Rita M. Pappas, MD

Podcast Transcript

Cara King:
Welcome back to Inspirations and Insights. Springtime has finally arrived here in Cleveland, and we are all hoping that it stays. We have a really tremendous guest on our show today, Dr. Rita Pappas. This woman is truly a force with an incredible journey. Rita is a pediatrician hospitalist, who is the Medical Director of hospital operations within the Division of Medical Operations here at Cleveland Clinic. She served as a Chief Medical Officer for our Hope Hospital, which was Cleveland Clinic's surge hospital during the COVID pandemic this past year. During our interview, we discuss her journey from her nursing career, back into medical school, her experience with coordinating the transition of the Health Education Campus main building, into the Hope Hospital and the tribe she has built to optimize her work and family integration. We hope you enjoy this vulnerable and truly powerful conversation. So we are really excited to have Dr. Rita Pappas on our show today, so welcome, Rita, to Inspirations and Insights.

Rita Pappas, MD:
Thank you, I'm so glad to be here.

Cara King:
Yes, as are we. So we're going to jump right into things today. And I want to start out by talking a bit about your journey because your journey is really, really interesting. And so, from what I know, you were a nurse for over 10 years in the beginning of your career, is that right?

Rita Pappas, MD :
That's actually very true, yes. I was a nurse, actually, here for 10 years. I started off in the Children's Hospital on M30, which was the adolescent floor at the time. And then I worked with Jack Andrish, who was (a pediatric) orthopedic surgeon. And it was through his mentorship that I decided to go to med school. And then I switched over to the Cardiothoracic ICU so that I could take the classes, the post-baccalaureate classes that you needed to apply to med school. And so I worked in, what currently is HVTI (Heart, Vascular and Thoracic Institute), right now in the intensive care units, but we were in the old building, so we were in the G building.

Cara King:
Wow.

Rita Pappas, MD :
It was a lot of fun. I learned a lot.

Cara King:
I can't even imagine. And I just love thinking about these really critical moments in our life that change the directions of our career, these sliding glass moments. So talk to me about what inspired you about medicine that made you want to go back to medical school? Was there any moment where you were like, "I need more, I want to go back."

Rita Pappas, MD :
Yes, so working with Dr. Andrish, he really treated me like a resident and always gave me the opportunity to ask questions, and I was always asking “why?” And so I think that differentiated my thought process in how things were done, I just didn't accept that these are the ways that we do things. And one of the things that came through very clearly was this thirst for knowledge. And I enjoyed nursing very much, I really enjoyed it, I enjoyed the patient care aspect. We were in the operating room two days a week, we were with patients two days a week, and then he did research one day a week. And so he kept saying to me, "You should really go to med school, you should really go to med school." And I was 31, I was single, and I thought, I could become a Nurse Practitioner.

Rita Pappas, MD :
Or at that time, you didn't have a lot of autonomy as a Nurse Practitioner, there were more regulations, and so I wanted to be independent. When I applied, my nursing actually gave me a very big advantage in medical school, so that it was very easy. The first two years, you're in the classroom a lot or in the library a lot, but then third year and fourth year back in the hospital, back in the clinics, it was second nature to me, so it was very fun.

Cara King:
And as physicians, we all know that nurses are absolutely critical to get anything done, they are the crux of all patient care. And so I think that's so interesting that you have that perspective. And when I was in undergraduate and medical school, I was a Phlebotomist and a Grossing Tech (Technician), so same flip of the lens, it gives you a whole new perspective.

Rita Pappas, MD :
It really makes you value teamwork. I had a lot of great physicians that I worked with as a nurse, and in the unit, if I was trending vital signs and saw that things were happening, and when I picked up the phone and I called the resident or the fellow, and have built that trust that there was something that was going to happen that was deteriorating as an early watch sign. It was really wonderful, the teamwork that we had at the bedside to help the patient. And so I really appreciate whenever a nurse calls to take it seriously. Yeah, I did learn a lot, teamwork definitely was one of the key motivating factors.

