Nisha Madhavan
Jamesville,USA
Summary
- Over two decades of progressive leadership experience in healthcare organizations, academic medical centers, skilled nursing facilities, behavioral health hospital, and LTACH. A hands-on visible leader with a record of accomplishments and expertise in health care operations, strategic planning, sustainable process engineering, designing and implementing EMR organization-wide, and program development with strong ability to make a direct and lasting institutional impact. Significant background in leading change management initiatives while promoting a culture of patient safety.
- Analysis, interpretation, and action plan development for collected data and surveys.
- Strategic management, systems re-engineering, and process improvement – HCAHPS and core measures
- Workflow analysis and management – lean methodology
- Union contract negotiation and successful ratification
- Financial analysis, budgeting, and benchmarking
- Planning and implementing electronic health records systems – project management.
- Business and client development with supportive marketing strategies
- Employee empowerment and physician engagement strategies
- Nominated two times to be the next CEO for a not-for-profit Behavioral Health organization.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Chief Nursing Officer
Maryland Department of Health
09.2022 - Current
- Developed and implemented process improvement models for major clinical initiatives and was instrumental in launching a hospital-wide Patient Safety Huddles initiative by developing protocol and training clinical staff and physicians in order to improve patient safety outcomes including a reduction in hospital acquired pressure ulcers and patient falls.
- Led hospital to a no deficiency status for CMS Survey by educating staff on standards and elements of performance of the Joint Commission and led repeat auditing and follow-up performance mock surveys. This included all departments of the Hospital – Clinical and Non-Clinical.
- Instituted patient hourly rounding to increase patient satisfaction scores and implemented best practices including i-round, scripting, and service recovery programs to enhance overall patient experience.
- Collaborated with medical staff and information technology team to implement CPOE for physicians.
- Collaborated, developed, and implemented evidence-based-practices to align with national quality metrics.
- Assessed and implemented strategies to improve efficiencies for Perioperative Services at 97 bed, acute care community hospital and re-instituted the Perioperative Services Council in collaboration with the Chief Operating Officer and Chief of Surgery.
- Implemented a new patient care delivery model – relationship-based care.
- Union contract re-negotiation and successful ratification.
- Acting Chief Executive Officer Jan – Feb 2025
Acting Chief Executive Officer
Maryland Department of Health
01.2025 - 02.2025
- Established foundational processes for business operations.
- Negotiated favorable contracts with suppliers and vendors, ensuring cost-effective procurement processes.
- Managed partnerships and strategic business relationships by negotiating contract terms and handling conflicts.
- Streamlined operations for improved efficiency, reducing overall costs and increasing profitability.
- Drove continuous improvement by fostering a culture of collaboration, accountability, and open communication across all levels of the organization.
- Improved operational efficiency by redesigning internal processes and implementing cutting-edge technology solutions.
- Managed high-performing teams to successfully execute corporate objectives and drive organizational success.
Interim Chief Nursing Officer
Signature Healthcare, CA
07.2021 - 03.2022
- Served as an Interim Chief Nursing Officer for a 90 bed Acute stand-alone Behavioral Healthcare Hospital.
- Implemented best practices in Leader Rounding for ‘all’ Leaders of the organization.
- Successfully worked with CDPH to improve relationships with surveyors.
- Collaborated with all stakeholders and cleared two separate 90-day de-certification plans of corrections from CMS in less than two months Hospital-wide including Dietary, Plant Operations, Environmental services, Life Safety, Infection control and Nursing.
- Engaged with Nursing staff to develop and implement floor-based staffing matrix for nursing.
- Reduced staff call-in rates from 40% to less than 5% a month.
- Successfully spearheaded a drive to increase nursing salaries to compete with other local facilities.
- Worked with CEO and CFO through a culture of accountability and have raised the level of professionalism of the nursing staff to where staff feel heard and their concerns are addressed.
