Connecting with Health Organizations Around the World

Podcast Transcript

Carol Pehotsky (00:05):

Different places across the country and around the world approach health care and nursing differently. All patients deserve the highest standard of care no matter where that care is delivered. How do we ensure that within those different approaches, patient safety and quality remain the priority? What are the opportunities to help nurses' voices be heard within those approaches? I'm joined today by Margee Pagnucco to talk more about these challenges.

(00:32):

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care to advancing your career, to navigating tough on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, associate chief nursing officer of surgical services nursing.

(00:53):

Welcome back everyone. When we think about nursing as a community, not just within our own country but around the world, what a fascinating thing to analyze and so many opportunities to reach across, and really learn from each other, and improve the care we have for our patients no matter where that care is delivered. So many of you have reached out and shared with us that you are listening from different countries who are not the United States. We've had opportunities to have Sheila Miller, our chief nursing officer from Cleveland Clinic London on. We've had other guests who have had international nursing experience, and it's always a lovely conversation that I learn from.

(01:29):

Preparing for today's episode I'm reflecting on my own experience in this space. Many, many, many years ago, there was the first International Conference of Perianaesthesia Nursing, so my clinical specialty. And I had just a fabulous opportunity to go present a poster in a short presentation as it was in Toronto. And that was really my first experience as a nurse looking outside, not just the four walls of the institution, but really outside of the United States that nurses came from all over, from Canada, from the UK, from India, from countries in Africa, all over the world came because it was the first one. And it was just, gosh, an overwhelming experience with how excited everybody was to come together.

(02:11):

And some things were very similar, some things were very dissimilar. And just really opened my eyes to what nurses sometimes don't have to work with in terms of resources and how fortunate we are with some of the resources we're able to connect with, how that heart of nursing is the same no matter where it's practiced. But really found myself curious of how can we move forward together and support each other, especially when resources are different, relationships are different.

(02:38):

And so, I'm so excited to have on the show today, Margee Pagnucco. So, Margee and I have known each other for many years, but today I get to speak to her in her current role as enterprise senior director of safety, quality and patient experience for Cleveland Clinic Connected. Margee, welcome. Thank you for joining me today.

Margee Pagnucco (02:54):

Well, thank you. Thank you for having me.

 Carol Pehotsky (02:56):

So, we'll get to the good stuff in a second. But first I would love for you to share with our audience, tell us a little bit about your nursing journey and how you ended up in such an interesting role.

Margee Pagnucco (03:04):

Well, I can say I never expected to be here.

 Carol Pehotsky (03:07):

(laughs) Yeah.

Margee Pagnucco (03:07):

I started out at the bedside in a cardiothoracic ICU. Really enjoyed the impact I felt like I was able to make with individual patients, became a nurse educator, felt like I could impact more patients. Moved into management again thinking my-

 Carol Pehotsky (03:24):

Yeah.

Margee Pagnucco (03:24):

... patient impact was getting larger and larger. Then I went into quality and realized I could impact all the patients at our hospitals and really find meaning in this work. And I feel like it's my purpose, it's my why.

(03:37):

And then, uh, back in 2021 I was approached to say, "Hey, could you take on some additional responsibilities? We have this thing called Cleveland Clinic Connected. Would you be interested? It's going to involve some travel and we're not exactly sure what this is going to look like yet."

 Carol Pehotsky (03:37):

(laughs).

Margee Pagnucco (03:52):

And I said, "Sure, I'll give it a try."

 Carol Pehotsky (03:52):

Yeah.

Margee Pagnucco (03:54):

And that was in addition to my role as south submarket senior director of safety, quality, and patient experience. So, it's been a great learning experience. Um, last year, so about for about a year and a half ago, I took the position permanently.

 Carol Pehotsky (04:06):

Oh, great.

Margee Pagnucco (04:07):

Yeah. And I can't believe that I'm in a role like this. Never would have dreamed it. So, it's really been exciting.

 Carol Pehotsky (04:13):

That explains why I haven't received emails about accreditation and quality opportunities in perinatal nursing. (laughs).

Margee Pagnucco (04:13):

(laughs).

 Carol Pehotsky (04:19):

Yes. Fantastic. So, can you spend a little bit more time explaining to us what Cleveland Clinic Connected is?

Margee Pagnucco (04:26):

Mm-hmm. Yes. It's our global affiliation program.

 Carol Pehotsky (04:29):

Okay.