Cara King:
I love it. I know, one of my secret superpowers is getting difficult blood draws and starting IVs. I don't want to tell anybody about my background, I could come in blind and just act like I get lucky, but it's awesome.

Rita Pappas, MD :
That's really great. That is really great.

Cara King:
All right, so went back to medical school, and then you became a pediatrician and then ultimately transitioned into the Medical Director of Hospital Operations, which is your current role right now, is that right?

Rita Pappas, MD :
That's correct. I still practice clinically in the Children's Hospital, but the majority of my time I spend within Medical Operations. It was probably in 2011 that I transitioned over to Medical Operations as a Medical Director with Dr. Robert Wyllie. And so I have oversight of the admission and transfer center, and I am an administrative partner, Joelle LoFaso,(RN, MBA, BSN) who's a Senior Director, who is my partner. And we have really built the Transfer Center to one of the biggest transfer centers in the country. And we roughly have around 3000 hospital transfers a month, which is a large number compared to, if you look at other programs across the country.

Rita Pappas, MD :
Half of them come from outside or external to Cleveland Clinic, and then half are internal within the clinic. As part of Medical Operations, I have other duties as assigned, so special projects that come into play usually around when we have large events that the Cleveland Clinic hosts. So for instance, the (2020) Presidential Debate, or when we were tasked to build the Hope Hospital in less than 30 days. So there's always other projects as assigned, which I really enjoy. I really enjoy working on the projects that we have.

Cara King:
That small task of Hope Hospital. That was just a quick little one on the side, right? Yeah.

Rita Pappas, MD :
You know what, it actually embodies a lot of teamwork again, so we had operations and we had nursing and then a physician lead. There isn't any way we could have done what we did without a large number of team players. Shannon Pengel (MSN, RN, NE-BC) was our Chief Nursing Officer, and Rob Stall was our Chief Operating Officer. So we treated it like a real hospital, and then I served as the CMO (Chief Medical Officer).

Cara King:
Wow.

Rita Pappas, MD :
And it actually was Dr. Sumita Khatri who gave the name Hope Hospital. Because people were calling it “The HEC” (Cleveland Clinic’s Health Education Campus), the health education campus, or the HEC.

Cara King:
Yeah.

Rita Pappas, MD :
So she was inspiring us that we're really giving people hope. We shouldn't be calling it “The HEC”. And then that's when she came up it, "We should call it the Hope Hospital." And it's really interesting of how everyone really motivated around it, and it gave us inspiration and motivation to get the work done. It was really a momentous task.

Cara King:
Yeah, “Hope” does resonate a little bit different than “HEC”, I think that was a good move. The HEC Hospital sounds just a little bit different feel to it. So I want to jump into this Hope Hospital task, so I want to take us back to early 2020. Not that we really want to go back there, but travel with me Rita. So let's go back to early 2020, when this COVID pandemic was really just unfolding. And you are the Medical Director of Hospital Operations, and I'm certain that you did not know this pandemic was part of your job description to figure out, with this Hope Hospital. And you're tasked with so many things, you're tasked with balancing caregivers with a whole range of emotions, including uncertainty and fear. While you're concurrently directing the operations, like you mentioned, of opening this brand new Hope Hospital. And then on top of that, you're also fueling questions from the media on, what are we going to do? Help us. How are we going to figure this out? What did you find most challenging during these months?

Rita Pappas, MD :
As you described, it was very chaotic, so we didn't know what to expect, and we didn't know how long the virus was going to last or what interventions... We were all learning what interventions needed to happen. One of the things that came very clear, was that we needed to, as a team, communicate powerfully. So it's part of servant leadership to say, "I don't have all of the answers, but this is what I know." And it makes you vulnerable, to say you don't know. We don't have a crystal ball, we didn't know how this was all going to turn out. But what we try to do as a leadership team with Shannon and Rob and myself, was really inspire and motivate, as I said, communicate powerfully, acknowledge that it was going to take collaboration and teamwork. And then that's the way we were able to build relationships.