- Implemented morning and evening Patient Safety Huddles based on IHI Patient Safety initiatives.
- Educated ‘all’ Nurse Leaders of the organization on EMTALA laws and regulation.
- Standardized Assignment sheets for the Nursing Units.
- Organized and implemented Communication Boards for Patient care areas.
- Collaborated in mitigating regulatory issues - CMS, TJC, and local DOH.
- Collaborated with Plant operations to mitigate Life Safety and EOC issues.
- Collaborated with CEO and CFO to create a culture of accountability and responsibility.
- Nominated to be the next CEO for the facility.
- Serving as the Chief Nursing Officer for approx. 300 bed Forensic Behavioral Hospital.
- Briefly served as the interim Administrator in the absence of the Acting CEO.
Interim Nurse Leader
North Oaks, MD
01.2021 - 03.2021
- Served as an Interim Nurse Leader for 50 bed LTC and AL facility in Pikesville, MD.
- Responsible for managing and leading COVID-19 related mitigation plans in coordination with the State of MD.
- Responsible for mentoring and educating staff on revised policies, processes, and procedures.
Interim Nurse Executive Consultant
Kendall Corporation, PA
10.2020 - 01.2021
- Served as Interim Nurse Executive Consultant for a 250-bed health services campus in Newtown PA.
- Responsible for managing and leading COVID related mitigation plans in coordination with the State of PA.
- Implemented Staff Assignment sheets for Nurses and Care Partners.
- Responsible for mentoring and educating staff on revised policies, processes, and procedures.
- Mitigated DOH survey findings and prepared organization for annual survey Organization-wide.
- Collaborated and implemented an organization wide COVID Program management and mitigated COVID19 cases in a Skilled Nursing facility.
Interim Executive Nurse Consultant
Soldiers Home, MA
07.2020 - 10.2020
- Served as the Interim Nurse Executive Consultant for a 277 bed LTC Veterans Home.
- Responsible for immediate mitigation of quality and safety issues related to COVID-19 Infection control practices.
- Responsible for mentoring and educating staff on revised policies, processes, and procedures.
- Prepared the organization for TJC that had preliminarily denied accreditation.
Interim Program Director (Behavioral Health)
St Frances Cabrini Hospital, LA
02.2020 - 07.2020
- An interim Program Director role to focus on re-structuring the operations of the Behavioral health unit.
- Successfully increased the average daily census by 40 percent thus having full occupancy.
- Re-structured the Operations of the department and increased productivity. Additionally, eliminated overtime of the department.
- Performed Ligature risk assessment as well as provided strategies to mitigate them.
- Performed an initial in-depth regulatory compliance assessment of the department and provided a plan of action to achieve compliance.
- Coordinated with Hospital EOC and Life Safety Officer to mitigate EOC and Life Safety issues within the department of Behavioral Health.
- Designed ‘restraints and seclusion’ power-point for Nursing Skills Fair.
Interim System Director
Behavioral Health services, Virginia
02.2019 - 05.2019
- A three-month engagement to focus on the behavioral health department (financial, regulatory, quality, compliance, and patient care operations) for three hospitals. Responsible for 450 FTE’s. The patients consisted of adults, adolescents, geriatrics, and detoxification units. The disease processes managed at the behavioral health units (adult, adolescent, and geriatrics) consisted of schizophrenia, neuro-degenerative, traumatic brain injury, schizophrenia, addiction services, depression, cognitive disorders, and behavior disorders of the adolescent.
Interim Regional Chief Compliance and Quality Officer
Pediatric Specialty Care, Pennsylvania
05.2018 - 11.2018
- Served as the Interim Regional Chief Compliance and Quality Officer (six facilities) for a for-profit health facility mitigating identified patient care and quality of care issues by Dept of Human Services. The patients consisted of pediatric population with medical and behavioral issues. The behavioral health disease processes included developmental disabilities, traumatic brain injury, eating disorders, as well as behavior issues.
