JENNIFER HAMILTON-GILPIN, RN MHA FACHE
Cape Girardeau,Missouri
Summary
Experienced Senior Leader with an extensive background in Hospital Leadership, Physician Relations, Value Based Purchasing, Population Health, Hospital Reimbursement, Accountable Care, HACS (Hospital Acquired Conditions), Regulatory Compliance, Core Measures and HCAHPS. Proficient in best practices, market trends and regulatory requirements with documented strengths in building and maintaining relationships with diverse range of stakeholders in dynamic, fast-paced settings. Collaborative leader dedicated to fostering a culture of safety, excellence and compassionate care through staff development, empowerment, strong physician collaboration, and patient-family centered initiatives. A results-driven leader poised to bring a wealth of experience and commitment to quality evidence-based care. Looking for a position in a facility that is commitment to innovative processes focused on patient-centered care.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Director of Quality
Mercy Hospital Southeast
01.2018 - Current
- Ensure clinical and administrative compliance with all program activities while developing and implementing plans to continually meet standards
- Facilitate Quality improvement initiatives throughout the organization managing regulations and actively removing barriers
- Oversight and responsibility of Complaints/Grievances, Performance Improvement, Patient Safety, Regulatory Compliance, Stroke Program, STEMI Program, Infection Prevention, Transition of Care, Physician and Quality abstraction
- Responsibility and oversight for data and quality metrics in the organization
- Development and review of long- and short-term strategic planning for quality, safety, and regulatory goals
- Successfully facilitated the organization patient care, and leadership team through TJC CCC/PHAC certification, Primary Stroke, ACR, CAP, AASM and TJC Accreditation survey
- Supported and assisted with facilitation of Home Health, Sleep Lab, and Lab/Pathology
- Oversight and responsibility for the review and maintenance of Organizational policy and plans through the review process
- Reduction in Falls
- Reduction in over-all Pressure Injuries by 50% and decreased stage 3-4 by 33% to one reportable for 2023
- Central Line Blood Stream Infection Reduction with education and implementation of the prevention bundles reduction in 2019 from 9 CLABSI to 2023 1
- Catheter Associated Infection Reduction decrease from 11 in 2019 to 2 in 2023 with education implementation of nurse driven protocols and Infection prevention daily rounding
- Cdiff Reduction through the implementation of nurse driven protocol “ticket to test” decrease from 2019-26 hospital onset to 2023 6 cases of hospital onset
- Implementation in 2019 of Transition of Care program that to support patients transition from inpatient stetting to post-acute setting
- Focusing on the Medicare High/complex readmission COPD, PN, HF, and AMI
- 30 Day house wide readmission has improved 22.8 % in CY 2019 during 12/01/2022-11/30/2023
- The Hospital Readmission Reduction Penalty has decreased from $346, 136 for FY 2020 to $74,300 for FY 2024 and removed the HR and COPD penalty
- Implementation of Social determinants of Health program focusing on primary areas of Food insecurity, housing, transportation, utilities and personal safety
- Started a Food Pantry program in 2021 with the SEMO food bank serving over 400 patients since inception
- Outpatient areas are also in a food prescription program grant with USDA and SEMO Food bank to see if connecting our chronic disease populations with health food choices improve overall outcomes
- Patient Safety increase in reporting with education program and decrease in harm to less than 8% and increase in near miss reporting by 25%
- Implementation of organizational safe start huddles, leadership huddles and bedside shift report focusing on High Reliable Organization Journey to Zero Harm.
- Increase Employee Culture of Safety Survey participation from 50% to 73.18%. Through frontline engagement and recognition programs
- Implementation of oral care program on all nursing units quarterly cost avoidance of $889,133 average of 22.29 less hospital acquired pneumonia per quarter at $39,897
- Heart failure program achieved honor roll for 5 years and type 2 diabetes honor roll for 3 years through AHA Get with the Guidelines
- Program ranked last two years number one in the state of Missouri for Readmissions.
- Facilitate Organization Leapfrog Multidisciplinary improvement team. Achieved 6 time "A" rating.
- Facilitate Organization Anthem Multidisciplinary improvement team to achieve maximum achievement.