Rita Pappas, MD :
And so then we had these calls every day, twice a day, seven days a week, where we said that everyone had a voice and we needed to hear the concerns. So for instance, when the workstation on wheels, are we going to have enough workstations on wheels? Or what beds we needed to choose, or whatever the topic was, we really needed everyone to come forward and share their concerns and then work to actually resolve the issues at hand. So that's what I think it really focused, that if you could, at least what I learned, was communication was the most important piece and allowing people to feel vulnerable, to say that they were worried and that they were concerned. But then also to provide inspiration and motivation to get the things done.

Cara King:
You're just making my head run with how emotional that must've been for you. So we're looking at you and your team as the experts, and we want you to have all the answers, but we're in this state of unknown, unknowns.

Rita Pappas, MD :
Unknowns, unknowns, and so I relied on other women too. So I picked up the phone and called Becky Stark (Rebecca Starck, MD, President, Cleveland Clinic Avon Hospital) and I knew she had opened Avon Hospital. I said, "Becky, I need your help." And, "Travis (Travis Laird, Cleveland Clinic Executive Administration), I need your help. I need to understand what I need to do to build a hospital, that's going to pass and be accredited because we needed to know so that we can send patients there." And so they had, it was wonderful, within 10 minutes, Becky sent me an Excel spreadsheet with all of the tasks that they actually created to actually open Avon. So I leaned in, I want to make that very clear, that I leaned in to the people that I knew in the organization and trusted for help. And it was very powerful that people were able to, as they were doing all of their activities too, lean in and help as well.

Cara King:
Yeah, no, I don't mean to laugh, but literally you had to call somebody and said, "I need to open a hospital in 30 days, can you just give me a quick to-do list?" This is wild.

Rita Pappas, MD :
It was. And then we had to brief our leaders, so we had to brief the leaders, and so we would do the cadence of the PowerPoints, let them know what we were doing and what roadblocks we were finding. We also had to figure out what were the medical criteria for the patients that needed to actually be seen in the Hope Hospital. And so I reached out to Rishi Singh, (Rishi Singh, MD) who has a crew of medical students that he works with. And he took a look at, I think, the first hundred patients we had cared for, and gave me a profile of what their medical criteria was like when they were on the floor. So then we understood that we needed to have three liters of oxygen that, that was the max capacity that we needed to provide for these patients. And that helped us with Praxair and all the vendors to figure out the oxygen tank that we needed to put outside of the Hope Hospital, so it was very, very interesting. Everyone leaned in, it was very helpful, but everyone leaned in.

Cara King:
It's truly amazing that you helped get all of this together and mobilize all of the people. And I think the things that you're saying that are really sticking out, is that being in this psychologically safe space to really be transparent with your vulnerabilities, doesn't make you weaker, but it makes us trust you more. And not reinventing the wheel, but turning to other people and really pulling in what we already know, to jump off of.

Rita Pappas, MD :
Right, and I think it's not something that you learn, as physicians you learn that you need to have all of the answers and that you need to be able to, if you're showing vulnerability, that maybe you're weak. The lessons that I learned is that you're stronger when you're more vulnerable, and that you're safe. Where we were, everyone felt psychologically safe to be vulnerable together.

Cara King:
Yes, egos aside. We're all in this for the exact same end point, which is safety for our patients and our caregivers. Amazing. Now, I want to jump into something that you just spoke about, how you were turning to experts to help at least delineate the small things that we know, like how much oxygen are these patients requiring, or their hospital stay, or all of those things that are gradually unfolding. But I also think about how we talk about ingrained thinking, thinking that is just monotonous thinking, things that we've been trained to do. It can sometimes be dangerous in complicated contexts, meaning unknown, unknown contexts, because it can sometimes overlook or even dismiss innovative suggestions by non-experts. So talk to me about how you balanced listening to experts, while still welcoming thoughts from others. How did you make that balance?