- Instrumental in coordinating compliance issues related to Housekeeping, Plant Operations, Infection control, Environment of Care, and Dietary department.
Consultant
Union Hospital, Maryland
02.2018 - 05.2018
- Served as a consultant primarily to assess and provide a plan of action for environmental (ligature risk assessment) for the entire hospital including off-sites as well as the behavioral health department.
Interim Chief Nursing Officer
Anoka Metro Regional Behavioral Health Hospital, Minnesota
02.2017 - 12.2017
- Served as the Interim Chief Nursing Officer in a free standing 150 bed behavioral health hospital mitigating CMS (Systems Improvement Agreement) and other regulatory survey issues. Total direct reports – 8. FTE responsibility – 550.
- Extensively collaborated with Physicians and senior leadership to perform a hospital-wide risk assessment to include environmental ligature risks, Patient safety protocols, clinical and non-clinical documentation to mitigate ligature risks thereby preventing suicides.
- Instrumental in coordinating compliance issues related to Housekeeping, Plant Operations, Infection control, Environment of Care, and Dietary department.
Interim Chief Nursing Officer
Eastern Idaho Regional Medical Center, Idaho Falls, ID
06.2016 - 09.2016
- Directed a Joint Commission for a 350-bed for-profit, full-service hospital, satellite out-patient behavioral health facility, and Physician clinics as the Interim Chief Nursing Officer. Total FTE responsibility – 700.
- Coordinated with various department Heads including Housekeeping, Dietary, Plant Operations, Life Safety to be survey ready with TJC and CMS standards.
- Engaged by the hospital to perform the final preparations for a successful Joint Commission survey for the hospital to include in-patient, out-patient, as well as residential (adolescent) Behavioral health. The behavioral health population consisted of adults, adolescents, child, as well as geriatrics. The disease processes included neuro-degenerative, schizophrenia, depression, anxiety disorder, etc.
Interim Chief Nursing Officer
Brookdale University Hospital and Medical Center, Brooklyn, NY
10.2015 - 03.2016
- As the Interim Chief Nursing Officer, oversaw clinical process alignment and change management for a 797 bed, nonprofit Academic hospital and 448 bed skilled Nursing facility. In collaboration with Medical staff and Quality leadership implemented performance Improvement strategies and initiatives for sustainable patient care outcomes. Additionally, collaborated and re-negotiated union (SEIU) contract specifically staffing matrix. The revised staffing matrix was successfully ratified and implemented.
- Collaborated with Life Safety Officer, Plant Operations, and Patient Safety Officer to mitigate issues in all Patient care areas.
- Responsible for clinical process alignment for the hospital as well as Psychiatric department to include, adult in-patient, pediatric Psychiatry emergency department, child psychiatry services as well as out-patient counselling. The behavioral health disease processes included developmental disabilities, addictions, neuro-degenerative, traumatic brain injuries, forensics, etc.
Fairbanks Memorial Hospital, Fairbanks, AK
03.2015 - 10.2015
- Mitigated immediate jeopardy of Joint Commission and led preparation for CMS discrepancy survey and subsequent re-survey Hospital-wide including Dietary, Environmental services, House-keeping services, Plant Operations, and Life Safety for 400 bed for-profit Hospital.
- Provided assessment of magnet program and associated plans of correction.
- The mitigation of immediate jeopardy included the behavioral health unit – in-patient, and out-patient satellite clinics. The disease processes managed at the facility included adult, geriatrics, and adolescent schizophrenia, depression, anxiety and cognitive disorders.
Baystate Noble Hospital, Westfield, MA
11.2014 - 03.2015
- Acted as Interim Administrative Director for Perioperative Services for 97 bed, acute care community hospital. Also, worked collaboratively with Massachusetts Nurses Union and re-aligned work-flow in the Surgical services department.
UMass Medical Center, Worcester, MA
01.2014 - 11.2014
- Assessed and reported the strategic business direction for 781 bed, academic, acute care hospital and implemented standards of regulatory compliance for a renal dialysis unit.