Margee Pagnucco (04:29):

So, the core elements of this are safety, quality, and patient experience. And that includes nursing quality and really continuous improvement. We're trying to offer ourselves to other hospitals and health systems to provide guidance-

 Carol Pehotsky (04:42):

Okay.

Margee Pagnucco (04:43):

... for all those things so we can really help them drive improvement. And we feel a moral obligation to share what we do. At Cleveland Clinic we are world renowned for our care and we want to share that with other hospitals that are interested in us. So that's really the core components of it. We do have expansion possibilities for our members.

 Carol Pehotsky (05:03):

Okay.

Margee Pagnucco (05:03):

They can add on virtual health, eClinical reviews, patient facilitation, clinical operational assessments. For example, our oncology, neurology, heart and vascular programs often come in at the request of the affiliates to do assessments and to offer clinical service line support.

 Carol Pehotsky (05:22):

And so, as you mentioned you are a nurse and there's several other nurses that are part of these efforts. Can you speak a little bit more to the n- unique role that you and other nurses play in the grand scheme?

Margee Pagnucco (05:32):

On my SQPE team, two thirds of us are nurses.

 Carol Pehotsky (05:33):

(laughs).

Margee Pagnucco (05:36):

And in the other service line affiliation, they have many nurses involved as well. And I think nurses, they're absolutely vital to the program. Nurses provide the majority of care at a hospital, any hospital.

 Carol Pehotsky (05:47):

Yeah.

Margee Pagnucco (05:48):

And nursing staff, not just nurses, but the ancillary staff that goes along with nursing. And so, we are uniquely positioned, I think to nurses are great at workarounds and-

 Carol Pehotsky (05:58):

(laughs) Innovation, you know.

Margee Pagnucco (06:00):

... Yes. Finding ways to do things with-

 Carol Pehotsky (06:02):

Yes.

Margee Pagnucco (06:02):

... few resources and doing what's needed for the patient. So, it's important for us to be able to go into an organization and have that eye to see, to really determine what the culture is like there.

 Carol Pehotsky (06:03):

Oh, wow.

Margee Pagnucco (06:15):

And are the nurses being supported? What's the relationship between physicians and nurses? Because it really speaks to the culture and the environment of safety for the patients. So, I think it's really essential that we have nurses with us, and a large part of our assessment is about nursing.

 Carol Pehotsky (06:30):

Yeah. So those of you who are nursing students, I know you just love talking about the nursing process. But really in this instance being able to assess, diagnose and issue, have a plan, intervene, and evaluate isn't just about patient care. It really is looking at a program of patient care.

Margee Pagnucco (06:45):

Mm-hmm. Right. It really is. Yep. We also see when you speak about plans of care, big variations across the world in-

 Carol Pehotsky (06:46):

Yeah.

Margee Pagnucco (06:56):

... nurses training regarding that.

 Carol Pehotsky (06:57):

Okay.

Margee Pagnucco (06:59):

And whether or not they even utilize that. And we're actually helping one of our affiliates right now with nursing assessments, which is just shocking actually to US nurses-

 Carol Pehotsky (06:59):

Yeah.

Margee Pagnucco (07:09):

... to think that nurses in some other countries don't do assessments on patients. And it's a one time a day when the physicians come in.

 Carol Pehotsky (07:17):

Huh.

Margee Pagnucco (07:17):

And so, it's just really exciting and rewarding to think we can impact patient lives by helping to train their nurses to do these assessments, to find conditions that might be deteriorating, and to really help intervene quicker with those patients.

 Carol Pehotsky (07:17):

Yeah.

Margee Pagnucco (07:35):

So, it's really exciting work.

 Carol Pehotsky (07:37):

Your, your career really has been sort of making the ripples in the pond bigger and bigger.

Margee Pagnucco (07:41):

Hopefully.

 Carol Pehotsky (07:41):

Now it's the whole world.

Margee Pagnucco (07:42):

Yeah.

 Carol Pehotsky (07:42):

(laughs) So knowing that this Cleveland Clinic Connected has some actual relationships and then some other interactions with other facilities, how does somebody become part of this program? Or what do we within this organization do to assess whether a partnership is appropriate, or what the next steps would be?

Margee Pagnucco (08:02):

We have a business and development team that works on the initial relationship conversations, and of course do some due diligence-

 Carol Pehotsky (08:10):

Yeah.