Rita Pappas, MD :
It was really through the help of (Cleveland Clinic’s Office of) Continuous Improvement, so with Nate Hurle (Nathan Hurle, Senior Director, Enterprise Continuous Improvement), because there were a lot of “nice to haves”. So we kept refocusing to, what's the goal? So what is our goal? It's a hard message to give to someone to say, "I hear what you're saying. I appreciate that that's a really good idea, but these are the constraints that we're working with." And one of the things that we need to do is, we've looked at all of these things and I think that the best decision to make is to move forward with this product because we've weighed the plusses and minuses of each. So one of the issues was around the medication delivery, just like you were talking about, so it would be easier if we didn't do the med delivery the way we normally do at the Cleveland Clinic Enterprise.

Rita Pappas, MD :
So we listed the pros and cons of each, and then ultimately, even though there were people who thought it was going to be too difficult to do the barcoding, we went ahead and said, "No." That we felt that it was safer, especially because the way the hospital was outlined that this was a must have, it's something that we had to do. So we went ahead and did the barcoding and we were able to do it with the help of nursing informatics and the pharmacy and a slew of people. But it was the right choice to make.

Cara King:
That can be hard to balance. We've got this ideal state, and then we've got where our resources are, and then we have logistically, and then we have what's safest, and then we put all this together into a plan.

Rita Pappas, MD :
Right.

Cara King:
Wow.

Rita Pappas, MD :
And a lot of times people had innovative ideas around how to transport people, or they were talking about, we should have our own CAT scan and we're right across the street from the main hospital. And so you have to have those people feel heard about what they were proposing, but then realistically, we did look at cost as well and said that it didn't seem feasible to do that, that it would be... If the person really needed a CAT scan, then they probably needed to be seen across the street. But we created the playbooks, and like I said before, Continuous Improvement was very helpful in helping us outline how to be more efficient and how to think about things differently.

Cara King:
Pulling in so many brilliant minds together, it takes a village.

Rita Pappas, MD :
It takes a village.

Cara King:
So during this time, on your Twitter feed, I love social media, I'm not going to lie Rita. So on your Twitter feed you posted a really fascinating article from the Harvard Business Review titled “A Leader’s Framework for Making Decisions” (November 2007). And it talks about this “Cynefin framework”, people who listen to this podcast know that I'm obsessed with Welsh and Danish words. I just love their translation. So Cynefin, it's a Welsh word that signifies multiple factors in our environment and experience that influence us in ways that we can never understand. I just love that. And so in that article, it talks about different ways to lead and hard decisions and frameworks on how to make those hard decisions. And part of the article, it talks about how leaders need to avoid micromanaging and stay connected to what is happening in the big picture, in order to spot a change in context, so what does this mean? Meaning, the forest and the tree scenario, so I want to tap into your mind about how you avoid micromanaging too much so you can still keep that global picture. How do you find that balance?

Rita Pappas, MD :
I really love that article. Someone had told me several years ago that you learn leadership in your childhood. And that I do think that there are skills that you learn as you're growing up that make you a leader. But one of the things that... We're just living in such a different time, and so I was looking for some sort of reference or guide because being in unprecedented times in the middle of a COVID pandemic, it seemed that either we were entering a phase where the answers didn't seem as apparent. And so that's why I turned to the Harvard Business Review and found the article around the leadership framework, which I really like because I ask myself, "Which type of problem is this?" In order to help classify what key traits you need to help solve the problem. So back to your original question about micromanaging, it involves trust.

Rita Pappas, MD :
And so one of the things early on as I learned, that if you provide people with guard rails and say that this is the goal that we're going to try to achieve, and this is how we're going to achieve it, it's up to you because you're so close to the work to come up with the ideas and how to actually do it. Then that provides the person the ability to, one, feel empowered and not feel micromanaged. And often they come with the best solutions, and instead of delivering something top down where you think you already have the answers, and you might not be close to the work. And it also encourages early adoption of whatever goal that you're trying to reach. It does require trust, so if you provide someone and you don't micromanage them and they don't deliver you're, as the leader, are ultimately responsible. Usually in terms of providing the ability to do that and working within Medical Operations, maybe I should say, I don't have any direct reports.

Rita Pappas, MD :
So everything I do is through influence, and so that, I think, also helps because you can't micromanage that relationship with someone who doesn't directly report to you.

