TRACY GORDON RN, MSN, CNL, PHN
Palm Springs,CA
Summary
Highly experienced Healthcare Quality & Risk Manager with 10+ years of expertise in identifying, assessing, and mitigating risks within hospital settings. Proven track record of enhancing patient safety, reducing liability, and ensuring compliance with healthcare regulations. Adept at leading cross-functional teams, implementing effective risk management strategies, and fostering a culture of safety and accountability.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Director, Quality Resources | Risk Manager
Adventist Health Simi Valley
01.2024 - Current
- Administrative Director oversight for Quality Management, Enterprise Risk Management, Patient Safety, Infection Prevention, Peer Review, Publicly reported measures, Performance Improvement Program (QAPI), Sepsis, Stroke, and Policy Management Program.
- Implements quality management systems that consistently meet or exceeded customer expectations while maintaining regulatory compliance standards.
- Implement and lead clinical risk management program to protect the interests of the hospital, clinics, and patients.
- Identify, investigate, analyze, and evaluate risk related events on a proactive basis through trend analysis of incidents, patient complaints, near miss events, reports etc.
- Conducts regular audits of existing policies and procedures, ensuring their continued effectiveness in addressing organizational goals related to mitigating risks.
- Develops strong relationships with internal stakeholders, promoting a culture of risk awareness and accountability.
- Trained employees on risk management best practices, empowering them to make informed decisions regarding potential risks.
- Design and implement the enterprise-wide ERM program, including documentation of RM policies, procedures and standards.
- Review contracts for potential liabilities or exposures, recommending adjustments as necessary to minimize overall legal and financial impact on the organization.
- Supported executive decision-making by providing accurate and timely reports on enterprise-wide risk exposure levels.
- Enhance risk identification processes for early detection and mitigation of potential threats.
- Foster a culture of continuous improvement in risk management, encouraging feedback from employees to identify areas for enhancement.
- Work closely with organizational leadership and board of directors to guide operational strategy.
- Reduce medical errors by conducting thorough risk assessments and developing targeted interventions.
- Served as an expert resource for colleagues seeking guidance on complex patient safety issues or questions related to risk or regulatory compliance requirements.
- Developed tools for consistent documentation of safety events and near misses, enabling accurate measurement of progress toward established goals.
- Collaborated with interdisciplinary teams to develop comprehensive patient safety initiatives, resulting in decreased adverse events.
- Expert facilitator for all root cause analyses for serious incidents, leading to the development of effective preventive measures.
- Streamlined incident reporting process, leading to faster identification of safety issues and implementation of corrective actions.
- Participated in external audits to validate the effectiveness of the organization''s patient safety and risk management programs, identifying opportunities for improvement.
- Collaborated with human resources to integrate patient safety competencies into job descriptions and performance evaluations, reinforcing staff accountability for maintaining a safe environment.
- Monitored key performance indicators related to risk management & patient safety, using data analysis to identify areas for improvement.
- Promoted transparency around incident reporting by sharing lessons learned from previous events throughout the organization, cultivating a shared commitment to improving patient outcomes.
- Collected detailed notes on investigations and other communication to adhere to legal requirements and enhance recordkeeping.
- Implemented effective data management strategies, reducing errors and improving overall data quality.
- Streamlined budget management, identifying cost-saving opportunities without compromising patient care quality or staff satisfaction.
Interim VP Quality, PS, Risk Management
St. Dominic’s
10.2022 - 11.2023
- Provided leadership for planning, management, implementation, & integration of the Quality, Patient Safety, Performance Improvement, Infection Prevention, Peer Review, & Emergency Management programs in support of facility goals dedicated to excellence, effective leadership, and financial stability.
- Responsible for the enterprise-wide Quality System effectiveness to include pay for performance outcomes, publicly reported metrics, safety outcomes, clinical quality measures, organizational quality goals, patient safety initiatives, and the CMS QAPI program.
- Responsible for organizational adherence and action on all applicable federal, state, Joint Commission, and local regulatory agency requirements.
