Marion Martin, RN
Burlington,NC
Summary
An experienced healthcare clinician who desires a role in assessment in efficiency, customer experience and clinical proficiency. Experience in project management, process redesign, and detailed medical record review, well versed in Joint Commission Standards and CMS regulations to include Med A and B. Competency in AHRQ and HAC standards of care and identification of gaps in performance. Knowledge of HEDIS measures and detailed medical record review. Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
42
42
years of professional experience
Work History
Field Representative and Team Lead
Joint Commission
01.2016 - 01.2023
- Surveyor and team leader for accredited healthcare organizations to include VA, Military Hospitals, free-standing emergency departments, Critical Access, Long term acute care, rehabilitation facilities and assisted with home health and Hospice assessments
- Assisted in the development of remote surveys during Covid
- Team educator on new standards and CMS requirements
- Responsible for Yellow Belt training for all surveyors
- (LSS) Lead teams to review and update all standards and CMS regulations on an annual basis
- Developed tracer tools and educational offerings for healthcare senior leadership
- Presentations at national healthcare meetings regarding compliance.
Chief Operating Officer/Director of Quality Services
Roper St. Francis Healthcare
Charleston, South Carolina
09.2010 - 01.2016
- Executive leader responsible for Patient Safety, Infection Prevention, Accreditation Services, Clinical Outcomes and Patient Family Experience
- Coordinate the Board Quality and Patient Safety Committee, presentation of outcomes and lead/facilitate quality discussions at board and senior staff level
- Oversight for compliance in regulatory agency requirements (JCAHO, DHEC and CMS)
- Work closely with VPMA and Chiefs of service in identification and implementation of quality metrics
- Oversight for all data submission to Medicare and Medicaid as required
- Oversight for Leapfrog submission, NSQIP and Heart Failure
- Responsible for additional performance improvement activities and projects with nursing and other ancillary departments, developing Nursing Peer Review process and contributor to Magnet journey
- Oversight, developer and instructor for system-wide Lean Sigma Green Belt classes for RSFH Leadership Development Institute (Certified over 600 Greenbelts)
- Lead numerous Lean projects to include financial, clinical and process strategies to reduce waste, variability and improve efficiency and operational excellence
- Work in partnership with leadership on evidenced-based projects to drive excellence and development of Centers of Excellence
- Leader for Just Culture implementation and new leader onboarding
- Responsible for the redesign of the quality strategic plan, scope and workflow/product of the quality department
- Leader for High Reliability with Joint Commission and SCHA
- Developed the Nurse Peer Review Program for the system
- Worked with senior leadership to develop genesis of accountable care organization
- Work within nursing to improve patient care, productivity, zero harm, patient safety
- Developed and implemented the Patient and Family Experience Council
- Co-Leader for the SCHA Patient and Family Engagement Collaborative
- President of Carolinas Association for Hospital Patient Advocacy (September 2016).
Executive Director of Quality and Patient Safety
Moses Cone Health System
Greensboro, NC
11.2008 - 09.2010
- Executive responsibility for Safety/Environment of care, Infection Prevention, Accreditation Services, Clinical Outcomes, Employee Health, Clinical Quality Black Belt departments
- Coordinate and oversee Board Quality Committee and Medical Performance Improvement Committee and Quality Leadership Team reporting, presentation of outcomes and lead/facilitate quality discussions
- Oversight for compliance in regulatory agency requirements (JCAHO, DFS and CMS)
- Work closely with VPMA and Chiefs of service in identification and implementation of quality metrics
- Oversight for all data submission to Medicare and Medicaid as required
- Responsible for additional performance improvement activities and projects with nursing and other ancillary departments
- Member of the Board of Directors for NCHA Center for Patient Safety and Quality
- Work closely with Information Systems in the design and implementation of the new clinical data repository
- Member of Sentinel Event Task force, identifying risk issues and lead root cause analysis and FMEA’s
- Design metrics for quality projects
- Lead and facilitate the “Getting Boards on Board” for the system
- Executive champion and facilitator for Just Culture implementation
- Design hospital and departmental report cards
- Implemented an infection prevention/pharmacy database to capture stewardship and surveillance.