Cara King:
Right.

Rita Pappas, MD :
Yes. And so it's really learning, I believe, how to influence and giving people autonomy. I leaned on those skills when I served as the Interim Chair for the Pediatric Institute (9/18/17-11/16/18). As a Peds Hospitalist (Pediatric Hospitalist), I had multiple pediatric subspecialists that worked within the institute. And so as a hospitalist, I understood the inpatient side, but really I hadn't practiced outpatients since residency. And so if, for instance, someone was in a cardiology outpatient clinic, I didn't know their workflows or how things moved and we wanted to try to improve access. And so I talked to them about the goals that we needed to achieve, and asked for input, for them to review and give us at least one recommendation per department, on how to improve access. And we got some really great ideas, and we were able to increase our access 14%, which yielded in positive results, but it's not because of me being prescriptive, it was providing the goal and asking the team to actually come with the solutions.

Cara King:
I think that's so important. The things I'm hearing you say are, number one, you have to have trust and to have trust, you have to have the right team around you so you can trust the outcomes that are going to happen. And allowing that space for your colleagues to have that autonomy, I think it really inspires creativity as well.

Rita Pappas, MD :
Right.

Cara King:
When people are just told what to do, I feel like it can be stifling and people aren't thinking outside the box, so I think there's so many benefits to allowing the space for reflection and creativity and ownership of your role, that can really make everybody flourish.

Rita Pappas, MD :
As hard as it is making time to think about where you're going and what you're doing is so critically important. And I found in the mornings, is my best time to think, early in the morning, because then after you sleep, you're refreshed and things seem clearer to you. And so thinking about how you're going to address a difficult subject, how you're going to talk to the leaders within your group, providing reflection around what you're saying, and then repeatedly saying the message.

Rita Pappas, MD :
I've learned at least seven times, you have to say it at least seven times before people really understand what message you're trying to deliver.

Cara King:
That's interesting.

Rita Pappas, MD :
…someone actually quoted what I said back to me in one of the meetings and I thought, "Wow." I always rallying around our mission, and I would say what our mission was. And we were opening the R building (Cleveland Clinic Children’s) at the time, and so I'd say, "This is our mission, these are our goals, and then this is how we're going to actually achieve those goals." And I kept saying, "This is our time. This is our time. This is our time." And so one of the physicians saw me in the hall and he said, "This is our time."

Cara King:
Oh, that's funny. That's funny. They were listening.

Rita Pappas, MD :
Definitely.

Cara King:
I was just reading an article about efficiency and productivity, and it's interesting that you said that morning is your time. And I've just recently reflected on my time and it's completely changed me, and everyone has a different time where they feel the most awake and the most productive. And taking the space to know what time you are in that state of creativity and blocking that out on your calendar can actually completely change your day. Even shifting your clinic to later in the night or evening when maybe you're not as creative, doing things that maybe don't take as much creativity during those times, can totally change your day.

Rita Pappas, MD :
Right. I wish I was better about blocking my time, but you're absolutely right. When I'm driving into work, I have the music on that I like, and I'm thinking about a lot of the things that are related to either some projects that we have, or work that needs to be done. So it's time in the car, but usually in the morning as well, when I have my first cup of coffee before I come to the hospital, that's the time that I felt like is the most productive.

Cara King:
Yeah. It's yours, you own it. I know, I like it. All right, I have one last question for you before we wrap up, if you don't mind, I can't help but ask this. I read in an article, in the Cleveland Magazine where you were interviewed and you were, again, talking about the Hope Hospital because this was the most magical beast I've ever seen in my entire life. And you stated, "As a widow and mother, I was able to show my children that when you are faced with adversity, you stand up and participate in creating the solution." And I get goosebumps every time I read those words, I am serious. As a mother, I feel like we are relentlessly trying to integrate our work life and our home life and be present for both, and sometimes it just feels impossible, at least for me, it just feels impossible. Can you open up a bit about what this integration looks like for you?

