Caitlin Heath

Quality Management: As a leader of the Quality Management Department, assists in the implementation and integration of the organization’s Performance Improvement Plan across the health system. Manages quality data required for compliance with regulatory and accreditation standards. Facilitates improvement teams directly related to addressing opportunities identified by data analysis, utilizing standard methodologies for; meeting management, quality improvement principles and statistical process control techniques. Collaborates with the Patient Safety Manager, other quality department staff and system leaders in tracking and analyzing outcomes. Works within the Quality department team on system-wide improvement initiatives in quality and patient safety.

Management of Accreditation and Regulatory processes: Oversees the preparation for accreditation surveys, collaborating with health system leaders to achieve a state of “continuous survey readiness.” Works with departmental leaders to support them in complying with standards, providing resources and staff education to enhance readiness. Works in conjunction with the Patient Safety Manager to address patient safety opportunities identified through assessment of readiness. Assures that new accreditation standards are addressed in a timely manner. Facilitates submission of required Joint Commission reports such as intra-cycle applications. Documents efforts made to address these opportunities and the outcomes resulting from those actions implemented for improvement. Serves as the health system’s Site Survey Coordinator during onsite surveys. Supervises the preparation of post-survey requirements, such as the Evidence of Standards Compliance submission.

Recently helped the organization in the Transition from TJC to DNV as of Q3 2024.

Management of External Reporting programs: Manages health system programs that are required for regulatory or accreditation compliance. Assures that deadlines are met, changes are made to internal reporting processes as data requirements/updates are published and monitors outcomes. These external data base programs include but are not limited to CMS programs (VBP, HAC, HRRP, Joint Commission Core Measures, HQIC participation and others that may be added that are approved by senior leadership for inclusion in the System wide quality management program.

Program Lead for Vizient Clinical Data Base (CDB) program: Lead the successful implementation and operation of the CDB, including leadership of the facility implementation team consisting of multidisciplinary departments. Works closely with the IT department in the project implementation plan for the CDB and in ongoing maintenance of this reporting system in order to provide data required to assess clinical performance outcomes.

Leapfrog: Leads the preparation for and submission of data to the Leapfrog program. Identifies areas for improvement based on the data submitted. Recommends PI initiatives to improve the scores for specific sections of the Leapfrog Safety report that can impact the overall ratings and grades for both campuses.

Supervisory responsibilities: Provides oversight of the processes that quality department staff providing quality and patient safety data and reports meet accreditation and regulatory requirements.

Reporting responsibilities: Prepares reports on the state of accreditation readiness and data outcomes and presents to other health system departments, medical staff, Leadership and oversight committees such as the Quality and Patient Safety Operations Council, the Quality Committee, Executive leadership, the Camden Advisory Committee and the Board of Directors.

Education & Training: Creates and facilitates educational initiatives based on accreditation standards and requirements and performance outcome opportunities that focus on best practices. Participates in system-wide educational initiatives focused on patient safety and quality improvement.

• Review and analyze facility activities and data to aid planning and cash and risk management and to improve service utilization.
• Develop and maintain computerized record management systems to store and process data such as personnel activities and information, and to produce reports.
• Develop and implement organizational policies and procedures for the facility or medical unit.
• Manage change in integrated health care delivery systems, such as work restructuring, technological innovations, and shifts in the focus of care.
• Maintain communication between governing boards, medical staff, and department heads by attending board meetings and coordinating interdepartmental functioning.
• Conduct and administer fiscal operations, including accounting, planning budgets, authorizing expenditures, establishing rates for services, and coordinating financial reporting.
• Prepare activity reports to inform management of the status and implementation plans of programs, services, and quality initiatives.
• Develop or expand and implement medical programs or health services that promote research, rehabilitation, and community health.
• Direct, supervise and evaluate work activities of medical, nursing, technical, clerical, service, maintenance, and other personnel.
• Maintain awareness of advances in medicine, computerized diagnostic and treatment equipment, data processing technology, government regulations, health insurance changes, and financing options.
• Consult with medical, business, and community groups to discuss service problems, respond to community needs, enhance public relations, coordinate activities and plans, and promote health programs.
• Direct or conduct recruitment, hiring and training of personnel.

• Developed healthcare plans for individuals and families. Provided necessary health education training for patients. Implemented and maintained core measures in patient safety patient satisfaction and holistic approaches to nursing.
• Treated patients using pharmacological and non-pharmacological treatment modalities to address various disorders diseases and injuries. Trained and mentored new RNs on best practices
• Clinical policies and standards of care. Cultivated working partnerships with patients and Team members using feedback and clinical data to improve quality care and patient outcomes. Maintained infection control logs
• Streamlined the charting process and improved patient outcomes through training and leadership. Managed Teammates to ensure a high level of staff morale
• Patient care and overall professionalism. Delivered quality care and comfort to patients with heart failure pulmonary hypertension pulmonary embolisms and end-stage renal disease. Completed comprehensive patient assessments to determine individual needs
• Formulating plans of care in collaboration with multidisciplinary healthcare professionals including physician case managers and social workers.

• Maintain accurate, detailed reports and records.
• Administer local, inhalation, intravenous, or other anesthetics.
• Prepare rooms, sterile instruments, equipment, or supplies and ensure that stock of supplies is maintained.
• Provide or arrange for training or instruction of auxiliary personnel or students.
• Order, interpret, and evaluate diagnostic tests to identify and assess patient's condition.
• Direct or coordinate infection control programs, advising or consulting with specified personnel about necessary precautions.
• Conduct specified laboratory tests.
• Monitor, record, and report symptoms or changes in patients' conditions.
• Instruct individuals, families, or other groups on topics such as health education, disease prevention, or childbirth and develop health improvement programs.
• Monitor all aspects of patient care, including diet and physical activity.
• Record patients' medical information and vital signs.
• Assess the needs of individuals, families, or communities, including assessment of individuals' home or work environments, to identify potential health or safety problems.
• Direct or supervise less-skilled nursing or healthcare personnel or supervise a particular unit.
• Modify patient treatment plans as indicated by patients' responses and conditions.
• Consult and coordinate with healthcare team members to assess, plan, implement, or evaluate patient care plans.
• Work with individuals, groups, or families to plan or implement programs designed to improve the overall health of communities.
• Prepare patients for and assist with examinations or treatments.

• Evaluated students with health concerns or injuries to develop plan of care or provide reference to appropriate healthcare providers. Coordinated with families
• School personnel and healthcare professionals on the behalf of students to advocate for healthcare needs and provide medical information to appropriate parties.