- Facilitate CMS STAR Organization Multidisciplinary team for continued opportunities for improvement.
- Facilitate and oversee Quality reporting and improvement project opportunities.
Patient Care Manager SCN, MB, Pediatrics and Lactation Services
Southern Illinois Healthcare
01.2007 - 01.2018
- As nurse manager lead co-workers by providing organization vision and served with Transformational leadership style
- Working closely with staff to make decisions that will inspire, engage, and motivate while maintaining safe environment
- Ensuring standards and quality of care are aligned with strategic plan
- Coordinated all department functions for team of 150 employees
- Maintained detailed administrative and procedural processes to improve accuracy and efficiency
- Coordinated meetings with other department managers and served as main liaison between Physicians and Administration
- Managed medical supply inventory, patient charts and company files using online tracking system
- Implementation of Trio Rounding with provider and nurse to promote patient experience and cohesive team
- Pioneered “commit to sit” program that supported excellence in care for patients supported by providers and nursing staff
- Improving customer satisfaction by 10%
- Maternal Child was highest ranked in Organization for their press Ganey survey results
- Implemented shared governance model and leadership structure in Maternal Child department fostering culture of ownership
- Improving employee satisfaction to 90% making Maternal Child department highest ranked in organization for employee satisfaction
- Driving improvements in patient & employee satisfaction, outcomes and retention
- Streamlined and optimized nursing documentation processes, resulting in improved quality and reduced redundancies with implementation EPIC implementation
- Development of Safety Rounds
- Implementation of Improvement boards and Lean Methodology.
Registered Nurse Charge Nurse SCN, Pediatrics, Mother/baby
Southern Illinois Healthcare
01.2005 - 01.2007
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Accomplished multiple tasks within established timeframes.
- Supervised day-to-day operations to meet performance, quality and service expectations.
- Developed and implemented process improvement strategies.
- Collaborated with fellow instructors to develop cohesive teaching strategies, ensuring consistent instruction across all classes.
- Participated in ongoing professional development opportunities to stay current on best practices Maternal Child population.
Registered Nurse Charge Nurse Lactation Consultant
Mobile Infirmary
01.2003 - 01.2005
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Administered medications safely according to established guidelines while closely monitoring for side effects or adverse reactions requiring intervention.
- Accomplished multiple tasks within established timeframes.
- Provided outstanding customer service.
- Differentiated instruction based on individual student needs, ensuring all learners were able to access and engage with curriculum materials effectively.
Registered Nurse Skilled Nursing Facility (SNIF) Unit
Thomas Hospital
01.2003 - 2003
Registered Nurse Case Management and APORS Coordinator
Egyptian Health Department
01.2001 - 01.2002
RN Resident Care Coordinator
Wabash Christian Retirement Center
01.2000 - 01.2002
Registered Nurse Orthopedic Neurological Care Center
Deaconess Hospital
01.2000 - 01.2002
Ortho/Uro Tech and Unit Clerk/Coordinator
Deaconess Hospital
01.1999 - 01.2000
Certified Nursing Assistant
Wabash Christian Retirement Center
01.1995 - 01.2000
Education
Associate of Science - General
Southeastern Illinois College
Bachelor of Science - Nursing
Olivet Nazarene University
Nursing -
Southern Illinois University Edwardsville
01.2000
MHA - Health Care Administration
Ashford University South Campus
01.2013
Change Acceleration Process Training -
01.2008
Six Sigma Yellow Belt Training -
01.2009
MHA Quality Director Training -
01.2018
Six Sigma Green Belt Certification -
01.2019
Evidence Based Practice Certification -
01.2020
Skills
- Effective policy and program development
- Polished communication skills
- Regulatory Compliance
- Quality Data Analysis
- Operational Implementation and Integration
- Strategic and financial planning
- Leadership/communication skills
- Business operations organization
- Staff leadership and development
- Evidence based practice
- Change management
- Employee relations
- Customer-oriented
Affiliations
- NANN
- MONL
- ANN
- NAHQ
- AWHONN
- ACHE
- ANA
- MoAHQ
- AONE
- IONL
National Conference Achievements
- NANN Publication on Staffing Models, 2013
- EBP Ohio Fuld, 2020
- NANN Poster Presentation on Staffing Models, 2013
- HQIN Readmissions, 2021
- NANN Nursing Navigator Award Recipient, 2013
- AHA Quality Collective, 2022
- NICU Leadership Forum Poster Presenter, 2014
- AHA Quality Collaborative Member, 2023
- NICU Leadership Forum Podium Speaker, 2015
- Public Health Forum Breastfeeding Podium Speaker, 2015
- International Breastfeeding Conference Podium Speaker, 2016
- Illinois Perinatal Quality poster presenter, 2016
- Perinatal Leadership Forum Poster Presenter, 2016
- Perinatal Leadership Forum Poster Presenter, 2017
Grant Achievements
- State of Illinois 'We Choose Health' Grant, 2014
- HRSA Food Insecurity, 2022
- Huggies No baby Un-Hugged, 2017
- USDA Prescription Food, 2023
Program Development
- Cuddler Volunteer Program
- Baby Friendly Designation
- Employee Recognition Star Program
- Illinois staffing acuity program and law compliance.
