Lauren Massey
Wendell,NC
Summary
Accreditation professional with solid foundation in managing and maintaining accreditation standards. Extensive experience in leading accreditation processes, ensuring compliance, and enhancing institutional reputation. Known for effective teamwork, adaptability, and focus on achieving high-quality outcomes through strategic planning and execution.
Proactive and goal-oriented professional with excellent time management and problem-solving skills. Known for reliability and adaptability, with swift capacity to learn and apply new skills. Committed to leveraging these qualities to drive team success and contribute to organizational growth.
Overview
14
14
years of professional experience
Work History
Accreditation Manager
UNC Rex Healthcare
10.2022 - Current
- Supervised and managed a team of direct reports, including: Bariatric Coordinator, Bariatric Clinical Reviewer, Sepsis Coordinator, Clinical Certification Coordinator, and Accreditation Coordinator.
- Ensured consistent application of policies across departments by creating standardized procedures for all aspects of the accreditation process.
- Developed training materials and led education sessions for staff, increasing understanding of accreditation processes and standards.
- Fostered a culture of continuous improvement within the organization by highlighting the importance of accreditation standards in maintaining institutional excellence.
- Led cross-functional teams in addressing accreditation findings, developing action plans to address identified gaps or weaknesses.
- Coordinated the scheduling and logistics of site visits by external evaluators, ensuring a smooth review process for all parties involved.
- Addressed compliance issues by developing and implementing corrective action plans.
- Facilitated communication between various stakeholders throughout the accreditation process including faculty, administration, and accrediting bodies.
- Performed regular compliance reviews and audits, identifying non-compliance issues.
- Coordinated with external accrediting bodies, fostering positive relationships and ensuring timely submission of required reports.
- Participated in annual reviews of institutional policies and procedures related to accreditation, recommending updates as appropriate for alignment with best practices.
- Facilitated communication between internal departments regarding accreditation matters, promoting collaboration and shared understanding.
- Oversaw and assisted with the completion of the annual Leapfrog Hospital Surveys for Rex Hospital and Rex Holly Springs Hospital .
- Led and organized the annual Computer Physician Order Entry (CPOE) Tests, contributing the Leapfrog Safety Grade.
- Collaborated, investigated, and wrote formal responses for quality of care insurance and patient inquiries, ensuring thorough and professional communication.
Bariatric Coordinator
UNC Rex Healthcare
09.2020 - 10.2022
- Served as a liaison for bariatric patients; work collaboratively with physicians and other departments to help obtain/expedite recommendations from physicians and other health team members for timely and appropriate patient care
- Maintained up to date knowledge of accreditation standards from regulatory bodies and communicate appropriately with the Bariatric Medical Director and Rex Leadership.
- Managed project timelines for successful completion, ensuring milestones were met and deadlines were adhered to.
- Prepare multi-disciplinary team and facility for the bariatric accreditation program survey
- Update applications for bariatric specific insurance recognitions
- Provide education, support and necessary resources for patients and their families; coordinate appropriate referrals for needed services
- Facilitate Rex teammate education and serve as a resource for staff
- Keep service line informed of accreditation requirements, program strengths and opportunities for improvement
- Assist and serve as a secondary to the Bariatric Clinical Reviewer to ensure all data requirements are being met from regulatory bodies; including entering data, generating reports, and produce tracking documents.
- Assist and participate in the following activities under the direction of the Manager of Accreditation: Ensure organizational readiness and ongoing compliance with standards and regulations across UNC REX Healthcare by assisting in leading activities such as, tracer rounds, mock surveys or educational sessions
- Assist in updating and submitting The Joint Commission application
- Prepare the multi-disciplinary team for The Joint Commission, DHSR, CMS and other regulatory agency surveys and achievement of accreditation or develop and monitor corrective action plans
- Maintain knowledge of the most current accreditation standards and related state and federal regulations
- Coordinate investigations and responses to complaints received from The Joint Commission or other regulatory agencies
- Participate in annual Failure Modes Effect Analysis (FMEA) project
- Serve as a key player in The Joint Commission, CMS and DHSR surveys
- Aid Leapfrog Computerized Prescriber Order Entry (CPOE) and application submission
Clinical Nurse IV (Team Leader) in Perioperative Planning Center
UNC Rex Healthcare
10.2019 - 09.2020
- Assist in the supervision of teammates and patients in the perioperative planning center (PPC)
- Collaborated with interdisciplinary teams for optimal patient outcomes and efficient care coordination.
