Encore Insights, Ep. 1: A Candid Conversation with Meredith Foxx, CNO of Cleveland Clinic

Some items of my leadership journey were purposeful, and some were serendipitous — but I don't think anything just happens. What I learned early in my career is that I always said yes to every opportunity. Any time I was asked — 'Do you want to be charge nurse?' Yes. 'Do you want to precept?' Yes. 'Do you want to be on this committee?' Yes. It became a running joke: if I left the room, they'd say she'll say yes anyway, just assign her. My first formal leadership role came when I was asked to be interim manager of my peer group — which means going from sitting at the lunch table with them to being talked about at the lunch table pretty quickly.

Traditionally, nursing has said 'they're a good bedside nurse, let's make them the leader.' We've had to reframe that. We look for the skills and behaviors that allow someone to be both a good clinician and a strong manager. At Cleveland Clinic, we talk a lot about managing versus leading — they are two different things, and you have to do both. One of the first questions I ask someone considering leadership is: are you ready to manage other people? Because managing people — accountability, change management, recognition — takes grit and humility. There are always going to be crucial conversations. Enabling nurses to take that next step means being honest with them about what it actually requires.

We come from a sense of continuous improvement. We're always on a journey — improved outcomes, improved metrics, ultimately improving patient lives. Working with teams to look at how we do things, versus doing things to teams, is a concept we think about a lot. The other piece is understanding what gets in the way of people delivering safe, high-quality care. Providing a safe space for people to share those barriers means we can actually solve for them — rather than coming down on metrics without understanding the root cause.

First, make sure everyone understands the expectations — these are the standards we're all held to, and this is what we're driving toward. When we fall short, ask why. There's a concept called the five whys: ask why five times to get to the actual root cause. Things don't happen by chance. I was at one of our nursing units recently where they hadn't had a patient fall in two and a half months. I told them: this isn't a coincidence anymore. You asked your team to focus on this, you understood why patients were at risk, and it's working. That's worth celebrating explicitly.

First reframe: was it necessarily a wrong decision, or did you make the best decision with the information you had at the time? If it was wrong, it was wrong — and as leaders we have to humbly admit that, be transparent with our teams, and course correct. About eight years ago, I told senior leadership I was going to fix a major problem in six months. I did not fix it in six months. But I still had a job. I committed to a timeline without all the information I needed. I still use that example with my team today. It's not about being right or wrong — it's about owning it and deciding what you're going to do differently.

There are so many metrics to watch, and the list in wound care alone can be enormous. We've tried to help our teams understand what the top priorities are: what's going to make the biggest patient impact? You can't watch everything — then it becomes whack-a-mole. We've had to cultivate a culture around how we sustain improvements, not just chase the next crisis. I'm also focused on how we give and receive feedback at every level. A mentor of mine always said feedback is a gift. If someone's giving it to you, they want you to do better. It's when they stop telling you that you should worry.

The handoff is a vulnerable moment, regardless of whether it's nurse to nurse, nurse to provider, or hospital to post-acute. Standards around what gets communicated are critical — if we drift from those standards, a piece gets missed that could really matter for the patient. I also want to involve patients and their primary caregivers in every handoff conversation. And technology is helping — AI summarization tools are starting to provide a more complete synopsis that follows the patient, so post-acute teams are spending less time searching for information and more time acting on it.

About a year ago, my team and I spent time working full 12-hour shifts side by side with nurses. One nurse said: 'I have such strong muscle memory the way I was taught, and I'm worried that if I don't follow it through the charting system, I'll miss something.' And I asked her: what if your muscle memory is already making you miss something? Trust is the key. They have to trust that the technology works. At some of our larger campuses, we've rolled out thermal imaging technology for assessing skin integrity below the surface. There were real skeptics — we took a chance, it worked, and now more people are interested. Showing the results makes people believers.

Go for it. The beauty of nursing is that we have so many specialties and so many opportunities. A nurse I met with earlier this week started as a float pool nurse, went through different surgery units, transitioned to home care, and is now in interventional radiology. In 13 years, she's moved through three completely different specialties. That's the profession working the way it should. The real question to ask is: do you want to change specialties for the exposure, or do you want to change roles entirely? Whatever your passion is — follow it.

We've been talking in our training programs about being strategic, operational, and tactical — and understanding which mode a leader should be operating in at any given moment. You can't be strategic if you don't understand the operational and tactical reality. I'm a strong believer in leader standard work. Even at my level, I have standard things I do every day and every week to stay on task with the ultimate objectives of the organization. Standardizing your work helps all leaders stay focused on what the ultimate goals actually are.

Post-pandemic, a lot of our work has focused on building the pipeline — for nursing and for all healthcare roles. We focus on reaching people in high school, college, and adult learner programs. One of the things that came out of the pandemic was greater awareness of the breadth of roles in healthcare that most people don't know exist. We've also had pilot programs supporting our own nursing assistants to go back to nursing school. And we've partnered with academic institutions in creative ways — using our own nurses as clinical faculty, so students get real-world experience with people who know the unit, the team, and the patient population.

About a year ago, I went and worked full shifts alongside nurses — showed up in my white scrubs and lab coat and was in it. I think it's critical for leaders at every level to go back to the bedside regularly. You have to walk in their shoes to understand what's actually going on. I recently went down to our sterile processing department and was overwhelmed — and completely impressed by the knowledge and diligence of those team members. Being able to see what individuals are doing and understand it means I can advocate for them when I'm at the leadership table.

Delegation is critical — making sure your assistant nurse managers and shift supervisors are empowered to handle what happens when you're not there. And set the right expectations from the start. I had a manager who made schedule changes on Saturday afternoon so she wouldn't forget by Monday. By responding on a Saturday, she was telling her team it was urgent. You set your own expectations. There's a meaningful difference between being accountable 24/7 and being available 24/7. Urgent matters are phone calls. Scheduled send is a lifesaver — think of something at 11pm, compose the email, send it at 8am without creating a false expectation of immediacy.

We've been working on ambient listening technology — a tool that picks up the conversation between the patient and the provider and creates the clinical note automatically. So the provider isn't typing into a flow sheet while the patient is talking. The goal should always be to use technology to increase face-to-face time with patients, not decrease it. When families see a provider looking at a device, their assumption is they're on their phone — so there's an education component around explaining: that's the tool they're using to document your care. It's about reframing technology as a tool for presence, not a barrier to it.

Don't underestimate your contributions — whatever type of healthcare provider you are. Stay curious. I follow someone on social media who always has great little tidbits, and something they said recently was: don't call yourself 'just a nurse,' or just anything. I've always tried to say that in my career — just drop the 'just.' I'm a nurse. Even in my own early years as a practicing clinical nurse specialist, I wouldn't always introduce myself as that. But underestimating that role underestimates the contributions a clinical specialist makes. Everybody has a role, and everybody is contributing to patient care and outcomes. Own that.

Every summer, I spend time with our summer nurse associate program — students in the final summer before their senior year of nursing school. At the end-of-program celebration, I see where they started in May versus where they are in August, and the enthusiasm, the confidence, the energy — it makes me know the future of nursing is bright. Every time I leave that celebration, I think: we've got this. It's not all doom and gloom. Nursing is a thriving profession that people genuinely want to be part of.