Connected to the World

Since launching its Connected program in 2022, Cleveland Clinic has made steady progress toward its goal of creating a global network of independent, like-minded, quality-focused organizations with the shared mission of improving patient care. The key criteria for membership in the program is an alignment with Cleveland Clinic’s mission to improve safety, quality and the patient experience (SQPE) with the overarching goal of improving reliability in healthcare.

To identify and support like-minded affiliate institutions, a rigorous vetting process has been put into place. Once a potential partner has been invited to join the Connected program, a select team primarily composed of Cleveland Clinic nurses is tasked with visiting and evaluating the new institution to understand its foundational safety, quality and continuous improvement processes.

“Our goal is to share our subject-matter expertise and best practices with these affiliates, both domestic and international,” explains Margee Pagnucco, MSN, RN, CPHQ, Enterprise Senior Director of SQPE for Cleveland Clinic Connected. “On both an initial and ongoing basis, we want to make sure our affiliates are keeping patients at the center of every decision they make while focusing on safety and quality.”

That mission has taken Pagnucco and members of a small but highly experienced team of nursing-quality specialists — including Laura Pease, MSN, RN-BC, NEA-BC, Senior Director, Nursing Quality and Wound Care; Maureen Schaupp, MSN, APRN-CNP, Executive Director/Associate Chief Nursing Officer, Advanced Practice Nursing; and Annie Fitz, MSN, MBA, RN, NE-BC, CPHQ, CCM, Program Director, Nursing Quality and Practice — to locations ranging from U.S. institutions in Washington, Florida and Indiana to international institutions in Ireland, India and Vietnam.

In recent months, the program has welcomed its three newest affiliates: two in Vietnam and one in Titusville, Florida.

Organizational onboarding

The vetting process begins with a collaborative on-site visit, which provides the team with an opportunity to learn about the facility and its practices over the course of two to three days.

“We start by meeting with multiple teams within the organization — nursing teams, quality teams, infection prevention teams and so on — to best understand how they are addressing each element of quality,” explains Pease. “We also try to spend time with direct caregivers, the clinicians who are at the patients’ bedsides, to really understand how care is delivered.”

“Although we avoid becoming overly focused on accreditation components, we do look at various departments — the lab, pharmacy, nursing units, etc. — to address each element of SQPE,” she adds. “We focus on assessing how each of these departments affects the safe and evidence-based delivery of patient care.”

Key performance indicators are also established to identify data that the affiliate is asked to track. “We want affiliate sites to set targets and work toward improvement in the areas we’ve established,” explains Pagnucco. “For example, we might look at mortality: How many patients died in your hospital last month? What are your processes around that, and what opportunities for improvement exist?”

The team also assesses the general culture and communication of facility personnel, she says. “What is the safety culture, for instance? Are people willing to speak up and bring things to the attention of the team leader? What are the interactions like between the nurses and physicians? Are teams leading improvement efforts? How do they work together — and do they actively collaborate on patient care?”

Pagnucco emphasizes the importance of cultural sensitivity during this part of the process.

“With international clients, we see quite a bit of variation in the roles physicians and nurses play,” she says. “And I think that, as nurses, we can be influential in helping affiliate sites understand our Western nursing professional-practice model. Nurses may be marginalized in certain places in the world, and our process gives us an opportunity to help nurses understand the potential benefits of elevating their roles.”

The team’s makeup itself emphasizes the influence of Cleveland Clinic nurses, adds Pagnucco, and can create space for meaningful discussion. “By modeling our leadership and executive presence, we hope to demonstrate our subject matter expertise and the level of influence we hold within our own organization.”

Building long-term connections

Once the partnership has been formalized, new affiliates can expect to receive ongoing support by way of remote quarterly meetings, which are used to follow up on key performance indicators that were established during the initial phase of membership. Regular meetings also enable the team to identify trends, discuss recent successes and consider opportunities for improvement.

“Not only do these quarterly SQPE reviews help affiliates focus on performance data,” Pease adds, “but they also help our partners exercise their general problem-solving skills through the use of continuous improvement tools.”

In cases where improvement has been difficult to attain, the affiliate can request the team’s expertise in taking an in-depth look at the issue. Previous areas of concern include postoperative care; pressure ulcer reduction or elimination; and medication administration, storage, reconciliation and safety practices.

“The program enables us to take a deep dive with the affiliate, going step by step as we work toward better outcomes,” Pagnucco says, adding that the length and scope of the program varies depending on the needs of each individual organization.

Quarterly remote visits are followed by annual in-person visits, which serve to highlight the affiliate’s performance improvement efforts and strengthen institutional relationships — a step that both Pease and Pagnucco agree is vital to the success of the program.

“Since basic differences in how healthcare is delivered in different countries can be a barrier, we have to be both knowledgeable and thoughtful in our approach,” explains Pease. “We can’t simply impose our own standards on an affiliate. The region’s regulations and educational standards may be different from ours, and there may be cultural variations that must be addressed with sensitivity.”

Sparking change

But challenges are not without their rewards. “I sometimes feel like navigating cultural disparities is the best part of my job,” says Pagnucco. “It’s fun to interact with nurses from different parts of the world and get the chance to really understand how they deliver care. Our conversations about how to improve practice at an international level can be incredibly rewarding.”

Pease recalls a particular exchange in Vietnam in which she and her team were able to share information about Cleveland Clinic’s shared governance structure with the Vietnamese nursing team. The discussion allowed the new affiliate to begin conceptualizing a similar structure there.

“Some of the more theoretical concepts can be hard to grasp for nurses who do not have experience working in environments with those structures in place,” she explains. “So being able to share our experience with them in a meaningful way — not just handing them a document to read — makes us feel like we’re making a difference.”

“That’s the core of what makes this job so cool,” Pagnucco adds. “When you’re a clinical nurse, you affect the lives of the patients you’re caring for that day. But in this role, I feel like we’re improving the lives of patients all over the world — now and in the future — even those we’ve never met. And that feels just great.”

It also helps put Cleveland Clinic’s work into perspective, Pease and Pagnucco agree.

“When working with such diverse organizations, it becomes easy to recognize how fortunate we are to be at Cleveland Clinic, where we have access to the best resources and practitioners anywhere in the world,” says Pagnucco. “We’re humbled by our good fortune.”