Rita Pappas, MD :
As you can imagine, being a widow, and my kids are really... When I was saying that I was going down to work and that we were building this Hope Hospital, they had fear, they were scared because they lost their father. And so one of the things is, we seriously sat down together and they said, "This is what we have to do. This isn't a time to be scared, this is a time for us to come together and help others. And we need to be part..." Like I said previously, "...part of the solution." And they understood, at first they wanted to protect me, they didn't want me to participate, and so they were worried about me catching COVID. One of the things that I rely on heavily is I have, what I call, my families. So I have my immediate family, my biological family, which provides a lot of support.

Rita Pappas, MD :
But I have my Cleveland Clinic family, my best friends at work who I leaned in on. And then through our church, I have my Parish family who actually helped me in terms of raising my children. So they had a lot of influence in terms of maybe helping me with my maternal guilt. So when the cookies had to be baked, I didn't bake the cookies, I outsourced them, Cara, and I didn't apologize. And the women within the community didn't belittle me or make me feel bad that I wasn't baking the cookies or wasn't participating in those activities. They helped me actually be stronger... They helped support me. And so whether if it was a ride or if it was dropping someone off or just really helping, knowing that we know you are very busy at work, but if you want to volunteer during this section, you can do it during this section for tournaments and things.

Rita Pappas, MD :
So really leaning in to all of my families. One of the things that I found really helpful, back to your original question, was I always insisted that we have dinner together as a family. Now, sometimes that meant dinner was at 8:00 PM, which was very late. And so the kids would eat before, but we'd all sit down together as a family. And then we used to play this game called “Peak and Pit”. So if you ask them, “how was school?” they'll just say “fine”. So we did, “What was your peak, and what was your pit?” And so that way they had to provide an answer instead of just, “it was fine”. We don't play Peak or Pit anymore, but it helped build the whole piece about, we all sit together at the table for dinner.

Rita Pappas, MD :
Now my daughter's in college, so it's just my son and I at home, but we still sit together and eat dinner together, regardless of whatever time it is. And so I really do think its dinner time is the amount of time that we spend together. And they actually watch you, even though you don't think they're watching you, they are, they're seeing how you're behaving and what you're doing and then they're learning. And they're independent compared... I feel like a lot of the kids who have other parents who do a lot for them, but because of our careers, our kids have to actually do for themselves, which I actually think teaches them to be more independent early on.
Cara King:
Thank you so much for your vulnerability. And I play Peak and Pit at dinner as well, I have three kids and we do that and it is, it's magical, it's so great.

Rita Pappas, MD :
Yes.

Cara King:
And what I'm hearing you say is, build your tribe and don't be embarrassed about that. And you are the (current) WPSA President (2021-2022), and so you are the leader of just that, you create this tribe of women here, which is just such an amazing resource that we are so lucky to have here at the (Cleveland) Clinic.

Rita Pappas, MD :
Yes. I feel very, very lucky to be here at the Clinic, even as you reach out even further, I'm meeting women every day that I didn't get to meet before. And like you said, you're surrounded by wonderful women who share, in what you're sharing, and understand what you're going through and how you're trying to raise your families and how you're trying to also be a physician. So these are the people that can actually help you every step of the way.

Cara King:
I feel like sometimes in the friend circles of my kids, those parents don't really fully get it, at least for me.

Rita Pappas, MD :
No, they don't. Don't you feel like a lot of times perseverate about things that seem very minor in our world compared to their world. I respect their choices and I respect how they're choosing to raise their children, but it makes you appreciate everything that you have.

Cara King:
Yeah. And it feels good to be around people who are living the same exact trials and the same exact difficulties, it just really normalizes it and it feels good. So thank you for leading us at the WPSA, thank you for creating such an amazing space for us.

Rita Pappas, MD :
No, thank you. And thank you for everything that you've done and helped with, making the podcast come alive. I appreciate all of your support, time and effort.

Cara King:
It's an honor. It's an honor Rita. So I think we have reached the end of our time, but again, I cannot thank you enough for your vulnerability and transparency and your time with us today. We definitely want to have you back sometime soon for part two.

Rita Pappas, MD :
Oh, thanks again, thank you.