- Perform team leader duties, such as: manage and approve staffing schedule in API, maintain and approve myTime for employee payroll, follow up and review SAFE events, coordinate and present at monthly staff meetings, serve as a resource and leader for teammates who work in PPC department, communicate with staff regarding system changes in a timely manner, assist in annual employee evaluations, etc
- Create and update policies, procedures and guidelines for surgical services and the PPC department
- Serve as a charge nurse by getting patients cleared and ready for surgery (medical clearances, lab work, EKG’s, anesthesia records, anticoagulation instructions/clearance)
- Mentored nursing staff, fostering professional growth and team building within the unit.
- Assist in daily surgical safety huddle by reviewing charts for next day cases and presenting at huddle
Bariatric Navigator
UNC Rex Healthcare-North Carolina Surgery
07.2018 - 10.2019
- Navigate patients through the preoperative bariatric surgery program, coordinating patient appointments to meet insurance requirements and obtain surgery approval
- Complete referrals for patients who require specialty testing/procedures and lab work for clearance, serving as patient advocate for any delays patients encounter in completion of their program requirements
- Complete thorough reviews of patient medical records to assist completion of insurance and program requirements
- Create and maintain patient-tracking spreadsheet, ensuring all patients pursing bariatric surgery are on-track with the program and facilitate in projected volumes for staff, surgeons and UNC REX Hospital
- Facilitate education seminars and hold individual consults for approximately 120 patients monthly to provide education about the pre-op bariatric surgery program, individual insurance requirements, health and nutrition, required testing/procedures and medical clearance from specialty physicians, etc
- Serve as a resource for all patients, bariatric surgeons, physician extenders and clinical/non-clinical staff regarding all requirements for the bariatric surgery program at NC Surgery
Bariatric Coordinator
UNC Rex Healthcare
10.2014 - 07.2018
- Manage and maintain bariatric program accreditation for Rex Hospital by following standards set by ASMBS and disseminate required education to successfully prepare for the triennial bariatric survey
- Coordinate bariatric resources for all bariatric surgeons, physician extenders, clinical/non-clinical staff, bariatric offices and patients who are affiliated with bariatric surgery at UNC Rex Hospital
- Facilitate maintenance of hospital bariatric program as a Bariatric Surgery Center of Distinction and of Excellence
- Help support and run the Bariatric Service Line, consisting of a multidisciplinary panel of ~35 professionals to evaluate patient outcomes, case studies, procedures, protocols and quality improvement projects
- Approve all Medicare cases for bariatric surgery, as dictated by national and/or local coverage determination criteria
- Serve as a patient advocate and liaison and hold support groups for patients pursuing bariatric surgery
- Participate in accreditation activities such as, tracer rounds, mock surveys or applications under the direction of the Manager of Accreditation
- Assist in preparing the multi-disciplinary team for Joint Commission, DHSR, CMS and other regulatory agency surveys and achievement of accreditation or corrective action plans
Clinical Nurse II (Staff Nurse) on a Medical Surgical Floor (7E)
UNC Rex Healthcare
07.2010 - 10.2014
- Deliver high quality patient-centered care and perform any procedures/tasks as required for the varying demographic of patients on 7 East; consisted primarily of patients who had undergone bariatric surgery, gynecological surgery, pediatric patients and medical/surgical overflow patients
- Serve as a patient advocate by coordinating multidisciplinary patient care and initiating consults, as needed
- Additional leadership roles include charge nurse, admission/discharge nurse and preceptor
Education
Bachelor of Science - Nursing
East Carolina University
Greenville, NC05-2010
Skills
- Program management
- Attention to detail
- Quality improvement
- Documentation review
- Accreditation expertise
- Teamwork and collaboration
- Problem-solving
- Time management
- Reliability
- Excellent communication
- Organizational skills
- Active listening
- Adaptability and flexibility
- Decision-making
Timeline
Accreditation Manager
UNC Rex Healthcare
10.2022 - Current
Bariatric Coordinator
UNC Rex Healthcare
09.2020 - 10.2022
Clinical Nurse IV (Team Leader) in Perioperative Planning Center
UNC Rex Healthcare
10.2019 - 09.2020
Bariatric Navigator
UNC Rex Healthcare-North Carolina Surgery
07.2018 - 10.2019
Bariatric Coordinator
UNC Rex Healthcare
10.2014 - 07.2018
Clinical Nurse II (Staff Nurse) on a Medical Surgical Floor (7E)
UNC Rex Healthcare
07.2010 - 10.2014
Bachelor of Science - Nursing
East Carolina University
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