, it means that our patients have to feel safe getting care here. So, there are things that we have to put in place to ensure that we fully understand the patients we serve and what their experiences are when they come to us for treatment.

And so, this really encompasses various things, but one of the key initiatives that the Office of Inclusive Excellence is working on, is hosting scaled events that include the community that also increases access to care. A second initiative is continuing to increase awareness and build skill sets to our team members to ensure that we that they have the tools and resources necessary to respectfully engage with our patients and provide that optimal care that we've been talking about.

And as you can imagine, both of these initiatives involve collaboration with teams across the health system, including Mr. Cunningham's team.

Host: Final question for both of you, Mr. Cunningham and Dr. Davis. Tell us, are there any exciting projects you'd like to share with our listeners that they should be aware of that would benefit them, or perhaps any benefits or services available to our patient community that they may not be using at full capacity? Let's begin with you, Dr. Davis.

Marcelle Davis, DSL: Cheryl, thank you so much. It's always a pleasure to share what we're doing in the Office of Inclusive Excellence. And my team is always looking for ways to partner, with Mr. Cunningham's team. And this year we kicked off a couple of inaugural events that united the community. It brought together the academic campus and the healthcare campus and really showed the integration of inclusive excellence in arts, healthcare and education. The first event was a celebration and community walk in honor of Dr. Martin Luther King, Jr. And the second was a cultural festival in June, that celebrated Pride, Juneteenth, and Caribbean American Heritage Month. We had an incredible turnout for both of these community events, and we plan to repeat them in 2025. So, we look forward to seeing you all there.

Host: Mr. Cunningham?

Nathan Cunningham, MPH: Well, first I have to thank Dr. Davis for such glowing words about me. I adore working with her and her team as well. So, regarding exciting projects, there's one that I love to boast of and now I have a platform to do so. So, I absolutely will take advantage of that. Last year, we really started looking at our data from a different perspective.

When I say data, I mean to reflect our patient satisfaction data. The surveys that our patients fill out and send back to us, so we can know, are we meeting the mark? And it's not just a measure of if they're happier. I disdain the phrase patient satisfaction, because nowhere on the survey does it ask, were you satisfied?

There are very specific questions about different communication practices and discharge practices, and were you able to receive the help you needed as soon as you wanted it? So, we wanted to look at all of that data collection, and we have hundreds of thousands of surveys that we can use for all of these data points annually.

And we found a very interesting disparity that we immediately decided to hone in on. So, when we looked at the question on the inpatient discharge survey, that did you have a good understanding for managing your health at home? We suddenly saw a huge disparity between our English-speaking patients and non-English speaking patients.

Our non-English speaking patients were answering favorably to that question at only a 53.5 percent mark at the beginning of 2023. That was a 30-point difference from our English-speaking patients who rated us about 85 percent of the time, favorably. Obviously, that gap is unacceptable. So, we engaged a very large interdisciplinary group of different team members, providers, social workers, care coordination experts, to really identify some root causes for that disparity.

We identified that while clinical communications were being translated into non-English languages quite effectively, and that interpretation was being effectively provided, some of the supplemental resources were unfortunately only being offered and educated using English. For example, VCU Health's Labor and Delivery and their postpartum sister unit, the mother-infant unit, they offered phone lines for patients post discharge to call with questions or concerns related to lactation or just general postpartum health.

But that service was only offered in English, as well as education materials about that service. So, we evolved it to offer a Spanish line and Spanish language resources that could be pre-printed and pre-provided to our patients prior to discharge. And we really enhanced those pre-discharge tools across the board.

We wanted to make sure that everything was offered in a wide variety and a varying array of languages that could be available at a moment's notice to our patients. We also realized that leader rounds, when our nursing and physician leaders were checking on patients, sometimes that those questions being monitored, were not being used in the language preferable to the patient.

So, for example, if we asked them to fill out this five-question little mini in-house surveys to see how are things going, it was only offered in English. So, it was underrepresented for non-English speaking patients. So, we're very proud to report that after some of the improvement efforts I've already mentioned and many, many aspects, after that performance improvement went through, we started monitoring and monitoring, we saw that 53.5 rate of favorability for non-English speaking patients having a good understanding for managing health at home; we saw 53.5 jump to an 87.5 by year's end.

And then to answer the second part of your question, I believe was regarding benefits or services available to our community that may be underutilized. Two really come to mind immediately. And the first is our offering of patient family advisory councils. In 2008, we were one of the first 10 organizations in the nation to really dedicate resources around standing up these interdisciplinary councils where patients, past and present and their family members can come to our tables, join in our meetings.

I'm not hyperbolizing, literally bringing patients and their family members to board meetings, to our executive meetings, to the meetings where decisions are made, and making sure that their voice was captured and that their perspective was understood. We didn't want to keep making decisions and growing as an organization in a direction that didn't meet our patients’ needs.

And that was a huge aspect. So any patients or family members out there, that want to participate or have an urge to have their voice further heard, I highly encourage you to go to the VCU Health website or just search for Patient Family Advisory Council, VCU Health, or PFAC, P-F-A-C V-C-U Health, and you'll come to our page where you can easily join one of our groups.

And the second, excellent services that I think are often underutilized are our inclusive offerings through the Arts in Healthcare program. We have the second oldest Arts in Healthcare program in the nation, starting in the late 70s. And while this team contributes clinically in the form of music and art therapy, we also look at our offerings from a holistic model lens.

Again, we recognize that healthcare is not a one size fits all model for everyone. So, we really intentionally diversify our artwork collections throughout the environment, our rotating artist galleries to really reflect the way our community looks, practices religion, and celebrates all culture. It really makes this be such an incredible world class health system, not just to deliver care and work at, but also to receive care.

Host: It is really obvious just listening to you, that VCU Health is not content with just resting on its laurels, but you're constantly examining things to see what you can tweak to take it to the next level and to be more excellent. This has been wonderful, wonderful. As we close our podcast, I just want to reiterate VCU Health's mission, and it is to preserve and restore health for all people of Virginia and beyond through innovation and service, research, and education.

Thank you to our guests this episode, Dr. Marcelle Davis and Nathan Cunningham for putting that mission at the center of what you do. For more information on VCU Health's commitment to inclusive excellence, visit vcuhealth.org/DEI. And to listen to other podcasts from VCU Health that may be of interest to you, visit vcuhealth.org./podcast. This is Healthy with VCU Health. Thanks for listening.