Margee Pagnucco (08:10):

... to determine if these are facilities and locations where we would benefit from having a presence. And then when it gets to where we're convinced that they do want to proceed with the relationship and they're in a probationary period, we go out and we go on-site, my team and do a two-and-a-half-day assessment.

 Carol Pehotsky (08:29):

Wow.

Margee Pagnucco (08:29):

We're, we're on-site touring going into the OR, shadowing nurses, talking to executive teams, talking to their safety and quality teams, really to get a feel for the culture.

 Carol Pehotsky (08:30):

Mm. Okay.

Margee Pagnucco (08:41):

And to see if it aligns with our culture and our vision.

 Carol Pehotsky (08:45):

Can you talk a little bit more about that, right? So, it's that really that culture of a focus on quality and safety.

Margee Pagnucco (08:51):

Mm-hmm.

 Carol Pehotsky (08:51):

Right. It's, that's so much of what we do as nurses. And so, with nurses on the team and trying to get so much information in two and a half days. (laughs) What are some ways that you're able to, to learn enough about that culture, about how an organization approaches quality and safety to really be able to make an informed evaluation?

Margee Pagnucco (09:10):

We talk to the executive teams.

 Carol Pehotsky (09:12):

Mm-hmm.

Margee Pagnucco (09:13):

Get a sense from them. As we all know, sometimes that is a different view than the frontline caregivers may have. So, we round on units, we look for cues of safety and quality. Do they have metrics posted? Or we talk to staff, are they aware of the performance improvement projects?

 Carol Pehotsky (09:31):

Oh. Okay.

Margee Pagnucco (09:32):

So, talking to managers, executives, and frontline caregivers really gives us a sense of how focused they are on safety and quality. And then we also talk a lot about speaking up.

 Carol Pehotsky (09:43):

Yeah.

Margee Pagnucco (09:43):

And watching dynamics between teams. So, in some of our international affiliates, you see a much more hierarchical environment than I think we're used to in the United States, or at least now in the United States. And um, you can see that in the teams in the way the frontline caregivers may not answer questions, they look to the leaders-

 Carol Pehotsky (10:03):

Oh, wow. Okay.

Margee Pagnucco (10:04):

... to answer questions. And that gives us clues into the culture at the facility.

 Carol Pehotsky (10:10):

So I want to linger there a little bit more because like you said, so much of what we do is either ourselves speaking up, or to the teams that we support, not just encouraging them but empowering them and expecting them to speak up. It doesn't necessarily look like that everywhere. How do you approach that? There's a decision maybe to move forward or even during the assessment. What are some things that you and the team have been able to bring to nurses that maybe are in part of that hierarchical relationship to help them? You mentioned learning assessment skills. What else can you do, or have you done to really help that nurse find his or her voice in that type of climate?

Margee Pagnucco (10:45):

A lot of it is just sharing what we do at Cleveland Clinic.

 Carol Pehotsky (10:45):

Okay.

Margee Pagnucco (10:49):

So, we meet quarterly to go over their performance on quality metrics. They give us their data on a monthly basis, and we help to monitor how are you doing and let's say CLABSIs mortality, all the usual quality metrics you would expect us to be looking at. And in those conversations when we share what we do, and that's how the nursing assessment component came up that we're doing with one of our affiliates. Nurses don't do assessments and we're helping to teach them-

 Carol Pehotsky (11:15):

Yeah.

Margee Pagnucco (11:16):

... why you would do this. They don't even understand the why. So that's just, I mean, an example.

 Carol Pehotsky (11:22):

That's fantastic. And you know, appreciating that, like you said the United States wasn't always that way either. We, we've come a lot in our healthcare in terms of empowerment of nurses’ autonomy. What else are you trying to do to bridge that gap? The organization has said clearly an organization seeking this partnership is at least indicating they're wanting some more of that.

Margee Pagnucco (11:23):

Mm-hmm.

 Carol Pehotsky (11:44):

For the nurse who you said maybe isn't, hasn't been exposed to some of this, how do we help them again sort of combat maybe even the local culture as well as the healthcare culture that says, "In these four walls, your voice is heard and your voice is expected."

Margee Pagnucco (11:59):

Now as you alluded to the benefit of us going into these affiliations or these hospitals is that they are open to and want us to come in and help them with these things. So that's the first barrier that has been overcome for us. And again, just sharing what we do lends to questions-

 Carol Pehotsky (12:18):

Uh.

