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Meredith Foxx, MSN, MBA, APRN, NEA-BC, PCNS-BC, PPCNP-BC, CPON, Chief Executive Nursing Officer of Cleveland Clinic, joins host Brian Bolwell, MD, on this episode of Beyond Leadership to discuss lessons learned throughout her nursing career, how to lead people, and the importance of finding the joy in every moment, including at work.

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Find the Joy

Podcast Transcript

Brian Bolwell, MD: Beyond leadership, a Cleveland Clinic podcast at the intersection of leadership and everything else. In this podcast, we will co-mingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

Hello everyone. I'm your host, Dr. Brian Bolwell, and today I'm delighted to be joined by Meredith Foxx. Meredith is the Executive Chief Nursing Officer at Cleveland Clinic. Meredith, welcome to Beyond Leadership.

Meredith Foxx, APRN, MSN, MBA: Thank you so much, Brian. So happy to be here today.

Brian Bolwell, MD: So, this is a treat for us. Nursing is certainly on the front pages of most newspapers, including the New York Times and others. But before we get to that, tell us about your career and how you came to be the Executive Chief Nursing Officer here at the clinic.

Meredith Foxx, APRN, MSN, MBA: So, it's been quite an adventure. I'm celebrating 20 years at the Cleveland Clinic this year, and some days it's hard to believe that I've already been in healthcare close to 25 years, thinking that I sometimes feel the same age as the residents and medical students still. So, hard to believe that I am over two decades within my professional journey. I started out as a nurse associate here at the Cleveland Clinic when I was in nursing school, and we still have that program here today, which is one of our most seasoned programs and well-respected programs within nursing where we garner a lot of our new graduate nurses. It's a summer program that allows nursing students to work at a little bit of an advanced role, obviously within guardrails and boundaries, but really learn the profession and what it takes to be a nurse at the bedside.

I started out in pediatrics and have been a pediatric nurse my entire career, specifically within pediatric oncology was where I found my love. I think about when I was in nursing school and I went to school out of state of Cleveland, Ohio and I was volunteering, and I had a patient that I was taking care of, and I knew the patient as I was spending time with him as a volunteer. I knew he had had something wrong with him chronically for some time, but I didn't know exactly what it was until I found out later when I transitioned to being a nurse that he had graft versus host disease as a pediatric bone marrow transplant patient. That's where I really found my love with taking care of pediatric oncology patients. Most people say, oh, my gosh. That's so sad. How could you take care of kids with cancer?

But what I would say about those patients and their families is that they truly are the most resilient individuals and families I've ever seen. They overcome and find really, sometimes, what the joy in what that illness is. To be honest, childhood cancer has a very high survival rate. So, I'm able to see kids survive cancer, become adults, have their own kids become nurses themselves, and that's been very rewarding. So, I spent the most of my clinical career taking care of pediatric oncology patients and critical care patients and then transitioned to an advanced practice nurse, both as a nurse practitioner and as a clinical nurse specialist. Most people don't know what a clinical nurse specialist is, but it is a type of advanced practice nurse that not only works with a patient population but also works with the team. So, works closely on quality improvement, working with nurses, working on system problems.

So, when I think about my nursing career so far, that was one of the best jobs, got so much autonomy, innovation, idea creation, and really improving care at the bedside for all kinds of different patient populations. When I think about going into leadership as a nurse leader, it's been a little bit over a decade now that I've been in nursing leadership, what has rang true my entire career is I've always said yes to opportunities. So, whenever someone said, hey, would you like to get involved and do this? Would you like to be the charge nurse? Would you like to take a student? Would you volunteer for this committee? I always said yes. I believe that's really served me very well in terms of my career opportunities, whether it's been to take on a new role, take a risk, or really also giving me opportunities to present and publish and do different professional development activities as well.

So, one day I was asked to take on the oversight of an advanced practice nurse group, temporarily, and I said yes. Now six months later I was interviewing and being named the senior director for advanced practice nursing at the Cleveland Clinic. Subsequently, within a few years became the Associate Chief Nursing Officer, the first named one for advanced practice nursing at the Cleveland Clinic. At that time, advanced practice nursing was really growing and blossoming not only with APRNs but also PAs. So that idea of an advanced practice provider and the growth was becoming tremendous throughout the Cleveland Clinic but across the United States, and really an opportunity to create a structure for those disciplines and those providers within our organization and had the opportunity to lead from around 450 advanced practice nurses in our organization to now we're pushing over 1,500, close to 2,000.

