Shirley Joseph
Hayward,USA
Summary
Skilled healthcare administrator with more than 30 years of experience in leadership, strategic planning, and healthcare operations. Conscientious, energetic, and motivated leader, who is highly adaptable, displays initiative and strives to deliver effective and safe patient care through quality improvement initiatives and collaboration with the interdisciplinary team. Strong leadership experience in providing high-quality and safe patient care with an understanding of healthcare strategies. Current and past healthcare experience is dedicated to improving the quality of patient care through the development of people and processes. Specific areas of expertise include: Business and financial operations and management of general healthcare inpatient and ambulatory divisions, service lines, and departments. Coordination of strategic initiatives across multiple divisions, service lines, and departments Evaluate, reorganize, and integrate existing departments and service lines into top-performing units. Evaluation of compliance with risk and liability indicators, patient safety, federal and state regulatory compliance, and quality performance improvement. Evaluation of organizational preparedness for Joint Commission, CMS, and state-mandated programs. Analyze clinical and financial data, comparing outcomes to benchmarks and optimal values to determine opportunities for improvement. Medical economic and medical management, including statistical and financial trending, analysis, productivity, and cost reduction. Personnel management, team building, and establishing self-directed work teams creating employee job satisfaction, diversity, and succession planning. Working with Press Ganey Team, leading the High-Reliability Organization (HRO) Process
Overview
34
34
years of professional experience
1
1
Certification
Work History
Chief Nursing Officer
Alameda Health System
10.2023 - Current
- Reporting to President/CEO, oversee the entire hospital operations for a 177-bed acute care hospital and STEMI Center.
- Direct oversight to all clinical and most non-clinical departments.
- Collaborates with three unions and contract negotiations.
- Oversight for the construction and licensing of a 30-bed Sub-acute unit under the acute care hospital which is ready to open.
- Overseeing the construction and licensing of a new Cath lab.
- Implemented ED Surge plan to improve throughput and ambulance offloading in the Emergency Department.
- Implemented nurse driven protocols to improve organizational goals and quality metrics.
- Oversees and facilitate collaboration between county officials and other stakeholders such as EMS and community partners.
Chief Nursing Officer, Assistant Chief Nursing Officer
Spring Valley Hospital /Valley Health Specialty Hospital
04.2021 - 10.2023
- Managing and supporting all Nursing operations in a market system.
- Reports to CEO and functions as administrator on duty (AOC).
- Voting member in the Valley Health System Board of Governors.
- Member of various hospital committees.
- Collaborate with all departments/teams (both campuses) on all strategic operations for the market.
- Managing and supporting directors of all interdisciplinary nursing departments.
- Work with local and system CNOs to develop and implement processes and policies to standardize market operations and performance improvement.
- Works closely with Nevada Hospital Association and Nevada State board of nursing and Nevada Donor Network.
- Participates in professional practice committee and processes improvement to improve the nursing profession and clinical practice.
- Responsible for overseeing recruitment, developing, and implementing all processes and policies for the hospital.
- Successfully completed regulatory surveys.
- Responsible for growing up to a million surgical service lines through surgeon recruitment.
- Maintain clinical and patient-care standards.
- Works closely with the hospital management and stakeholders to acquire the proper infrastructure and resources.
- Offers the best insights to the divisional leadership on how to improve the quality of care in the facility.
- Responsible for formulating and implementing new nursing strategies.
- Performs the duties of a chief administrator, CEO, or COO as necessary.
- Plans and oversees the daily activities within the hospitals.
- Helps in planning budgets and setting rates for health services.
- Participated in contract negotiation, staffing committees, and productivity management.
- Maintain ambitious standards other staff members can follow.
- Inspires others and encourages them to uphold the best practices.
- Created a positive culture and reduced staff turnover to less than 2%.
- Increased employee engagement survey participation from nursing to 97% with green zone results.
- Established a recruitment process through employee engagement and filled all open nursing positions that reduced the need for overtime and agency/travel staff.
Director Quality, Regulatory, Risk, & Patient Safety
St. Rose Dominican Hospital
01.2018 - 03.2021
- Company Overview: Dignity Health
- Prepared the organization for a successful Joint Commission survey.
