RN Quality Manager with 10 years’ experience in healthcare to include 7 years with a strong background in all aspects of healthcare quality. Experience in coordinating with all levels of hospital staff and administration. Effective and creative problem-solver with ability to work under considerable pressure. Strong analytic skills with practical knowledge of how to identify key performance quality metrics to set targets for maintaining a state of compliance while identifying areas for improvement.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Manager of Quality and Infection Prevention
Havasu Regional Medical Center
Lake Havasu City, Arizona
08.2022 - Current
Active member of the Association for Professionals in Infection Control & Epidemiology (APIC)
Infection Prevention and Quality Manager oversight of Acute-Care Hospital, Skilled Nursing Facility, Outpatient Surgery Center, Wound Care Center, Cancer Center, Sleep Center and associated Medical Offices.
Ensure compliance with all accrediting and regulatory agencies through monitoring of quality improvement programs
Active Member of Patient Safety Quality Council, Hospitalist Committee, Environment of Care Committee, Antibiotic Stewardship, Water Management Committee, Lab Process and Skilled Nursing Quality Improvement Committee
Appointed Chair over the Infection Control Committee
Develop and implement processes and action plans to improve performance
Lead and provide committees with quality activities and outcome reports
Regulatory reporting of quality measures and tracking of compliance
Lead facility wide tracers to ensure regulatory compliance of OSHA, Joint Commission, federal, state and local regulation standards
Responsible for programs annual plans and risk assessment with actionable items for improvement
Maintain quality and infection prevention policies to ensure up to date evidence-based practice guidelines
Monitor and operate daily, weekly, and monthly activities of the infection prevention program to include surveillance, isolation adherence, micro reviews, device utilization, tracking and reporting at the county and state level
Compile and interpret surveillance data among patients, staff, and providers
Assist and lead Command Center for facility surveys
Responsible for organizing and operating the Fit Test Program
Assist in vaccination clinics
Tracking and reporting of vaccination status to CDC/NHSN
Cardiovascular Quality Coordinator and Recovery Lead
Havasu Regional Medical Center
Lake Havasu City, Arizona
09.2018 - 08.2022
Facilitate collaboration to ensure quality improvement disease prevention and health promotion related to cardiovascular disease process
Responsible for compliance of Chest Pain and Cath Lab Accreditations through the ACC and maintaining hospital recognition of being a Cardiac Receiving Center by the Arizona Department of Health Services and Arizona Registry
Chest Pain Coordinator for the Chest Pain Accreditation
Responsible for and overseas data abstraction for cardiovascular registries
Registry site manager for the following registries: CathPCI, ICD, STS, Chest Pain, AZ Share
Develop and maintain registry dashboards, track and trend data for compliance with quality metrics and determine benchmark standards
Perform quality assurance studies and performance improvement projects related to cardiovascular and quality registries
Lead monthly department and accreditation meetings, reporting of data metrics and dashboards, discuss trends and implementation of action plans
Provided Cath Lab and chest pain education at new hire orientation
Provide direct patient care in the post operative phase for Cath Lab in accordance with standards of practice of a Registered Nurse
Interim managerial duties.
Quality Coordinator
Havasu Regional Medical Center
Lake Havasu City, Arizona
07.2017 - 09.2018
Responsible for data abstraction and reporting for CMS Core Measures
Work with Directors, Staff, and Physicians on process improvements, education, and documentation compliance
Review medical records for physician documentation accuracy in compliance with quality measure indicators and Ongoing Professional Practice Evaluation (OPPE) as required by Medical Staff Bylaws and the Joint Commission Regulations
Lead Harms Collaborative to include drilling down, tracking, and trending harms
Presenting drilldowns to the multidisciplinary team of Physicians, Coders, CMO, CNO, CFO, and Risk Management
Management of Complaints and Grievances in compliance with The Joint Commission Regulations
Collaborate with Unit Management, Physicians, CMO, CFO, and CEO for resolution of grievances
Oversee Safety Incident Management (SIM) occurrence reports, delegate tasks, and ensure accuracy of completion
Participate and lead tracers for facility-wide survey readiness
Assist and lead Command Center for facility surveys
Report of data at facility-wide meetings to include Hospitalist Meetings, Patient Safety and Quality Council, Harms Collaborative and Grievance Committee.
RN, Team Lead, Medical-Surgical/Telemetry/Orthopedics (Team Lead, Safety Champion)
Havasu Regional Medical Center
Lake Havasu City, Arizona
06.2015 - 07.2017
Deliver patient-centered care, promote health and wellness, and assist in patient recovery
Provide education related to disease processes and diagnosis, perform physical exams, and administer medications as appropriate
Coordinated staff assignments and patient placement, provided leadership, guidance, and support, precepted and oriented new staff
Collaborate with physicians and the multidisciplinary team to assure patient safety and continuity of care
Promote safety initiatives and encourage the use of learning boards and track resolutions
Lead performance improvement huddles
Coordinate and participate in mock codes and drills.
Nurse Extern
Havasu Regional Medical Center
Lake Havasu City, Arizona
08.2014 - 06.2015
Work alongside the Registered Nurse to acquire the clinical skills needed to be a successful RN providing safe patient-centered care.
Education
Master of Business Administration - Healthcare Management
Western Governors University
Salt Lake City, Utah
01-2023
Bachelor of Science in Nursing -
Western Governors University
Salt Lake City, Utah
01-2020
Associates of Science in Nursing -
Mohave Community College
Lake Havasu City, Arizona
01-2015
Skills
Quality Management
Adaptability and Flexibility
Professional Demeanor
Organizational Skills
Surveillance
Data Collection
Infection Control
Policies Development
Regulatory Compliance
Operations Management
Certification
Arizona, #193814, Registered Nurse
Professional References
Upon Request
Timeline
Manager of Quality and Infection Prevention
Havasu Regional Medical Center
08.2022 - Current
Cardiovascular Quality Coordinator and Recovery Lead
Havasu Regional Medical Center
09.2018 - 08.2022
Quality Coordinator
Havasu Regional Medical Center
07.2017 - 09.2018
RN, Team Lead, Medical-Surgical/Telemetry/Orthopedics (Team Lead, Safety Champion)
Havasu Regional Medical Center
06.2015 - 07.2017
Nurse Extern
Havasu Regional Medical Center
08.2014 - 06.2015
Master of Business Administration - Healthcare Management
Director of Acute Quality Services/Infection Prevention/Interpretive Services and Patient Safety Officer at UNC Health Pardee Hendersonville 222 bedsDirector of Acute Quality Services/Infection Prevention/Interpretive Services and Patient Safety Officer at UNC Health Pardee Hendersonville 222 beds