Vice-President Patient Care Services & CNO
Regional Medical Center, Anniston, AL
04.2012 - 11.2013
- Reported to the President and CEO at a 350 bed, not-for-profit, regional hospital and directed administrative, financial, quality, regulatory, risk/legal and compliance for the Division of Nursing and Patient Care Services.
- Implemented best practices such as i-round, scripting, and service recovery programs to enhance patient experience and improved overall HCAHPS rankings by 60% in the first eight months of tenure.
- Planned and readied the hospital for a successful TJC and DOH survey including out-patient clinics and non-clinical departments i.e. Housekeeping, Dietary, Human Resources, Plant Operations, Life Safety by assessing the gap analysis and strategically partnering with stake holders to enhance established processes.
- Engaged in the development, implementation, and maintenance of hospital quality improvement programs including the Relationship based Patient care model on the Medical Surgical unit(s) of the hospital to improve efficiency.
- Ensured nursing and patient care standards, practices, policies, and procedures were in accordance with all applicable laws, regulatory, and accreditation requirements. Spearheaded nursing service performance improvement activities.
- Collaborated with medical and information technology staff to implement electronic medical record and successfully passed the Stage 1 and Stage 2 meaningful use criteria.
- Participated with CEO and CFO in networking and acquiring physician owned clinics and hospitals.
- Collaborated with Medical staff and IT to design and implement EMR organization-wide including outpatient clinics.
- Regional VP of Operations August 2009 – April 2012
- Florida Radiation Oncology Group, Jacksonville, FL
- Oversaw administrative, financial, human resources and compliance activities and collaborated operations of free-standing Radiation Oncology Centers with Radiation Oncologists and clinical staff (radiation therapists, physicists, office managers).
- Provided leadership support to the development and continuous improvement of internal processes to maintain enhanced customer focus. Assisted in the development of the strategic plan for all operational activity and worked with the President and business partners to strategically identify target markets aligned with company’s business model. Implemented and monitored annual operational plans, programs, and projects to meet overall goals and objectives.
CNO/Vice President of Patient Care
Community General Hospital, Syracuse, NY
05.2007 - 03.2009
- Led operations for clinical, financial, quality, and service functions of all patient care departments at 305 bed, not-for-profit, acute care hospital. Developed and directed the implementation of and ensured compliance with standards of patient care that promoted optimum health care delivery.
- Planned and launched strategic initiatives for the hospital with focus on increasing volumes and reducing costs. Created and executed survey activities for a successful State Survey of the skilled nursing facility (long term care). Collaborated and implemented a nursing performance improvement matrix for the Division of Nursing.
- Actively participated and successfully ratified renewal of the SEIU contract (Nursing union) in its entirety.
- Created and coordinated quality programs for the hospital such as hyperglycemic protocol on surgical units, wound care program, fall reduction program, and infection control program.
- Actively participated and chaired the Peri-operative Governance Committee with focus on improving surgeon satisfaction and turnaround times. Instrumental in facilitating strategies to improve ED throughput and diversion times. Provided feedback and guidance at Root Cause meetings of the Quality Department.
VP of Special Projects, Support Services and Hospital Audits
Southern Maryland Hospital Center, Clinton, MD
06.2006 - 05.2007
- Reported to the CEO at 358 bed, for-profit, acute care hospital and oversaw multiple departments including skilled nursing facility, engineering, plant operations, purchasing, materials management, biomedical engineering, laundry and linen, house officers, tumor registry, IRB, Quality Assurance, and the Cardiac Institute. Served on hospital committees including Ethics, Utilization Review, Critical Care, Quality Council, Medical Executive, Pharmacy and Therapeutics, and JCAHO functional teams.
- Charged with the development of a statewide electronic medical record system as part of the Maryland Healthcare Commission Task Force. Chaired the Purchasing Committee with focus on managing inventory levels and decreasing supply costs per patient day.