Margee Pagnucco (12:18):

... from them and they're like, "What do you mean the nurses do that?"

 Carol Pehotsky (12:19):

Uh.

Margee Pagnucco (12:23):

And then we further explain. So, it's just through conversation, reviewing the metrics, asking them about successes and obstacles. So, we do that very intentionally during those quarterly-

 Carol Pehotsky (12:33):

Yeah.

Margee Pagnucco (12:33):

... review meetings to say, "What have you tried? What hasn't worked?" In those conversations is usually where those things come up. And then we can help say, "Well, here's how we do it in the United States, and here's where we used to be, and how we got to where we are."

 Carol Pehotsky (12:33):

Okay. Yeah.

Margee Pagnucco (12:49):

So, I've been a nurse long enough to have had those-

 Carol Pehotsky (12:49):

(laughs).

Margee Pagnucco (12:53):

... very real firsthand moments where, you know, the doctor comes into the room, and you get up from the chair because-

 Carol Pehotsky (12:59):

That was the relationship.

Margee Pagnucco (13:00):

... that's what we used to do. Yeah. And so, helping them understand we weren't always like this.

 Carol Pehotsky (13:06):

Yeah.

Margee Pagnucco (13:06):

"And here's the things that we did." And a lot of that is through the professional practice model with nursing.

 Carol Pehotsky (13:06):

Yeah.

Margee Pagnucco (13:11):

Is really for our international affiliates in particular. But some of the domestics too are early in their journey.

 Carol Pehotsky (13:11):

Mm.

Margee Pagnucco (13:17):

And having a mature professional practice model where we've really defined what nursing is at that organization. And that's, so of course these are things we assess when we're there. And so those conversations start early on about shared governance.

 Carol Pehotsky (13:31):

Yeah.

Margee Pagnucco (13:32):

And many times, they're like, "What do you mean?"

 Carol Pehotsky (13:35):

(laughs) Shared what? (laughs)

Margee Pagnucco (13:36):

What is shared governance?

 Carol Pehotsky (13:37):

Yeah.

Margee Pagnucco (13:37):

That's right. And so, we can really open their eyes to nurses having a voice, and when we talk to them too about safety event reporting.

 Carol Pehotsky (13:46):

Mm. Sure.

Margee Pagnucco (13:46):

And-

 Carol Pehotsky (13:47):

That visibility.

Margee Pagnucco (13:48):

... what would you do if this situation occurred? Talking about near misses in actual events and really talking about safety events they've had and what they've done about it.

 Carol Pehotsky (13:58):

Okay.

Margee Pagnucco (13:58):

Again, all of that and all those types of questions lend to giving us some more insight into the culture and the status of nurses at the facility.

 Carol Pehotsky (14:08):

So, you mentioned both domestic and international. Where are some of the places you've been? Wha- what are some stories you have from your travels?

Margee Pagnucco (14:14):

Yes. We have been to Ireland, India, The Bahamas, Vietnam, several times, several places domestically.

 Carol Pehotsky (14:23):

Mm-hmm.

Margee Pagnucco (14:24):

Washington, Florida, Indiana. We're soon off to California.

 Carol Pehotsky (14:28):

Nice.

Margee Pagnucco (14:29):

So yeah, we've been all around the world and have had incredible experiences. And the camaraderie that develops especially between the nurses is really rewarding as well. We're always welcomed, and they love to have pictures taken with us.

 Carol Pehotsky (14:29):

(laughs).

Margee Pagnucco (14:45):

And just are really open to having us help them. And they, they want to grow and expand their careers and their, uh, the profession.

 Carol Pehotsky (14:53):

It's fascinating to me, you know, how much the world has changed in the few short years. Talk to me a little bit about the ability to make and continue relationships with some of these teams through things like Teams and Zoom and that connectivity.

Margee Pagnucco (15:07):

Yeah. It can be a challenge. Some of our affiliates aren't used to using cameras.

 Carol Pehotsky (15:11):

Oh, sure.

Margee Pagnucco (15:13):

So let alone the language barrier.

 Carol Pehotsky (15:15):

Yeah.

Margee Pagnucco (15:15):

So, there may be limited people who speak and read English, let alone the idea of being on camera is new to them. When we are actually in projects with them, we highly recommend cameras so that we can try to overcome some of those barriers and really help establish the relationships. And then there is nothing like our on-site visits to-

 Carol Pehotsky (15:38):

Yeah.

