Nicole Caruvana, DNP, MS, RN, CPHQ
Charlotte,NC
Summary
Nurse leader with over thirteen years of progressive leadership experience, including performance and quality improvement, project management, shared governance, professional development, data management and analysis, Lean methodology, Magnet Recognition Program, Department of Health regulations, and Joint Commission Standards.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Director of Quality Management
MJHS Hospice & Palliative Care
01.2023 - Current
- Oversees the Quality Assurance and Performance Improvement (QAPI) Program, and Patient Experience Program for a hospice & palliative care organization with an average daily census of 776 patients
- Develops a comprehensive QAPI plan that incorporates regulatory requirements, clinical performance indicators, and patient satisfaction metrics to ensure high-quality care and evaluate the effectiveness of performance improvement activities
- Implements organization-wide quality improvement (QI) projects to implement clinical best practices, improve clinician workflows, and enhance patient experience
- Developed an organization-wide QI project that increased hospice visits at end of life by 12.3% within 6 months of implementation
- Ensures regulatory compliance with CMS Conditions of Participation and NYS Department of Health (DOH) regulations and coordinates regulatory survey activities
- Responsible for investigating, reporting, and tracking patient occurrences and complaints
- Developed and implemented an enhanced patient safety event and root cause analysis (RCA) process to accurately categorize patient safety events, implement system-based solutions, and support clinician well-being.
Quality & Patient Safety Manager
New York Presbyterian, Brooklyn Methodist Hospital
06.2022 - 12.2022
- Oversaw the Quality & Patient Safety department of a 591-bed academic hospital with 8 direct reports
- Responsible for managing the significant event process including investigating safety events, facilitating weekly Significant Event Committee meetings, conducting Root Cause Analyses, submitting state reporting requirements, and initiating plans of correction
- Facilitated Quality & Patient Safety (QPS) goals to reduce falls and falls with injury, sepsis rates, hospital-acquired infection rates, mortality rates, and enhance maternal safety
- Developed a Building Psychological Safety training program to enhance the Culture of Safety and enhance feelings of psychological safety for health care providers
- Coordinated regulatory preparation and survey activities to meet regulatory requirements during New York State Department of Health and Joint Commission surveys.
Quality & Patient Safety Specialist
New York Presbyterian, Weill Cornell
05.2020 - 06.2022
- Facilitated QPS goal activity in support of hospital acquired infection reduction; facilitated bi-monthly CLABSI workgroup meetings, hospital acquired infection (HAI) champion monthly meetings, and conducted bi-weekly device rounds at multiple campuses within the organization
- Project manager for the Patient Flow Steering Committee with a goal of decreasing length of stay and reducing barriers for patient flow throughout the inpatient hospital stay
- Project manager for the 2022 QPS Mortality goal to reduce the mortality index
- Participated in the 2020 and 2021 QPS goal to reduce falls and falls with injury by 10%
- Collaborated with unit leadership to facilitate unit dyad leadership goals and mini-RCAs
- Facilitated monthly Quality Assurance meetings for multiple hospital departments
- Prepared the Board of Trustee’s PSQ committee annual written report outlining departments’ yearly performance towards annual goals and QI initiatives
- Facilitated the Root Cause Analysis process for appropriate departmental safety events; conducted case reviews and developed comprehensive timeline of events
- Collaborated with departmental QA chairs to track QA reports, request quality reviews, and follow up with plan of correction compliance
- Assist in regulatory survey preparation, conducted monthly Joint Commission Tracing.
Quality Management Coordinator
MJHS Hospice & Palliative Care
01.2019 - 05.2020
- Collaborated with Hospice leadership to develop, implement, and monitor Quality and Process Improvement Plans
- Investigated patient occurrences and complaints for the organization with an average daily census of 750 patients
- Facilitated Root Cause Analyses for serious safety events; developed action plans and quality improvement projects as necessary
- Facilitated a Lean Rapid Process Improvement Project/Kaizen Event to streamline processes, improve clinician workflow, and increase communication between departments
- Performed routine chart audits and data collection to identify opportunities for improvement and ensure compliance with CMS Conditions of Participation and DOH regulations
- Collaborated with organizational leadership in the development and implementation of a hospice-wide comprehensive suicide prevention policy
- Developed and implemented a hospice-wide telephonic patient experience program to enhance communication and reduce patient complaints.
Nurse Manager
MJHS Hospice & Palliative Care
09.2016 - 01.2019
- Responsible for the coordination of care for a diverse population of community and facility-based hospice patients for two interdisciplinary community-based hospice teams with 26.5 FTEs
- Coordinated RN Case Manager assignments; ensured RN visits were conducted in accordance to CMS Conditions of Participation and patients’ plan of care
- Led weekly Interdisciplinary Team meetings according to CMS Conditions of Participation; reviewed medication reconciliation, oxygen safety, care plans, Trans-Assistance level, HHA plan of care, team member visit frequencies, and recertification eligibility for all appropriate patients
- Investigated and developed action plans for occurrences and complaints in collaboration with the interdisciplinary team
- Developed an updated fall prevention policy hospice-wide for community and residence settings to reflect current best practice
- Managed and implemented increased safety and communication measures at an 18-bed hospice residence including implementation of daily staff huddles, post-fall huddles, patient information board, adherence to DOH standards, and hourly rounding.