- Managed the risk management program and addressed all complaints and grievances referred by the patients and clinical team members.
- Assessed clinical and operational risks for potential liability suits and compliance issues.
- Assisted in developing an Emergency Operations Plan (EOP), a Continuity of Operations Plan (COOP), and a Pandemic Plan.
- Assisted in the design of an After-Action Report to be implemented after the emergent situation had been resolved.
- Responsible for Quality goals and priorities through the innovation, planning, directing, controlling, and implementing activities designed to support quality improvement.
- Serves as a vital member of the quality leadership team, which includes administration, risk management, and patient safety, and provided leadership in planning and directing the vision of Dignity Health’s (DH) overall quality improvement strategy in partnership with the executive team, entity executive teams, and other quality leaders.
- This position is also responsible for the oversight & administrative management of the Infection Control & Wound (HAPI) Management team.
- Chaired & Co-chaired Accreditation and Regulatory Committee, Patient Safety Committee, and Quality Improvement Committee; Served on and facilitated Board level Quality Council; reported monthly to the Board of Directors on quality and patient safety outcomes.
- Led Dignity Health’s Quality and Patient Safety Committee and Intensive Review/ Root Cause Analysis (RCA) Process, providing direction for the case review process and management of quality concerns and clinical adverse events at DH.
- This position’s focus on events analysis assured the development and completion of actions designed to provide a safer care environment.
- Works with the Medical Director, Chief Nursing Officer, Associate Administrators, Associate Medical Directors, Assistant Administrators, Patient Safety Officers, Risk Management, and clinical quality improvement representatives to regularly investigate, refer or track priority cases.
- Provide leadership regarding data access management through participation in the Dashboard Steering Committee and DH Executive Data Access Governance/Management Committees.
- Participate in workgroups related to developing policies around data access, data work prioritization, and dashboard design/development.
- These committees included ITS Leadership, entity Medical Directors and Quality Leaders, Associate Vice President of Finance, and Graduate Medical Education.
- Lead the quality goals, including the selection, development, and implementation of Quality Goals through recommending, defining, and gaining approval by Executive and entity leadership, setting targets for performance, and supporting entity work to meet or exceed the Quality Pillar targets.
- This includes the oversight of the accuracy of goal targets and consistent documentation of goals, targets, and data across the market.
- Design and evaluate annual quality plans and patient safety plans.
- Provide oversight for the Patient Experience survey data management.
- Responsible for timely evaluation and written responses to payer requests for quality-of-care reviews.
- Provided direction, leadership, and support for the initiative-taking assessment of national and state quality indicators, proposed measures, and upcoming programs to allow for strategic planning, implementation, and management of resources.
- Participated in the impact assessment of proposed local and national Pay for Performance initiatives through initiative-taking review of governmental programs, participation in state and federal quality programs, and, where possible, providing feedback on national measure development to improve compliance with external mandates.
- Assist in developing strategic planning related to the fiscal impact of quality and safety initiatives through collaborative work with the Finance, Health Information Management, decision support, and clinical operations.
- Responsible for claims management, i.e., discovery, participating in trial preparation, depositions, settlement conferences, and mediation; acting as the liaison to attorneys, insurance companies, staff, and physicians providing risk management and regulatory consultative services as needed.
- Lead & implement High-Reliability Organization HRO process.
- Dignity Health
Manager, Clinical Compliance
St. Rose Dominican Hospital
09.2016 - 01.2018
- Directed the implementation of patient safety and quality initiatives.
- Develop and address emerging physician/leader needs.
- Provide support to the Patient Safety objectives by focusing on Healthcare-Associated Infections, falls, Pressure Ulcers, Adverse Drug Events, and Sepsis, and reducing Readmissions.
- Designed and developed readiness toolkits for surgical infections, C-diff, and workplace violence prevention in collaboration with the Nevada service area leaders.
- Completed complex projects and supported the Hospital Improvement Innovation network contracts (HIIN), implementing a data-driven, multidisciplinary partnership and collaborative approach resulting in achieving the HIIN goals.