Patient Safety Officer
Moses Cone Health System
Greensboro, NC
08.2006 - 01.2008
- Director and oversight for all patient safety activities, projects, follow up and risk management issues
- Director and oversight for Infection Prevention department
- Oversight for compliance in regulatory agency requirements (JCAHO, DFS and CMS)
- Director of IHI Quality projects to include national patient safety initiatives, patient flow through the health system, reducing mortality rates, Saving 100,000 Lives Campaign, 5million Lives Campaign
- Oversight for all data submission to Medicare and Medicaid as required
- Responsible for additional performance improvement activities and projects with JCAHO
- Oversight for Organ Donation Collaborative, winning the second Medal of Honor from Federal gov’t
- Participant in NC Hospital Association Center for Patient Safety and Quality
- Director of Clinical Quality initiatives to include core measures and other performance improvement initiatives impacting patient safety.
Director of Emergency/Trauma Services
Moses Cone Health System
Greensboro, NC
04.2003 - 08.2006
- Director and oversight for nursing operations for 70,000 visit/yr Trauma Center
- Responsible for compliance in regulatory agency requirements (JCAHO, DFS and CMS)
- Responsible for 170 employees
- Implementation of new policy, quality improvements, staffing models, strategic planning for emergency services
- Developed and implemented Chest Pain Center, Pediatric Emergency Dept
- And Code Stroke Program
- Oversight for the operations of the new Urgent Care Center 2005
- Active participant in hospital committees and education sessions
- Facilitator for the Organ Donation Collaborative for the entire healthcare system, recently winning the Dept
- Health and Human Services Medal of Honor for the healthcare system
- Active member and speaker for Emergency Nurses Association at the national level
- Participate in Risk Management investigations, Service Excellence improvements, Six Sigma improvement projects, education and training on performance improvement methodologies
- Participate in Disaster management planning and training for the system
- Member of IHI Team to address patient Flow throughout the healthcare system
- Member of IHI Team to address Organ Donation
- Member of the RACE Team to improve Acute MI Care and Treatment
- Participate/facilitate in Root Cause Analysis process for Risk Management
- Implemented an electronic documentation system within the emergency Services areas.
RN/Military Officer
United States Air Force
01.1981 - 01.2001
- Worldwide duty to include Air Training Command and Tactical Air Command (Clark AFB, CONUS)
- Worked in Open Heart Surgery, Intensive Care, NICU and Emergency Services
- Participated in research and publication on acute respiratory distress syndrome
- Burn Nurse Specialist for PACAF.
Education
Master’s, Business Administration -
University of Health Sciences: USAF MBA, University of Arkansas
01.1993
Bachelor of Science Nursing -
University of North Carolina and UNC-G
05.1982
Other
Skills
- Customer Relations
- Project Management
- Time management abilities
- Task Prioritization
- Effective Communication
- Attention to Detail
- Staff training and motivation
- Continuous Improvement
- Problem-Solving
- Teamwork and Collaboration
- Multitasking
Personal Information
Title: RN, MBA, LSSBB
Timeline
Field Representative and Team Lead
Joint Commission
01.2016 - 01.2023
Chief Operating Officer/Director of Quality Services
Roper St. Francis Healthcare
09.2010 - 01.2016
Executive Director of Quality and Patient Safety
Moses Cone Health System
11.2008 - 09.2010
Patient Safety Officer
Moses Cone Health System
08.2006 - 01.2008
Director of Emergency/Trauma Services
Moses Cone Health System
04.2003 - 08.2006
RN/Military Officer
United States Air Force
01.1981 - 01.2001
Master’s, Business Administration -
University of Health Sciences: USAF MBA, University of Arkansas
Bachelor of Science Nursing -
University of North Carolina and UNC-G
Other