So that's been pretty exciting. I will say my love's always been on the quality patient satisfaction, quality improvement, safety, how do we make care better? How do we deliver care better? I had the opportunity to take on quality and nursing practice within my Associate Chief Nursing Officer role as well. So, it just expanded my scope of responsibilities, again, going back to that quality, safety experience, professional practice improvements, and really fell in love with that piece of the role leading nursing quality and partnering with our hospital quality and safety individuals on how we can improve infection rates, how we can improve safety. A few things come to mind in terms of thinking about how we monitor patients or how we prevent infections. So, my passion's always been there, but my passion hasn't been with those improvements. It's been more about getting other people passionate about that and leading through others. That's always been my greatest reward and leading others and developing others.

So how I got to being the executive chief nursing officer here. Well, during the pandemic it was 2020 and Kelly Hancock was serving as the Executive Chief Nursing Officer and she was asked to take on the chief caregiver officer role and she graciously, and probably one of the most humbling things I've been asked to be interim ECNO. As that transition was happening, I then was afforded the opportunity to be considered for the role and interview and was named the Executive Chief Nursing Officer of the Cleveland Clinic in fall of 2020, which, if you would've asked me when I was a staff nurse, when I was a clinical nurse specialist, even when I was a director is this is where I would've saw myself. I don't think I would've said, "Oh, yes. I would've saw myself here at this timeframe during that time of challenges of healthcare or possibly ever." But I do think it's about me always saying yes to different opportunities throughout my career, whatever my role was.

Brian Bolwell, MD: So, number one, congratulations. That's a great story and obviously a lot of very hard work. So, starting with when you were director of the APPs, leadership isn't easy. How did you learn about leadership? Did it come naturally? Did you have a coach? What mistakes did you make and what did you learn from them? What happened initially with your, I think you said there were 450 APPs at the time?

Meredith Foxx, APRN, MSN, MBA: I think some of it has come naturally. I would say some of my outgoing extrovert has landed itself to taking charge or speaking up first. When I think about the advanced practice piece of it, this was a blossoming role and expanding role and people were relying a lot on this role to help fill a void in healthcare, whether that was access support services, but what we had to do was make sure that it was respected and that the individuals in those roles and the individuals leading those providers who also had leadership values and behaviors of mind. I think we all know in healthcare, if you've been in leadership, a good clinician doesn't always make a good leader. So, I think that was one of the first lessons I learned and was taught that just because you're a good clinician doesn't mean you'll be a good leader. So, trying to navigate through that with whether it was a host of disciplines or even individuals.

Sometimes you learn the hard way. I can reflect on one particular experience. I had always worked in academic medical centers up until my formal leadership role and had to learn a lot about community hospitals and private practice and that they are partners with us as well and part of the team and understanding that different, for lack of better words, employment model. For me, I had to really learn about how to engage those individuals in working with advanced practice, recognizing on as providers, and just knowing what I didn't know, which was really about that whole private practice piece of it. I think the other lesson I learned was back to that whole clinicians and leaders is that we had to ensure that when we built our advanced practice structure, that we had individuals that had strong leadership skills, strong emotional intelligence because there was going to be navigating a culture, navigating political issues at times, and also being able to manage people and understanding what it took to manage a group of providers that would have to be respected professionally, but also that mix and being respected as those that can deliver healthcare.

Brian Bolwell, MD: So clearly a big part of leadership is in fact managing people. How do you do that?

Meredith Foxx, APRN, MSN, MBA: Again, lots of different lessons learned. I would say I pride myself on being transparent and trying to be as direct as possible, and that can be seen as good or bad depending on the individuals. I've had to learn over time, different approaches. I also think something one of my great uncles said to me years ago when I became an official people manager, he said, you have to treat people fair, but that doesn't mean that it's always going to be equal. So, I kind of reflected on that because what does that really mean? We always say we want to hit, everything's equitable, but it is about fairness. It's about being just; I'd like to say that I tried to role model that and one of my strategies always was managing people: are you coming to me because you want help or are you coming to me to solve the problem for you? Or are you coming to me just to confide?