- Supported the implementation of patient safety and quality initiatives.
- Reviewed and analyzed data and assisted in implementing successful programs in the areas of fall reduction and readmission reductions through care management and utilization review.
- In collaboration with leadership, served on the Quality Council, Accreditation and Regulatory and Patient Safety Committees.
- In partnership with Compliance and Internal audit, responded to privacy breaches and conducted proactive risk assessments, implementing recommendations for mitigation of the identified risk.
- In conjunction with nursing leaders, physician champions, and the executive team, implemented a Comprehensive Unit-Based Safety Program in high-risk clinical areas and organization-wide to improve patient outcomes and patient safety culture.
- Provided support to the Patient Safety objectives by focusing on Healthcare-Associated Infections, Falls, Pressure Ulcers, Adverse Drug Events, Sepsis, reducing Readmissions and Disparities, Mental and Behavioral Health, looking at our processes for care management, and other areas as needed.
- Served as lead researcher and author of implementation-ready toolkits, collating the applicable science and best practices for Surgical Site Infections, Clostridium Difficile Infections, and Workplace Violence Prevention in collaboration with expert consultants and multiple high-level hospital leaders.
- Lead complex projects utilizing best practices for hospital leaders, clinicians, and Chief Medical Officers (forums to share best practices).
- Vital role in providing guidance and developing implementation toolkits.
- Assisted and supported Hospital Improvement Innovation Network (HIIN) contracts.
- Using a data-driven, multi-disciplinary partnership and collaborative approach helped achieve HIIN goals.
- Provided support to Patient Safety objectives by focusing on Healthcare-Associated Infections, falls, Pressure Ulcers, Adverse Drug Events, and Sepsis reducing Readmissions, and looking at our care management process and other areas as needed.
- Monitoring, interpreting, and reviewing quality projects and Data, recommending quality improvement solutions to improve sepsis care and blood therapeutics.
- Accelerated Physician collaboration for the success of all projects.
- Facilitated Root Cause Analyses for Sentinel/Adverse Events, developing action plans with measures of success, striving towards 'zero harm' and high reliability.
- Managed complaints, grievances, occurrences, and events and partnered with performance improvement and medical staff to effectuate corrective action plans and resolution.
- Served on Quality Council, Accreditation, Regulatory, and Patient Safety Committees.
- In conjunction with Compliance and Internal Audit departments, responded to privacy breaches and conducted proactive risk assessments, implementing recommendations to mitigate risk.
- By leading data-driven initiatives, achieve desired outcomes in patient safety, quality, and risk reduction/loss prevention with a multidisciplinary team, effectively improving performance in NPSGs, core measures, HACs, PSIs, Leapfrog Hospital Safety Score, patient satisfaction, physician satisfaction scores, and department morale.
Joint Replacement Programs Manager, (Disease Specific Programs TJC)
St. Rose Dominican Hospital
01.2011 - 09.2016
- Responsible for The Joint Commission Certification (TJC) /CMS and operation of the Total Joint Program.
- Worked closely with regulatory agencies to ensure the department met federal mandates.
- Managed the complaint and grievance process to ensure compliance with state and federal agencies.
- Achieved the Joint Commission (TJC)/CMS Total Joint Program Accreditation.
- Directed the successful Joint Commission re-accreditation for all District entities by completing six consecutive surveys with 'Zero' findings.
- Ensured compliance with required regulatory and federal mandates.
- Maintained clinical practice guidelines and evidence-based practices to improve quality and reduce cost in the orthopedic service line.
- Achieved desired patient safety, quality, risk reduction, and loss prevention outcomes.
- Created performance improvement measures using CMS/TJC recommended clinical practice guidelines (CPG).
- Implement and maintain patient, family, and staff education.
- Supervised data-driven initiatives achieving desired patient safety, quality, risk reduction, and loss prevention outcomes.
- Improved performance in NPSG, Core Measures, HACs, PSIs, Leapfrog Hospital Score, and patient satisfaction.
- Work closely with the hospital’s Infection control department to ensure proper guidelines are in place and design projects to reduce infection rates if needed.