- Developed and integrated department wide performance improvement activities within the organizational infrastructure and guided the annual planning and budgeting process. Contributed to key programs including the Cardiac Institute, C-port, CORE measures, and stroke and chest pain programs.
- Assisted CEO with the recruitment of physicians by cultivating relationships with medical schools and initiating a branding campaign.
- Led operations for a 15-suite operating room, endoscopy/short procedure, PACU, PAT, and anesthesia services while managing 120 FTE.
- Accountable for JCAHO (TJC) corrective action plan related to the surgical environment and redesigned safety practices to meet standards. Improved first case start and turnaround times, decreased wait times, and improved access to the facility resulting in improved efficiencies and physician satisfaction.
- Managed clinical, financial, and regulatory performance of all professional services including Radiology, Laboratory, Outpatient Services, Respiratory Services, Rehabilitative Services, Case Management, Cardiology, Pharmacy, Information Services, and select clinical programs.
- Streamlined workflow processes within the Maintenance and Engineering department to ensure compliance with life safety codes and maintained contracts with external vendors.
- Collaborated with the management team to develop and implement plans for operational improvements related to infrastructure of systems, processes, and personnel and achieved outstanding JCAHO survey results. Created and administered the Patient Relations Department.
- Vice President of Surgical and Emergency Services August 2005 – June 2006
- Vice President of Nursing & Professional Services September 2003 – August 2005
Director of Critical Care
Prince William Hospital, Manassas, VA
10.2002 - 07.2003
- Oversaw clinical and financial performance for the Critical Care Department in 250 bed, not-for-profit, acute care hospital and was accountable for more than 40 FTE. Developed and integrated department wide performance improvement activities.
- Supported the implementation of Meditech, Midas and the Track System to enhance the clinical and financial performance of the division.
Director of Patient Care Services
Medlink Hospital & Nursing Center at Capitol Hill, Washington, DC
02.2001 - 09.2002
- Managed Nursing Services, Respiratory Therapy, Rehabilitation, Laboratory and Diagnostic Services, and Staff Development Education at 185 bed, long term acute care hospital and nursing center with oversight for approximately 200 FTE.
- Coordinated activities for medical staff meetings pertaining to Peer Review, Performance Improvement, and Infection Control. Successfully led the hospital and nursing center through annual regulatory surveys.
- Improved cost effectiveness of departments, decreased expenses and labor costs while ensuring continued quality patient care through process improvement and buy-in from supporting departments.
- Director of Nursing/Chief Nurse May 2000 – February 2001
- Nursing Supervisor December 1998 – May 2000
Cardiology Services Manager
District of Columbia General Hospital, Washington, DC
01.1997 - 01.2000
- Directed operations of the cardiac catheterization and EP labs in publicly owned, 350 bed, Level I trauma center. Restructured patient flow and internal processes to support increased patient volume. Standardized practices and policies in concert with the medical staff to improve patient safety and outcomes.
- Clinical Nurse – CCU 1991 – 1997
- Performed supervisory, charge nurse, and preceptor duties in a busy inner city trauma center. Provided clinical expert care of acute coronary care patients, cardiac catheter lab and support of clinical staff. Assisted in developing standards, staffing plans, bed assignments, and schedules.
- Nurse Instructor/Supervisor 178 Military Hospital, Gangtok, India 1987 – 1990
- Acted as Captain Nurse Corps Officer and supervised numerous clinical units including the CCU, OB/GYN, NICU, and Pediatrics. Taught advanced level classes to clinical nurses and assistants in the Medical and Surgical departments. Supervised and evaluated clinical skills and patient centered activities in respective clinical areas.