Kind of setting those expectations at the beginning. And then also sometimes you might say it's just to confide, but there might be something I need to act on as a people leader. I think people always knew that I was going to ask, the first question I was always going to ask in managing relationships and managing people is, have you talked to the person yourself first if they were coming to voice a concern? They always knew that was going to be the first question I would ask. So, I think they over time either decided they were going to talk to the person themselves to manage the conflict, the interpersonal conflict, or that maybe they weren't going to come to me to confide in that because they knew that was going to be my first question.

Brian Bolwell, MD: So, transparency is a big deal to certainly to me, and I think to almost every leadership book there is, so hardly agree with that. I also think you're right about the direct thing. Something I had to learn more than once was being direct can be good, but it can also be a challenge for oneself because it's the whole intent versus impact thing. Your intentions might be very pure, but I certainly had to learn that sometimes even with good intentions, if I was too direct or if my impact was certainly not what I perceived it to be, my intentions could get lost. Did you have to learn something similar?

Meredith Foxx, APRN, MSN, MBA: I'm nodding my head and they can't see us obviously listening to a podcast, but I absolutely agree with you and definitely had those same previous experiences around intent versus impact.

Again, I put myself in the place of saying why I'm direct is because I want that direct feedback myself. So, if I was not behaving in a professional manner or a colleague didn't prefer the way I handled something, I want that direct feedback. Tell me when I screwed up, tell me when I wasn't my best self, tell me when I went off the rails or, hey, probably could have done that better. I would want to know that. So that's my intent. So back to intent versus impact. My intent is I would want to know myself, so I hope others would want to know, but I have realized over time that the impact can have multiple ripples or waves or tsunamis sometimes because that's not how everyone always views what information they want or they aren't as direct, so may not appreciate that perspective.

Brian Bolwell, MD: So, team building is essential in nursing, and again, I think it's essential in all forms of leadership. So today in healthcare we've got a shortage of nurses and you're the executive nursing director of one of the largest healthcare organizations in the country. How are we managing it? How are you managing it and how does that affect teamwork and team building within nursing here at the clinic?

Meredith Foxx, APRN, MSN, MBA: So, I’d be remiss and would not be being transparent to say we haven't been challenged by it despite being one of the best healthcare organizations in the world and our challenges have come and we've recovered from some of them post this pandemic and workforce shortage. I do say that it's not just about a nursing workforce shortage, it's many different shortages within the healthcare arena. Getting back to your question about teamwork, how do we work together when any of the care support is limited? So, whether it is nursing, laboratory, phlebotomy, respiratory therapy, everyone's had their challenges. So how do we support each other? How do we not make it about one area being short versus another? How do we come together to do what's in the best interest of the patient and making sure that we are still taking care of patients in the highest quality, safest care possible?

I think on the flip side of it is while we're up against many of these challenges, not only here at the Cleveland Clinic but nationally, and it's a global challenge, specifically with nursing, is what I am most proud of is when I round and I go to our hospitals, our nursing units, our emergency rooms, our ambulatory care centers, our specialty care centers, infusion suites. When I ask any of the nurses there or the nurse leaders what they're most proud of, the first thing out of their mouth is teamwork. So, the teams are working cohesively together, and they rely on each other, whether it's the nursing team with the physicians and the APPs, everyone says teamwork is what they're most proud of and everyone lifts each other up. So, I think it's somehow, we are instilling that it is the team that makes things happen and that they can rely on each other.

I still believe that nursing is the best career. We are with people at their most vulnerable. We see them overcome great challenges. So, I think there's opportunity for us to instill in our younger generations what it means to have a career in healthcare and to be giving back people and improving their health and getting them out of illness or chronic disease. So, I think there's opportunity there. Not to say it's not without its challenges, but we still need nurses, and we need nurses to think about why they're in the profession. I'm proud to say that at this point we are seeing our turnover continually decrease month over month here at the Cleveland Clinic as well as we have wonderful retention efforts. When I think about what the Cleveland Clinic's offered our caregivers during the pandemic and some of the challenges, we are truly very blessed to have the support and resources we have, and I know many of our caregivers have been able to take advantage of that.

Brian Bolwell, MD: So that's actually a bunch of really cool stuff. So, it's interesting that the nurses say they're most proud of teamwork because that's also, in my opinion, one way to retain people if they're proud to be working with a team that's high functioning, they're more likely to stay. You'd mention rewards and retention. How do you continuously express appreciation?