- Detailed Chart reviews, performance reviews, and assessments and prepares recommendations.
- Ensured compliance with external regulatory and accreditation requirements, including survey preparedness, preparation of clarifications, and plans of correction for the programs.
- Served as the lead liaison with surgeons, patients, nursing leadership, case management, surgical services, inpatient and ambulatory rehabilitation programs, and vendors to ensure exceptional services to patients in the Joint Replacement Program.
- Implemented performance excellent guidelines, best practice standards, and case management principles to effectively care for orthopedic patients with a comprehensive understanding of the Joint Commission’s disease-specific programs.
- Reviewed and investigated adverse outcomes within the program.
- Reported events to appropriate authorities or agencies.
- Ensured compliance with state, federal, and Joint Commission requirements.
- Participated in Root Cause Analyses.
- Collaborating with Nursing and Physician leadership, successfully implemented the Safety Attitudes Questionnaire (SAQ) and Comprehensive Unit-Based Safety Program (CUSP) in high-risk clinical areas.
- Provided educational in-service coursework in quality, risk management, and patient safety topics.
Charge Nurse
St. Rose Dominican Hospital
01.2003 - 01.2011
- Oncology /Chemotherapy
Registered Nurse
St. Mary’s Hospital
01.2000 - 01.2003
- Oncology and Chemotherapy
Registered Nurse
Ministry of Health
01.1995 - 01.1999
- Critical Care/Surgery
Registered Nurse
All India Institute of Medical Sciences (AIIMS)
01.1991 - 01.1995
- RN in Med-Surge/Tele, Emergency Room
Education
Doctorate in Nursing Practice (DNP) - Executive Leadership
University of Nevada, Reno (UNR)
Master of Science in Nursing (MSN) - Education
Grand Canyon University (GCU)
Bachelor of Science in Nursing (BSN -Hons) - undefined
All India Institute of Medical Sciences
Delhi01.1995
Skills
- Business and financial operations and management of general healthcare inpatient and ambulatory divisions, service lines, and departments
- Coordination of strategic initiatives across multiple divisions, service lines, and departments
- Evaluate, reorganize, and integrate existing departments and service lines into top-performing units
- Evaluation of compliance with risk and liability indicators, patient safety, federal and state regulatory compliance, and quality performance improvement
- Evaluation of organizational preparedness for Joint Commission, CMS, and state-mandated programs
- Analyze clinical and financial data, comparing outcomes to benchmarks and optimal values to determine opportunities for improvement
- Medical economic and medical management, including statistical and financial trending, analysis, productivity, and cost reduction
- Personnel management, team building, and establishing self-directed work teams creating employee job satisfaction, diversity, and succession planning
- Working with Press Ganey Team, leading the High-Reliability Organization (HRO) Process
Certification
- RN NV
- RN CA
- ACLS
- BLS
- Orthopedic National Certification
Timeline
Chief Nursing Officer
Alameda Health System
10.2023 - Current
Chief Nursing Officer, Assistant Chief Nursing Officer
Spring Valley Hospital /Valley Health Specialty Hospital
04.2021 - 10.2023
Director Quality, Regulatory, Risk, & Patient Safety
St. Rose Dominican Hospital
01.2018 - 03.2021
Manager, Clinical Compliance
St. Rose Dominican Hospital
09.2016 - 01.2018
Joint Replacement Programs Manager, (Disease Specific Programs TJC)
St. Rose Dominican Hospital
01.2011 - 09.2016
Charge Nurse
St. Rose Dominican Hospital
01.2003 - 01.2011
Registered Nurse
St. Mary’s Hospital
01.2000 - 01.2003
Registered Nurse
Ministry of Health
01.1995 - 01.1999
Registered Nurse
All India Institute of Medical Sciences (AIIMS)
01.1991 - 01.1995
Doctorate in Nursing Practice (DNP) - Executive Leadership
University of Nevada, Reno (UNR)
Master of Science in Nursing (MSN) - Education
Grand Canyon University (GCU)
Bachelor of Science in Nursing (BSN -Hons) - undefined
All India Institute of Medical Sciences
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