Margee Pagnucco (15:39):

... further establish the relationship. It's absolutely necessary to be on-site to meet people, to see them as individuals with lives at home and not just workers at the hospital, so.

 Carol Pehotsky (15:51):

(laughs). And you probably have to be really in touch with the world clock on your phones.

Margee Pagnucco (15:54):

Yes.

 Carol Pehotsky (15:54):

(laughs) To know what time it is.

Margee Pagnucco (15:56):

Yeah. Um, this, this week I have 6:00 AM every day, which for our affiliates around the world is 6:00 PM.

 Carol Pehotsky (15:56):

Yeah.

Margee Pagnucco (16:03):

So, on both ends, we're burning the candles-

 Carol Pehotsky (16:07):

For everybody.

Margee Pagnucco (16:07):

... Yeah.

 Carol Pehotsky (16:08):

For sure. So, we've touched on this a little bit, but I'd like to spend a little more time talking about every hospital has its own culture, but it also lives within the society's culture at large. Talk to us a little bit about some of the- what you've learned on cultural sensitivity, some of the things that you've had to really think about to acknowledge both those cultures, both the healthcare one as well as where that organization is located.

Margee Pagnucco (16:32):

The first example that comes to mind is as we were working with one of our international partners on quality metrics and talking about mortality, they said they don't have mortalities.

 Carol Pehotsky (16:44):

Oh, okay.

Margee Pagnucco (16:44):

And that was like-

 Carol Pehotsky (16:44):

(laughs).

Margee Pagnucco (16:45):

... "Wait a minute, there can't be, this is a hospital, there can't be people who don't die here." And they said, "Yes, they only die in the ICU." And you know, we were skeptical about that.

 Carol Pehotsky (16:45):

Yeah.

Margee Pagnucco (16:54):

Like, "Why is that?"

 Carol Pehotsky (16:54):

Mm-hmm.

Margee Pagnucco (16:55):

That can't be. But then for further conversation, they don't keep people in the hospital who are at the end of life.

 Carol Pehotsky (17:03):

Oh.

Margee Pagnucco (17:03):

So, they go home to be with their families.

 Carol Pehotsky (17:06):

Uh-huh.

Margee Pagnucco (17:06):

And so, it was kind of a one of those moments where I had a light bulb moment like, "Well, just because we do it this way doesn't make it the right way." And wow, isn't that rather heartwarming to think that at the end of your life you're going to go home to be with your family? So, it was just one of those examples where we're like, "Huh, are we trying to impose our Western thoughts and culture on a different culture that may have- it might be better."

 Carol Pehotsky (17:35):

Yeah.

Margee Pagnucco (17:35):

It might be a great thing, you know. So, it's just a different way of doing things. So that's one thing. The hierarchical nature of some of the international relationships is probably the biggest challenge.

 Carol Pehotsky (17:46):

Yeah.

Margee Pagnucco (17:46):

Is we're very used to having a voice speaking up and being bold.

 Carol Pehotsky (17:52):

Yeah.

Margee Pagnucco (17:52):

And that's not always the case with some of these other countries where it's just not the expectation. Again, nurses aren't even doing assessments, so there's hesitancy to speak up about things that aren't going well. So that's probably the biggest challenge we face in addition to the language, the language issues.

 Carol Pehotsky (18:08):

Yeah. I love how you talked about different is not better or worse, and there probably are no shortage of examples you have around those moments where you say, "Ah, this might be better."

Margee Pagnucco (18:08):

Mm-hmm.

 Carol Pehotsky (18:17):

Any other aha moments that you've had along the way?

Margee Pagnucco (18:21):

Um, there's metrics or things that we monitor that in the international space, they don't for say readmissions.

 Carol Pehotsky (18:28):

Oh, okay.

Margee Pagnucco (18:30):

DBTs, pulmonary embolisms, returns to the OR, surgical complications. So those are topics that I think we bring a lot of value-

 Carol Pehotsky (18:41):

Yeah.

Margee Pagnucco (18:41):

... to these organizations. They believe... I had one organization say, "Oh, we don't ever, we don't have DBTs and PEs."

 Carol Pehotsky (18:48):

(laughs).

Margee Pagnucco (18:48):

"Really? Are you monitoring them? Can I see your data?" And they say, "Well, we don't collect that data."