- Hospital incivility program and reporting
- Just Culture Policy and education
- Shared Leadership implementation
- ILPQC MNO committee
- PAC/IDPH site visit level of care committee member
- NICU leadership forum program planning committee
- EMR/EPIC implementation team
- Lean Daily management and 5 S standardization implementation
- Mentorship Program Development and Implementation
- Zero Hero Team and implementation
- Safe Start Huddles
- Bedside Shift report
- Implementation Patient Family Advisory Counsel
- Covid Incident Command team/Vaccination Center Program Development
- OSHA Covid plan development/review
- Implementation team member Chronic Disease/Management
- Downtime Committee Facilitation
- Banyan Virtual Nurse program team member
- HQIN Health Care Quality Network participant
- Development of Organizational Mortality and Morbidity Committee
- Workplace Violence Committee
- NDNQI Site and Survey Coordinator
- AHRQ Patient Safety Survey facilitation
- Leapfrog Survey Coordinator
- High Reliability Organization program
Board Membership
- IHI Culture of Safety Development 2023
- MoAHQ Board Member 2023
- AHA Quality Collaborative Member 2023
Phone
618-694-3729, 618-694-3729
Personal Information
Title: RN, MHA, BSN, RN, CPHQ, CLSSGB, EBP-C, FACHE
Certification
CPHQ
FACHE
EBP-C
CLSSGB
Timeline
Director of Quality
Mercy Hospital Southeast
01.2018 - Current
Patient Care Manager SCN, MB, Pediatrics and Lactation Services
Southern Illinois Healthcare
01.2007 - 01.2018
Registered Nurse Charge Nurse SCN, Pediatrics, Mother/baby
Southern Illinois Healthcare
01.2005 - 01.2007
Registered Nurse Charge Nurse Lactation Consultant
Mobile Infirmary
01.2003 - 01.2005
Registered Nurse Skilled Nursing Facility (SNIF) Unit
Thomas Hospital
01.2003 - 2003
Registered Nurse Case Management and APORS Coordinator
Egyptian Health Department
01.2001 - 01.2002
RN Resident Care Coordinator
Wabash Christian Retirement Center
01.2000 - 01.2002
Registered Nurse Orthopedic Neurological Care Center
Deaconess Hospital
01.2000 - 01.2002
Ortho/Uro Tech and Unit Clerk/Coordinator
Deaconess Hospital
01.1999 - 01.2000
Certified Nursing Assistant
Wabash Christian Retirement Center
01.1995 - 01.2000
Associate of Science - General
Southeastern Illinois College
Bachelor of Science - Nursing
Olivet Nazarene University
Nursing -
Southern Illinois University Edwardsville
MHA - Health Care Administration
Ashford University South Campus
Change Acceleration Process Training -
Six Sigma Yellow Belt Training -
MHA Quality Director Training -
Six Sigma Green Belt Certification -
Evidence Based Practice Certification -
CPHQ
FACHE
EBP-C
CLSSGB
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