- Assured timely & accurate submission of data and process improvement initiatives/projects to all medical staff, board, and hospital committees.
- Worked collaboratively through the Medical Staff with physician groups to promote evidence-based quality and safety, patient-focused care aimed at optimal patient outcomes.
- Facilitated a successful Joint Commission triennial survey, Leapfrog Safety Grade improvement from a score of a “C” to an “B”, CMS star rating from a 2 to a 3, and a reduction in mortality, readmission, and LOS metrics across all payors.
- Led cross-functional teams for the successful completion of major projects, resulting in increased efficiency and client satisfaction.
Interim Director Quality, PS, Risk Management, EM
Sutter Delta Medical Center
07.2021 - 09.2022
- Provided oversight for the strategic development and implementation of the quality, risk management, peer review, regulatory, patient safety & infection prevention programs with responsibility for planning, organizing, and directing the managerial and operational activities of the infrastructure required to support these services.
- Responsible for ensuring compliance with regulatory standards related to the quality management system, medical staff performance, performance improvement data/QAPI, and clinical contract quality monitoring to meet regulatory standards for deemed status.
- Collaborated with the finance department, providers, leadership, and other stakeholders to monitor organizational costs to ensure compliance with CMS cost standards.
- Ensured administrative team, Quality Board, and other involved leadership remained abreast of new and potential quality/cost measures as outlined in the Federal Registry and publicly reported measures.
Risk Manager, PS Officer, Patient Advocate
Desert Regional Medical Center, Tenet Healthcare
01.2019 - 08.2021
- Managed the development, coordination, and monitoring of the activities of the Patient Safety & Risk Management programs.
- Managed the development, coordination, and monitoring of the activities of the Patient Safety & Risk Management programs.
- Directed administration, providers, and employees within the facility towards process improvements to support the reduction of medical/health care errors, preventing adverse outcomes.
- Managed the hospitals active litigation cases; functioned as the liaison between Office of General Counsel, hospital management, staff, providers, local law enforcement, and community agencies.
- Provided leadership for safety assessments/pro-active risk analyses and acted as the Chair of the Patient Safety Committee.
- Organization subject matter and facilitator of process improvement activities to maximize team function and roles using appropriate function and roles by using appropriate QI framework.
- Implemented the first “Just Culture” program in the organization to include buy-in and enthusiasm from all levels of leadership contributing to improved Employee satisfaction scores.
- Managed all hospital grievances, quality of care concerns, billing complaints and real-time patient/family issues, co-chair of the Patient & Family Advisory Council.
Regional Risk Manager & Patient Safety Officer
Veterans Affairs Regional Health Network Office
10.2016 - 12.2018
- Managed the regions 8 risk management programs which included the oversight of protected peer review, federal litigation, tort claim, and risk assessment activities.
- Collaborated effectively with General Counsel, Office of Medical Legal Affairs, and US attorneys to address and resolve risk management issues.
- Led 6 facility patient safety teams working collaboratively with analysts and field-based Patient Safety Managers to strengthen, and maintain facility-based patient safety and risk management programs across the enterprise.
- Provided consultation/ management through a working knowledge of HRO, Just Culture, national directives, medical center policies, bylaws, and PI initiatives to the VHA, regional network and local Medical Center CEO’s.
- Developed and directed the implementation of a (1) national “Just Culture” Program for Veterans Affairs Leadership and 2) a national “High Reliability Hospital” model for piloting and implementation throughout the Veterans Affairs network.
- Forecasted, developed, justified, implemented, and maintained financial components of the region’s Patient Safety programs to maximize the utilization of network resources.
Chief Quality Officer
Veteran’s Affairs Healthcare System
09.2015 - 10.2016
- Developed comprehensive OIG, TJC, CARF, and VISN oversight readiness plans; provided accurate and timely continuous readiness tracking reports and action plans to the medical center Director and senior leadership team
- Developed comprehensive OIG, TJC, CARF, and VISN oversight readiness plans; provided accurate and timely continuous readiness tracking reports and action plans to the medical center Director and senior leadership team
- Reviewed and responded to all OIG, OMI, and congressional inquiries
- Oversaw Patient Safety activities, Peer Review, Risk Management, Infection Control, Systems Redesign, Accreditation & Licensure programs including the review, development, and implementation of all medical center policies
- Established a vibrant improvement program and environment for adoption of Lean, and use of Six Sigma performance models to improve performance measures and promote a culture of continuous improvement.