 Carol Pehotsky (18:52):

(laughs).

Margee Pagnucco (18:53):

Uh, and so now they're collecting it.

 Carol Pehotsky (18:55):

Okay.

Margee Pagnucco (18:55):

And guess what? They have DBTs and PEs. So, it's really been value that we've brought to them that they can now, you know, see that and do something about it hopefully.

 Carol Pehotsky (19:06):

In terms of education of nurses, you've mentioned this a little bit. Is there an opportunity or have you had opportunities to sort of go that one step further and talk to these hospitals about the nursing programs locally? Any opportunity to advocate for different preparation of nurses?

Margee Pagnucco (19:23):

I don't think up to this point, but I think in the near future we will have opportunity especially in light of as we're beginning to understand more about what nurses don't get taught in nursing school.

 Carol Pehotsky (19:35):

Yeah.

Margee Pagnucco (19:36):

For example, assessments. I think we really have the opportunity to advocate on an international basis for nursing, and to really show the world that the value that nurses can bring to patient care outcomes, safety, and experience.

 Carol Pehotsky (19:53):

Yeah, absolutely. To try to get that sort of one step removed. They're learning so much now, but how do we get that to those preparations? Nice.

Margee Pagnucco (20:01):

Yeah.

 Carol Pehotsky (20:02):

Any challenging situations you've had to navigate in terms of maybe some hesitancy to, whether it's language barriers or just trying to get on the same page to really help those that you're interacting with appreciate the intentions behind it, the things that could be executed?

Margee Pagnucco (20:20):

Yes. Actually recently, we're in the middle of a couple projects with one of our international partners. And we of course want to make valuable use of everyone's time when we do get together.

 Carol Pehotsky (20:31):

Mm-hmm.

Margee Pagnucco (20:31):

So, we schedule a one-hour meeting and there's a lot of prep work that goes into that, but it's very hard to do by email. So, what we take for granted-

 Carol Pehotsky (20:38):

(laughs) Yeah.

Margee Pagnucco (20:39):

... like think of SolVE. SolVE where we're getting people together to work through a problem.

 Carol Pehotsky (20:44):

Mm-hmm.

Margee Pagnucco (20:44):

And it's so valuable to have the in-person conversation with the people who do the work to actually-

 Carol Pehotsky (20:51):

Yeah.

Margee Pagnucco (20:51):

... identify the problems rather than have managers or executives who think they know the problem or try to work through the problem. That's very challenging right now.

 Carol Pehotsky (20:51):

Yeah, for sure.

Margee Pagnucco (21:02):

And we've had that circumstance where we're trying to do it by email and not really getting to the people who do the work.

 Carol Pehotsky (21:07):

Uh.

Margee Pagnucco (21:08):

Because that's not the culture there.

 Carol Pehotsky (21:10):

Right.

Margee Pagnucco (21:10):

It's hierarchical and they believe the... The executive teams believe they know the problem so they're going to come up with the solutions. And of course, here at Cleveland Clinic, we really believe that the people best suited to tell us what the problems are and what the solutions are, are the people who do the work.

 Carol Pehotsky (21:27):

Right. How you, how you embed that continuous improvement-

Margee Pagnucco (21:29):

Mm-hmm.

 Carol Pehotsky (21:29):

... approach. Sure. So, we've talked a lot about giving organizations sort of our why and our approach to speaking up. How then does that get translated into the actual work? Right. How we help maybe that physician that's used to being the authority learn how to listen to nurses and, and how to really sort of where the rubber meets the road of that nurse in that moment. How do we help that nurse speak up in that moment?

Margee Pagnucco (21:56):

In the example of the nursing assessment, one of the tools that we typically use in continuous improvement is like RACI diagrams which is, you know, who's, who's responsible, accountable, consultant, and informed-

 Carol Pehotsky (22:08):

Okay.

Margee Pagnucco (22:08):

... with RACI-

 Carol Pehotsky (22:08):

Mm-hmm.

Margee Pagnucco (22:09):

... where we identify the stakeholders.

 Carol Pehotsky (22:11):

Okay.

Margee Pagnucco (22:11):

And what each of their roles is in this project. In that we needed to make sure that they have the physicians on board, like have you talked to them about this.

 Carol Pehotsky (22:21):

(laughs).

Margee Pagnucco (22:21):

So even just that tool is new to them. So, it's just been rewarding to be able to see how we can teach them somewhat we consider basic tools-

 Carol Pehotsky (22:33):

Yeah.