Meredith Foxx, APRN, MSN, MBA: We have heard that over and over again from our caregivers around our engagement surveys or feedback is they do want to be recognized and rewarded. It is sometimes the simple thank you from a manager, it is from the team members, it's from a provider, it's from a family. I would say one of my leadership skills, assets, strengths I've tried to build out on is reaching out and recognizing individuals myself, whether it's by an email directly to a caregiver, if I hear something, if I'm told a story about a great catch or a good save, again, reaching out directly to that manager and that caregiver and recognizing them and really talking about it. People enjoy being recognized regardless of how humble and unbeknownst to them the recognition they do enjoy. It is some of the small stuff. I think the team building that people try to do on the individual units.

What I've heard over the last year is people want to have fun and enjoy work as well. So, the work's hard enough, but how can we have fun? Does that mean having themed parties for a different celebration during the year and that brings everybody together? One of my favorite things is that I think people know, that I have two dogs and love my two Labrador retrievers. So, whenever I go to a unit and they have their pet pictures up, it's one of the places they take me. So, they're like, do you want to see our pet board? But it brings joy, people smile. The last unit I was at was in ICU and there were people who don't have pets, but they put pictures of pets they wanted up and just talking about it with them, it sounds silly, but it made everybody smile. Everybody was smiling and it brought some fun and enjoyment to the unit and it was team building essentially, people getting to know each other outside of the, you know, the scrubs and the care they're delivering.

Brian Bolwell, MD: So, Meredith, I'm a really big believer in that stuff. In fact, I'm talking about it more and more in coaching. How can we make our own local worlds wonderful? One way to do it is to do stuff like that. There's a book called Love 2.0, which expresses the perspective that you can create a positive or even loving encounter with somebody in 30 to 45 seconds. I think that people who have titles have an enormous ability to do that if they extend the effort. It's incredibly meaningful if one does that. I love hearing stories like you just shared. I think that they're really powerful and really important, so congratulations for that because I'm a big believer in that stuff.

Meredith Foxx, APRN, MSN, MBA: Well, thank you. I think it also allows to create a connection between people. So, there are nurses, there are nurse leaders out there. They know I have dogs; I know they have dogs. So, it's kind of that icebreaker, but an ability just to build a connection. I do, you know, skip meetings, which is a standard thing in leadership that we've learned here at the organization and from other leaders started a little bit within the caregiver office, and I do those with the leaders. I kind of start off with a non-work-related question or a non-nursing related question, and it's gotten again them to know me a little bit better is I'll say, is anybody reading a good book? I love to read. So, I get my list of books to read from the individuals that I'm meeting with. Again, it's just a way to have a personal connection and it’s kind of just builds those relationships that I hope of trust and that they can come to me and feel safe and secure talking to me because we've built some type of personal connection.

Brian Bolwell, MD: Well, trust is everything when it comes to leadership. But I think the other thing it does is it generates authenticity if people think that you're real and that, I actually found that the more I shared about myself sometimes as awkward as it was, was almost a glue, you know, to the folks that I was leading, that they really do welcome that because it does generate this connection and ultimately, work is about relationships.

Meredith Foxx, APRN, MSN, MBA: Yeah.

Brian Bolwell, MD: Going back to a couple of things you said earlier, which I wrote down, and I want to make sure that we touched on just briefly. Almost everybody that I've interviewed when I ask about their leadership journey, said what you said and that is you say yes. You say yes to opportunities. Do you still say yes?

Meredith Foxx, APRN, MSN, MBA: My short answer is yes. Yes, but I've had to make different choices. So, every time you say yes to something, you're saying no to something else. I've had to give my saying yes, more thought and direction about where my priorities are and the obligations and what the expectations of what I do now as the Executive Chief Nursing Officer supporting the nursing caregivers at the Cleveland Clinic. So, what is that choice about saying yes possibly to something on a smaller scale that's maybe not directly related to leading nurses overall, but how does it benefit it? So, being a little bit more thoughtful, in my saying yes. I think that's the short answer. So yes, I do say yes, but with a little bit more thought. It doesn't come out roll off my tongue immediately as it used to.

Brian Bolwell, MD: Yeah, I agree with that. One of the things I think that you have to learn the higher you evolve in leadership is when to say no, because you are kind of used to saying yes, but at some point, your bandwidth gets stretched so thin if you're going to be effective in your primary role, that sometimes you have to be honest and say, I don't think so, but here's some other people who might be able to do that quite well.

