Rona Capps
Prattville,AL
Summary
To obtain a position of employment within my level of degree, skills and experience. Proven leader in Quality Management, offering strong expertise in establishing and maintaining quality systems. Bring deep understanding of regulatory compliance, process improvement, and risk management. Noteworthy for driving operational excellence while ensuring adherence to industry standards. Successful track record in leading cross-functional teams and implementing strategic initiatives that enhance overall quality performance.
Overview
28
28
years of professional experience
Work History
Director of Quality and Risk Management, Joint Commission Coordinator, Patient Experience Coordinator
Encompass Health Inpatient Rehabilitation Montgomery Location
Montgomery
2021.12 - Current
- Daily responsibility to direct, oversee, plan, coordinate and evaluate a comprehensive program to improve clinical outcomes, enhance value, and minimize patient harm
- Oversee all quality management activities including patient and care relations, Joint Commission Compliance, OSHA, other State and regulatory compliance, risk management, safety, performance improvement and infection control
- Guiding best practices to organizational staff
- Developing programs and initiatives that promote quality
- Training staff as necessary
- Collecting and interpreting data that could affect the quality of care delivery
- Served as the Patient Safety Officer
- Served as the Fall Team Coordinator
- Served as the patient advocate/patient experience coordinator.
Director of Quality & Regulatory Compliance, Risk Manager, Joint Commission Coordinator
HSI (Health Services Inc)
2021.06 - 2021.12
- HSI is a Federally Qualified Health Care Center, Joint Commission accredited with a certification as a Primary Centered Medical home
- Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas
- Clinical quality measures are to be monitored and analyzed often to ensure prompt grant funding on a yearly basis
- I was responsible for those measures as far as monitoring, educating, updating and reporting
- Joint Commission standards for ambulatory setting were also monitored by me with the assistance of various coordinators who collected data and returned that data to me
- I was responsible for aggregating that data, reporting and trending
- Any areas of improvements were addressed immediately
- Additional responsibilities included: annual policy reviews/revisions, dashboard summary of measure scores, risk management events summary, provider scorecards, provider incentive scorecards, contract updates along with presentation of all data to a Board of Directors quarterly.
Quality and Regulatory Coordinator
Jackson Hospital Quality and Regulatory Compliance Department
2010.02 - 2021.06
- Serving as a subject matter expert for Joint Commission and Medicare mandated core measures that are directly tied to the Hospitals reimbursement
- My area of expertise were in the surgical area otherwise known as SCIP Core measures, Colonoscopy usage, Sepsis care and VTE (blood clot) prevention of all admitted patients
- My duties included but not limited to: educating staff and physicians on expectations of the measure info and how to accomplish it
- Also meet monthly to discuss process improvement opportunities to help meet the measure with the least interference
- Data abstraction of about 20-30 charts a week that includes inpatient and outpatient measures
- Written feedback is provided in a professional and scripted manner to physicians and nursing with each fall out or near miss found
- I worked directly with department heads and education leaders to discuss areas of needed improvement and educational needs
- Assisted in meeting the measure requirements in various ways beyond abstraction by posting reminders quarterly, education send outs as needed, assisting in arranging speakers, standardized order set builds or revision of current ones (electronic and paper) for each measure/diagnosis
- Revision of orders sets are on-going as the requirements change
- Policy build and revision on-going as well
- Attended and presented at nursing and physician meetings as requested to provide education as well as Q&A sessions to hospital staff
- Risk assessment and educational tools ongoing provided to MD’s and staff to serve as triggers/reminders of all the measure requirements.
PACU RN (part-time), Employee Health Nurse (part-time)
Jackson Surgery Center, Jackson Hospital
2009.02 - 2010.02
- Responsible for the care of immediate post op patients ranging from general anesthesia to local and regional blocks
- Wide range of surgeries performed on patients; ENT, general, orthopedics to diagnostic procedure such as EGD and colonoscopy
- Education provided to each patient prior to leaving on their specific needs and general concerns post-surgery
- Worked directly with the anesthesiologists and surgeons to ensure proper and efficient care was delivered
- During this time, I also was the Interim Employee Health Nurse for Jackson Hospital during the absence of the full time nurse
- This included a health screening for all new hires
- Monitoring and follow-up for incomplete paper work, immunizations, drawing blood work, verifying vaccinations, TB skin tests and TB mask fit testing for the appropriate departments and reporting to local health department when applicable
- Transferred to a full time Quality position within Jackson Hospital February 2010.