Nurse Manager, Medical-Surgical Unit
Mount Sinai St. Luke’s
10.2015 - 09.2016
- Responsible for the quality, safety, and continuity of patient care for a 32-bed medical-surgical unit with 42.4 FTEs
- Utilized the Relationship Centered Care Model as the primary Nursing Care Model in delivery of patient care
- Includes implementation of purposeful hourly rounding, daily nurse manager rounds, bedside shift report, AM/PM huddles, and 5-minute sit downs for all nursing care providers on unit
- Co-chair of Peer Review Committee; member of Nursing Operations Committee, Nursing Quality Improvement Committee, Patient Experience and Operations Committee, Nursing & Pharmacy Committee, Medication Safety Committee, Safe Patient Handling Committee, Falls Prevention Committee, HCAHPS Committee, and Nursing Education & Research Committee
- Established a multi-unit Medicine Unit Practice Council in order to promote shared decision making and improve RN work engagement
- Team leader of a Lean Rapid Process Improvement Project (Kaizen Event) that redesigned and improved the Nurse Attendant workflow hospital-wide
- The new workflow increased efficiency and communication across all three shifts, as well as improved patient and staff satisfaction.
Interim Nurse Manager, Ambulatory Surgery Unit & Pre-Admission Testing
New York Eye & Ear Infirmary of Mount Sinai
01.2015 - 10.2015
- Responsible for daily operation of a high-volume Adult Ambulatory Surgery Unit and Pre-Admission Testing Unit specializing in ophthalmology, otolaryngology, plastic, and reconstructive surgery with 47 FTEs
- Responsible for developing an annual operating budget of $2.5 million
- Designed and implemented patient comment cards to rate overall satisfaction, identify areas of improvement, and recognize staff members that provided excellent care, leading to several process improvements
- Member of the OR Committee, Nursing Informatics Council, Nursing Research Council, Lean Committee, Nursing and Pharmacy Committee, and Cardiac Arrest Committee
- Implemented new discharge phone call process, increasing discharge follow-up phone calls by 98%
- Implemented daily management rounds and weekly staff huddles to improve patient safety, patient satisfaction, and nurse engagement
- Created a Patient Liaison Program in collaboration with the Patient Experience Department to address patient needs, provide updates on surgical time, answer questions, and improve overall patient and family satisfaction.
Assistant Nurse Manager, Ambulatory Surgery Unit & Pre-Admission Testing
New York Eye & Ear Infirmary of Mount Sinai
08.2011 - 01.2015
- Redesigned the nursing orientation process to reflect Benner’s Novice to Expert framework
- Core team member involved in the 18-month development and implementation of a hospital-wide Electronic Medical Record system
- Collaborated with inter-professional healthcare team in developing, applying and evaluating patient care processes, protocols, and guidelines; including revision of the discharge process and criteria for safe patient discharges, Morse Fall Risk Scale, and TeamSTEPPS
- Served as the Team Leader of a Lean Rapid Process Improvement Project (Kaizen Event) that sustained decreased waste in the pre-operative process and increased patient throughput by 32%
- Presented a Quality Improvement Project poster, Ensuring Superior Outcomes: The Discharge Process, at NJSNA’s 2012 Professional Summit
- Co-investigator of therapeutic music research study aimed to decrease pre-operative patient anxiety.
Registered Nurse, Ambulatory Surgery Unit
New York Eye & Ear Infirmary of Mount Sinai
04.2010 - 08.2011
- Provided direct nursing care in a pre-operative and post-operative ambulatory setting, including but not limited to detailed nursing assessments, coordination of care from all disciplines, medication reconciliation, patient education, medication administration, evaluation of patients’ condition, and safe discharge.
Education
Doctor of Nursing Practice -
Yale University
New Haven, CT05.2023
Master of Science, Nursing Administration -
New York University
New York, NY05.2015
Bachelor of Science, Nursing -
CUNY College of Staten Island
Staten Island, NY06.2011
Certification
- NYS Registered Professional Nurse License #627700-1
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Lean Six Sigma Green Belt
- BLS certified
Affiliations
- National Hospice and Palliative Care Organization
- New York Organization for Nursing Leadership
Timeline
Director of Quality Management
MJHS Hospice & Palliative Care
01.2023 - Current
Quality & Patient Safety Manager
New York Presbyterian, Brooklyn Methodist Hospital
06.2022 - 12.2022
Quality & Patient Safety Specialist
New York Presbyterian, Weill Cornell
05.2020 - 06.2022
Quality Management Coordinator
MJHS Hospice & Palliative Care
01.2019 - 05.2020
Nurse Manager
MJHS Hospice & Palliative Care
09.2016 - 01.2019
Nurse Manager, Medical-Surgical Unit
Mount Sinai St. Luke’s
10.2015 - 09.2016
Interim Nurse Manager, Ambulatory Surgery Unit & Pre-Admission Testing
New York Eye & Ear Infirmary of Mount Sinai
01.2015 - 10.2015
Assistant Nurse Manager, Ambulatory Surgery Unit & Pre-Admission Testing
New York Eye & Ear Infirmary of Mount Sinai
08.2011 - 01.2015
Registered Nurse, Ambulatory Surgery Unit
New York Eye & Ear Infirmary of Mount Sinai
04.2010 - 08.2011
Doctor of Nursing Practice -
Yale University
Master of Science, Nursing Administration -
New York University
Bachelor of Science, Nursing -
CUNY College of Staten Island
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