Margee Pagnucco (22:33):

... to work through problems, to make sure you've got the right people on board, that you've got the right people engaged. And through those things, we're hopeful to start breaking down these barriers of, we're not going to change their culture, we're not going to impose our Western culture on them.

 Carol Pehotsky (22:50):

Right.

Margee Pagnucco (22:51):

However, we can hopefully help to improve the environment of safety where everybody feels empowered and expected to speak up. It's not just a tag, Cleveland Clinic tagline.

 Carol Pehotsky (23:02):

Right. (laughs)

Margee Pagnucco (23:02):

It's really for all healthcare workers; they need to be able to speak up. And so, physicians are going to help test if you will, nurses’ assessment skills.

 Carol Pehotsky (23:12):

Okay.

Margee Pagnucco (23:13):

And so that collaboration-

 Carol Pehotsky (23:15):

Collaboration, yeah.

Margee Pagnucco (23:15):

... should help get the physicians more comfortable. So those... That's just one example of how we try to help overcome.

(23:23):

And then with safety event reporting, we try to help them, and we share with them, our high-reliability coach program, how we're trying to have people on the units that are looking for behaviors. When they don't see the behaviors, speaking up. So just hoping that they start to adopt some of those things. And again, we're not trying to force our ways on them, we're just looking for the invitations from them to assist.

 Carol Pehotsky (23:49):

Well, when you think about, you know, you'd mentioned earlier the ability to say to other organizations, "This is where US healthcare was and is, or even Cleveland Clinic healthcare." You think about transparency around safety events and near misses.

Margee Pagnucco (24:04):

Mm-hmm.

 Carol Pehotsky (24:04):

By and large, not specific to our organization, was not really something you talked about.

Margee Pagnucco (24:08):

Mm-hmm.

 Carol Pehotsky (24:09):

Not that long ago when you think about the-

Margee Pagnucco (24:10):

Yeah.

 Carol Pehotsky (24:10):

... span of healthcare. So, I'm sure that's also very impactful for them to hear that journey that says, "We in our own country have evolved quite a bit when it comes to reporting, and transparency and, and talking candidly about these things."

Margee Pagnucco (24:22):

Yes. Yeah. And I think sharing those examples really gives us more credibility. I know in my personal experience as, uh, in the southern submarket I've been... I had the privilege to onboard Akron General, Mercy, Union. And those experiences I believe, give me a little credibility with these affiliates.

 Carol Pehotsky (24:41):

Yeah.

Margee Pagnucco (24:41):

Because they say, "Oh my goodness, you're the Cleveland Clinic. You can't possibly relate to our 200-bed hospital-"

 Carol Pehotsky (24:47):

But we can.

Margee Pagnucco (24:48):

..."who has all of this work to do?" And I said, "Yes, yes we can because we do it." We've acquired hospitals and I've been there early in the journey.

 Carol Pehotsky (24:48):

Yeah.

Margee Pagnucco (24:58):

And we've really helped. And we know those things that we need to do, and we've learned good ways of doing it and better ways of doing it as we've gone through these acquisitions.

 Carol Pehotsky (25:08):

So, we've spent most of the time talking about international programs. We do have a few domestic partners.

Margee Pagnucco (25:08):

Mm-hmm.

 Carol Pehotsky (25:12):

How does the approach change? What's that been like?

Margee Pagnucco (25:15):

Okay. Because we're... The domestic partners are following the same rule book.

 Carol Pehotsky (25:19):

Okay.

Margee Pagnucco (25:20):

Typically, joint commission.

 Carol Pehotsky (25:21):

Yeah.

Margee Pagnucco (25:21):

And um-

 Carol Pehotsky (25:22):

That's true. (laughs)

Margee Pagnucco (25:22):

... all the CMS CoPs are the same. The conditions of participation for hospitals, we all are reimbursed under the same inpatient perspective payment system. So, the rules are essentially the same. So, when we go to do work with quality metrics, the definitions are the same. We don't have to negotiate-

 Carol Pehotsky (25:41):

Oh, sure.

Margee Pagnucco (25:42):

... the numerator denominator population that we're... You know, the definitions. So that makes it much easier. We kind of speak the same language, so to speak.