Nurse Manager/Director II
Prattville Baptist Hospital (PBH)
Prattville , Alabama
2006.07 - 2008.10
- Nursing Manager over 44 beds in the Medical/Surgery inpatient department as well as a 6 bed Critical Care Unit
- Responsible for overseeing approximately 35 FTE’s
- Responsibilities included: Accountable for department wide coordination, facilitation, and direct delivery of patient care
- Maintain 24-hour accountability for overall operations and integration
- Responsible for planning, organizing, directing and evaluating department specific quality improvement projects
- Supervising approximately 50 employees that included RN’s, patient care technicians and unit clerks (secretaries)
- Duties included hiring, orienting, discipline, counseling, monthly schedules, daily staffing and assignments
- Financial responsibilities of maintaining staffing productivity of 95-105%
- Analyzing and explaining variances to budgets and staffing plans
- Utilizing financial and statistical reports for managing budget
- Supply and expense control – reconciling charges
- Interacted with several disciplines in order to improve patient outcome and employee environment
- These disciplines included Hospital physicians, Quality Manager, Infection Control Practitioner, CNO and Case Management
- Served on various local and system wide committees with shared decision making and voting
- Also served on several quality improvement committees that would look at trends or error reporting in an effort to correct or improve.
PACU Staff Nurse, Preoperative and Recovery Room
Baptist Health South
Montgomery , Alabama
2000.01 - 2006.07
- Preoperatively prepare patients for surgery including but not limited to gathering health information, accessing for risk factors, explaining procedures/medications as well as assisting MDA with regional blocks at the bedside
- Recovery room includes care for patients immediately after surgery with age range 6 months to geriatrics
- Varying anesthetic agents used with a wide range of surgeries such as: eye correction, plastic surgery, orthopedic, GYN, ENT, vascular, gastrointestinal and diagnostic procedures.
Clinical Support Specialist RN
Johnson and Johnson, CODMAN (Neuro-modulation division of Johnson & Johnson)
2001.03 - 2002.12
- I was involved in a pain management group, which represented an implantable, constant flow pain/chemo pump
- I traveled to different areas of the country to teach and train physicians and/or nurses, the make-up, function, and concepts of a constant flow pump for pain management or chemo delivery to the liver
- I was involved in the direct demonstration of the refill process including the type of medications that could be used, emptying, refilling and troubleshooting
- I entered the operating room to provide support to the OR team and physicians during the preparation and the surgical implantation of the pump
- I had a rotation schedule of taking responsibility for the 24 hour call line
- This call line was a 1-800 number that allowed patients and physicians to call in for any questions concerning their pain pump.
Interim Nurse Manager/Director
Medical/Surgical Inpatient Floor, Baptist Health South
Montgomery , Alabama
1999.06 - 2000.01
- With the resignation of the Nurse Manager, my job duties of that role were added
- Additional duties included but were not limited to the following: Responsible for staff scheduling of all 3 shifts, attended all departmental and hospital wide meetings, conducted monthly staff meetings and submitted reports/feedback to administration and prepared 6 month and annual evaluations for all 3 shifts of nursing and technician staff.
Assistant Nurse Manager
Medical/Surgical Inpatient Floor, Baptist Health South
Montgomery , Alabama
1999.01 - 1999.06
- I was involved in shared management of floor employees and total management in the absence of the Nurse Manager
- I was responsible for guidance, teaching/training, evaluation and discipline of the current employees
- I interviewed new employee candidates and feedback given for possible hire
- I was involved in various committees for improvement changes as well as required needs as outlined by Alabama Board of Nursing, i.e., care plans, CE classes and constant on the job training.