- Clinical Nurse Supervisor, Army Command Hospital, SC, Pune, India 1984 – 1987
- Served as Lieutenant Nurse Corps Officer and provided basic education, training, and clinical service to medical, surgical, critical, and trauma patients. Taught hospital corpsmen basic nursing care course and emergency care/disaster preparedness. Acted as hospital liaison for school activities and teaching programs and oversaw the Technical School of Nursing Assistants.
Education
Doctorate in Business Administration (c) -
University of Phoenix
Phoenix, AZMaster of Science - Management Information Systems
Bowie State University
Bowie, MDBachelor of Science - Nursing
Armed Forces Medical College
Skills
- Clinical care
- Nursing staff management
- Patient care services coordination
- Patient safety
- Patient treatment planning
- Clinical management
- Acute care
- Clinical expertise
- Electronic medical records
Accomplishments
- Achieved patient care outcomes through effectively helping with collaborating and coordinating across disciplines.
- Directly supervised team of 15-20 Hospital Leaders.
- Collaborated with Nursing Leadership and Hospital Leaders in developing strategies for TJC Compliance.
- Used Microsoft Excel to develop inventory tracking spreadsheets.
Certification
Certification in Adult Critical Care Nursing (CCRN) Instructor for CPR, PALS, ACLS
Affiliations
- American Nurses Association (ANA)
- American Society for Radiation Oncology (ASTRO)
- American Association of Critical Care Nursing (AACN)
- American College of Healthcare Executives (ACHE)
- Maryland Association of Health Quality Care, Past President, 2006
Languages
English
Full Professional
Hindi
Full Professional
Timeline
Acting Chief Executive Officer
Maryland Department of Health
01.2025 - 02.2025
Chief Nursing Officer
Maryland Department of Health
09.2022 - Current
Interim Chief Nursing Officer
Signature Healthcare, CA
07.2021 - 03.2022
Interim Nurse Leader
North Oaks, MD
01.2021 - 03.2021
Interim Nurse Executive Consultant
Kendall Corporation, PA
10.2020 - 01.2021
Interim Executive Nurse Consultant
Soldiers Home, MA
07.2020 - 10.2020
Interim Program Director (Behavioral Health)
St Frances Cabrini Hospital, LA
02.2020 - 07.2020
Interim System Director
Behavioral Health services, Virginia
02.2019 - 05.2019
Interim Regional Chief Compliance and Quality Officer
Pediatric Specialty Care, Pennsylvania
05.2018 - 11.2018
Consultant
Union Hospital, Maryland
02.2018 - 05.2018
Interim Chief Nursing Officer
Anoka Metro Regional Behavioral Health Hospital, Minnesota
02.2017 - 12.2017
Interim Chief Nursing Officer
Eastern Idaho Regional Medical Center, Idaho Falls, ID
06.2016 - 09.2016
Interim Chief Nursing Officer
Brookdale University Hospital and Medical Center, Brooklyn, NY
10.2015 - 03.2016
Fairbanks Memorial Hospital, Fairbanks, AK
03.2015 - 10.2015
Baystate Noble Hospital, Westfield, MA
11.2014 - 03.2015
UMass Medical Center, Worcester, MA
01.2014 - 11.2014
Vice-President Patient Care Services & CNO
Regional Medical Center, Anniston, AL
04.2012 - 11.2013
CNO/Vice President of Patient Care
Community General Hospital, Syracuse, NY
05.2007 - 03.2009
VP of Special Projects, Support Services and Hospital Audits
Southern Maryland Hospital Center, Clinton, MD
06.2006 - 05.2007
Director of Critical Care
Prince William Hospital, Manassas, VA
10.2002 - 07.2003
Director of Patient Care Services
Medlink Hospital & Nursing Center at Capitol Hill, Washington, DC
02.2001 - 09.2002
Cardiology Services Manager
District of Columbia General Hospital, Washington, DC
01.1997 - 01.2000
Master of Science - Management Information Systems
Bowie State University
Bachelor of Science - Nursing
Armed Forces Medical College
Doctorate in Business Administration (c) -
University of Phoenix
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