Meredith Foxx, APRN, MSN, MBA: When I think back to times when I said yes pretty quick out of the gates, I'm not sure some of the quality of the work I did was always what I would've wanted it to be. I'm not saying it was bad, but did I devote enough time and resources to something or was I just trying to get it done because I was owed an obligation? So that's where I've been more mindful and thoughtful about, can I give the time and energy and resources to make either the true product I want it to be or the outcome I want it to be.

Brian Bolwell, MD: A lot of talk about burnout in healthcare, and I want to go back to when you started, because obviously I've spent my whole career in oncology, and you said you started in pediatric oncology, and one of the things you said was a lot of people don't realize the joy there is in caring for folks with cancer or families with cancer. But I think that's a pretty profound statement. I agree with it entirely. I remember when I read one of Brene Brown's books called Daring Greatly, in which she talks about the courage to be vulnerable. She told this story that she'd interviewed a lot of people who suffered great loss and what advice did they have? They said, don't squander joy. I think in healthcare as we think about how challenging it is. Every day, there's some wonderful moments, and you mentioned the thing about pets, but it can be anything. It can be some little interaction between somebody and a patient, but any sort of relationship that can truly be a joyous thing, a joyous encounter, and we shouldn't minimize those things because I think we see more of them in healthcare than in any other profession. What are your thoughts about joy in healthcare?

Meredith Foxx, APRN, MSN, MBA: I think it goes back to a couple of the things we already talked about is finding joy with the team and recognizing and rewarding patients and their families’ victories. So, if that meant, as simple as going back to an oncology patient, hey, I didn't get nauseous or sick from the chemo this time around because we got the antiemetics right. And I got to enjoy a milkshake every day. That was a goal and that was an achievement. Then there's the young child who I took care of with stage four neuroblastoma, which is a primarily pediatric diagnosis. She just wanted to walk again. Her and her family knew that she wasn't going to live to adulthood, but she wanted to be able to walk again and not always have to be pulled in the wagon. And she got some special treatment 20 years ago that got her to walk again, and that was joy seeing her running down the hall, to her smiling and her mom. So, it is those little accomplishments, and I think people put it all in perspective when they are up against some of those challenges and what they can find out, what they can accomplish. I think the joy comes then from the nurses, the doctors, anyone involved in those teams, taking care of them, getting those people to that joy.

Brian Bolwell, MD: So, as we're wrapping up, Meredith, you've been doing this for a while. I think leadership is a lifelong learning exercise. Any pearls for our listening audience about things that you're doing right now from a leadership perspective or aspire to do in the future?

Meredith Foxx, APRN, MSN, MBA: So, I thought about this because it's something that came up to me in the pretty four simple rules, and they came to me during the pandemic, and they applied to others as well as they applied to ourselves. I think as leaders to always be kind, we never know what anybody is up against what happened the morning before they left for work or before they came to this appointment or got admitted to the hospital. I think of our empathy video that every time I watch that I'm grounded. We don't know what people are up against and be kind to yourself because you're not always going to have a great day.

Being humble and terms of humble about yourself and just in general about what you can and can't accomplish and that it does take a village and large teams to get stuff done. Be forgiving. So, the idea of forgiving yourself, again, and be forgiving of others, not everybody comes again with their best self every day for whatever reason. So, allowing their forgiveness and then being patient. So those were my four very simple things I've figured out leading through the pandemic. Be kind, be humble, be forgiving, and to be patient.

Brian Bolwell, MD: So, I think that's wonderful, and I think those are useful tools for anybody in any encounter with anybody. I do think that everybody has stuff and most of the time we don't know what's going on at home. We don't know what's going on in their personal lives, and I agree entirely. I mean, try to walk in their shoes and cut them a break and being forgiving is I think really, really important. All four of those are really important, so thank you for that. I think it's a great way to wrap up. Thank you so much, Meredith. To our listeners, thank you for listening and we look forward to sharing another episode of Beyond Leadership in the near future. Have a great day.

This concludes this episode of Beyond Leadership. You can find additional podcast episodes on our website, clevelandclinic.org/beyondleadership, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. We welcome any topic ideas you may have for future episodes, comments and questions about this or any past episode. You can let us know by emailing us at executiveeducation@ccf.org.

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Beyond Leadership

Host Dr. Brian Bolwell escorts you through a network of thought leaders, sharing world-class insight on leadership and cutting-edge hospital management approaches. They will inspire and perhaps compel you to reinvent your practices – and yourself.

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