Staff Nurse – Charge Nurse
Medical/Surgical Inpatient Floor, Baptist Health South
Montgomery , Alabama
1996.06 - 1999.01
- I was hired out of school to the medical/surgical floor
- I took the role of day shift and evening shift Charge Nurse after 1-year experience (varying days)
- I was responsible for nursing care of the following types of patients: Vascular; plastics, ENT, GYN, general abdominal surgeries, amputations and medical illness patients
- Charge Nurse Role involved assigning and delegating patient load and responsibilities and ensuring that everything was carried out by the end of each shift
- I assisted with training of the new computer charting that went online in 1997
- I was involved in training the upgraded version in September 1998
- I participated in the Preceptorship Program with various local nursing schools as well as the same programs for newly hired Registered Nurses
- Preceptors took on the role of educator/trainer for new nurses and nursing students in every aspect of nursing care.
Education
Associates degree of Science in Nursing -
Troy State Nursing School
Montgomery, AL01.1996
General Studies with advanced English -
Prattville High School
Prattville, AL01.1991
General Studies and Nursing prerequisites -
TSUM
Montgomery, ALSkills
- Quality management
- Risk management
- Joint Commission compliance
- OSHA compliance
- State and regulatory compliance
- Performance improvement
- Infection control
- Patient safety
- Fall prevention
- Patient advocacy
- Patient experience coordination
- Clinical outcomes improvement
- Program development
- Data interpretation
- Staff training
- Policy review and revision
- Dashboard summary
- Provider scorecards
- Contract updates
- Presentation skills
- Medicare Core measures
- Sepsis care
- VTE prevention
- Data abstraction
- Feedback and reporting
- Process improvement
- Education and training
- Order set builds and revisions
- Policy build and revision
- Risk assessment
- Employee health nursing
- Post-operative care
- Anesthesia care
- Health screening
- Nursing management
- Patient care coordination
- Budget management
- Supply and expense control
- Interdisciplinary collaboration
- Quality improvement
- Committee participation
- Preoperative preparation
- Recovery room care
- Pain management
- Chemo pump training
- Troubleshooting
- 24-hour call line support
- Staff scheduling
- Staff meetings
- Evaluation and discipline
- Interviewing and hiring
- Care plans
- Continuing education
- Computer charting
- Preceptorship program
- Complaint handling
- Communication skills
- Documentation Control
- Corrective Action Planning
- Team Collaboration
- Customer Service
- Multitasking
- Data Collection
- Employee Supervision
- Critical Thinking
- Attention to Detail
- Time Management
- Policy Reinforcement
Licensures
Alabama Board of Nursing, 1-080652, 12/2021, Present
Timeline
Director of Quality and Risk Management, Joint Commission Coordinator, Patient Experience Coordinator
Encompass Health Inpatient Rehabilitation Montgomery Location
2021.12 - Current
Director of Quality & Regulatory Compliance, Risk Manager, Joint Commission Coordinator
HSI (Health Services Inc)
2021.06 - 2021.12
Quality and Regulatory Coordinator
Jackson Hospital Quality and Regulatory Compliance Department
2010.02 - 2021.06
PACU RN (part-time), Employee Health Nurse (part-time)
Jackson Surgery Center, Jackson Hospital
2009.02 - 2010.02
Nurse Manager/Director II
Prattville Baptist Hospital (PBH)
2006.07 - 2008.10
Clinical Support Specialist RN
Johnson and Johnson, CODMAN (Neuro-modulation division of Johnson & Johnson)
2001.03 - 2002.12
PACU Staff Nurse, Preoperative and Recovery Room
Baptist Health South
2000.01 - 2006.07
Interim Nurse Manager/Director
Medical/Surgical Inpatient Floor, Baptist Health South
1999.06 - 2000.01
Assistant Nurse Manager
Medical/Surgical Inpatient Floor, Baptist Health South
1999.01 - 1999.06
Staff Nurse – Charge Nurse
Medical/Surgical Inpatient Floor, Baptist Health South
1996.06 - 1999.01
Associates degree of Science in Nursing -
Troy State Nursing School
General Studies with advanced English -
Prattville High School
General Studies and Nursing prerequisites -
TSUM
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