Patient Safety Officer
Palo Alto Veteran’s Affairs Health Care System
07.2014 - 09.2015
- Oversaw, coordinated, and managed all Patient Safety related activities at the facility level focusing on continuous improvement
- Contributed to the strategic planning and administrative management of the facility care delivery, assessing organizing, developing, managing, and evaluating the facilities various patient safety activities.
- Organized Patient Safety Manager Conferences for the region and presented on Systems Improvement (Lean) & how it relates to the VHA Patient Safety Programs.
- Facilitated all RCA activities by acting as an Advisor and providing “Just in Time” training (National Center for Patient Safety) improve the quality and outcome of the analyses.
Clinical Nurse Leader, Ambulatory Care
Palo Alto Veteran’s Affairs Health Care System
11.2013 - 07.2014
Nurse Manager
Southern Arizona Veteran’s Affairs Health Care System
08.2011 - 10.2013
Education
MASTER OF SCIENCE, NURSING -
University of San Francisco
San Francisco, CA05.2011
BACHELOR OF ARTS, PSYCHOLOGY -
University of San Francisco
San Francisco, CA12.2004
Skills
Program Administration and Optimization, Litigation & Claims Management, Regulatory Compliance, Black Belt Lean Six Sigma, HRO development, Master Trainer for Just Culture & Cause Analyses (Common, Apparent & Root), Humans Factors Engineering, Patient Safety Systems (Midas, RL Datix), EHR Systems (Epic, Cerner), Expert in HAC TJC & DNC Stroke Accreditation, CMS Quality Reporting (HQR, IQR VBP), Core Measure Abstraction, Leapfrog Survey Management, Data Analysis & KPI Tracking, Policy Development and Enforcement
Certification
- CA Registered Nurse (RN), 797276
- Clinical Nurse Leader (CNL), 106402471
- Public Health Nurse (PHN), 82673
- CPHQ, Test date: June, 2024
Interests & Hobbies
Hiking, Yoga, Ted Talks, Stand-Up Comedy, Mindfulness Mediation Coach, Practicing the UkuleleVolunteer Work
Affiliations
- - American Society for Healthcare Risk Management (ASHRM)
- - National Patient Safety Foundation (NPSF)
- - American Nurses Association (ANA
Timeline
Director, Quality Resources | Risk Manager
Adventist Health Simi Valley
01.2024 - Current
Interim VP Quality, PS, Risk Management
St. Dominic’s
10.2022 - 11.2023
Interim Director Quality, PS, Risk Management, EM
Sutter Delta Medical Center
07.2021 - 09.2022
Risk Manager, PS Officer, Patient Advocate
Desert Regional Medical Center, Tenet Healthcare
01.2019 - 08.2021
Regional Risk Manager & Patient Safety Officer
Veterans Affairs Regional Health Network Office
10.2016 - 12.2018
Chief Quality Officer
Veteran’s Affairs Healthcare System
09.2015 - 10.2016
Patient Safety Officer
Palo Alto Veteran’s Affairs Health Care System
07.2014 - 09.2015
Clinical Nurse Leader, Ambulatory Care
Palo Alto Veteran’s Affairs Health Care System
11.2013 - 07.2014
Nurse Manager
Southern Arizona Veteran’s Affairs Health Care System
08.2011 - 10.2013
MASTER OF SCIENCE, NURSING -
University of San Francisco
BACHELOR OF ARTS, PSYCHOLOGY -
University of San Francisco
- CA Registered Nurse (RN), 797276
- Clinical Nurse Leader (CNL), 106402471
- Public Health Nurse (PHN), 82673
- CPHQ, Test date: June, 2024
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