 Carol Pehotsky (25:52):

Yeah. And literally. (laughs)

Margee Pagnucco (25:54):

Yes, yes. Yeah. Literally we have the same raters and rankers, so Leapfrog, CMS star ratings. So, there's a lot of similarities and it's kind of easier to, for them to understand our processes. And we're typically not too far off in the professional. For example, the responsibilities of a nurse are pretty similar.

 Carol Pehotsky (26:16):

Yeah.

Margee Pagnucco (26:16):

So, it's a slightly different assessment when we go in, and usually different strengths and opportunities that are identified.

 Carol Pehotsky (26:24):

Excellent. So, we have some listeners who are nursing students. We have listeners from outside Cleveland Clinic. So, I imagine you've piqued a lot of interests with nurses who are trying to imagine what a unique opportunity in nursing could look like as their career move, moves forward.

Margee Pagnucco (26:38):

Mm-hmm.

 Carol Pehotsky (26:38):

So for those listeners who aren't able to directly tap into Cleveland Clinic Connected but are intrigued, what advice would you give somebody when it comes to considering a big leap like moving into an international area, or advocacy sort of outside of the four walls of where someone practices?

Margee Pagnucco (26:56):

Mm-hmm. Learn as much as you can about everything you can. I believe that's why I've gotten to this place in my career is I was continuously seeking out new opportunities to learn more. When I got into quality it was all about the rule books.

 Carol Pehotsky (27:10):

Yeah.

Margee Pagnucco (27:11):

And you mentioned accreditation earlier. I love accreditation and regulatory stuff, so raters and rankers. Learning about those things in addition to bedside nursing. And then being in management and learning more about operations, staffing challenges that nurses face.

 Carol Pehotsky (27:27):

Probably a bit of courage too, huh?

Margee Pagnucco (27:29):

Yes. And I will say, I think starting out in a CVS ICU was a great experience for me. Learned very early on how to navigate some challenging situations and just getting that exposure, I think, and just always thinking to learn and being willing to go beyond your comfort zone.

 Carol Pehotsky (27:48):

That's fantastic advice.

Margee Pagnucco (27:50):

(laughs).

 Carol Pehotsky (27:50):

And thank you so much for sharing your journey, and really how those ripples in the pond you are just touching more and more and more patients and they're all the better for it.

Margee Pagnucco (27:59):

[inaudible 00:27:59].

 Carol Pehotsky (27:59):

Before we call it a day it's time for our speed round where we ask you a couple questions that help our audience get to know you as amazing human being as well as an amazing nurse and leader. So, we'll start with, what's something you do for you to recharge?

Margee Pagnucco (28:14):

I love to garden and cook. Gardening is where I go to get rid of any frustration.

 Carol Pehotsky (28:20):

(laughs).

Margee Pagnucco (28:20):

I can tackle those weeds, but I also have a greenhouse. So, in the winter-

 Carol Pehotsky (28:24):

Ooh.

Margee Pagnucco (28:24):

... it's just a like oasis for me to go and get away from the rest of the world. So, I just really enjoy plants.

 Carol Pehotsky (28:30):

And hopefully they can handle you being gone for little bits of time.

Margee Pagnucco (28:34):

Yes. They have a watering system, so.

 Carol Pehotsky (28:35):

(laughs). Very good. (laughs)

Margee Pagnucco (28:36):

Yes.

 Carol Pehotsky (28:37):

And then how about, what's something you wish you knew as a brand-new nurse?

Margee Pagnucco (28:41):

That the possibilities in nursing are almost endless. I just don't understand when a nurse feels like they're burnt out, or that there's nothing different they could do. Because it's, it's almost limitless. Again, various bedside nursing positions. You can go into specialties, you can become an expert in diabetes, you can become an expert in heart failure. You can go into the OR. You can be- go into administration, education, research. It's just almost limitless. And I never dreamed of a job like mine. I often say I have the coolest job at the Cleveland Clinic.

 Carol Pehotsky (28:41):

(laughs).

Margee Pagnucco (29:13):

So that's what I would say to a new nurse is try out different things, and find out what your why is, what's your purpose and what, what makes you tick and where you get the most reward.

 Carol Pehotsky (29:24):

Beautifully said. Thank you so much for joining me today.

Margee Pagnucco (29:27):

Right. Thank you. Thank you for having me.

 Carol Pehotsky (29:32):

As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentialsatccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing.

(29:59):

Until next time, take care of yourselves and take care of each other.

(30:06):

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.