Tracy Johnson, MBA, MS, BSN, RN, C-ONQS
Potsdam,New York
Summary
Transformational Nurse Leader | Women & Children Healthcare Expert | Advocate for Exceptional Patient Care
With over 25 years of experience in Women & Children healthcare and 13+ years in progressive nursing leadership, I am passionate about building motivated, high-performing teams and fostering a collaborative, professional culture.
My career is defined by a steadfast commitment to outstanding patient care, staff satisfaction, and strategic growth. From managing financial responsibilities to securing a $9 million NYS grant for innovative patient support programs, I deliver results that matter.
Leadership Highlights:
- Spearheaded the development and expansion of critical patient support initiatives, including Quantitative Blood Loss, Postpartum Hemorrhage, Cardiac Bundles, Infant Falls, Substance Use, Depression, Neonatal Abstinence, and more, enhancing patient safety and outcomes.
- Successfully oversaw four Joint Commission (JC) and DNV department surveys, showcasing operational excellence and regulatory compliance. - Collaborated effectively with CMS, and ensured readiness during unannounced state Department of Health (DOH) visits.
- Subject matter expert in EPIC EMR and fetal monitor software conversions, driving pre-build to optimization success.
- Key player in expanding Women & Children departments in NC and NY.
What Drives Me:
I am dedicated to ensuring that patients and families receive the exceptional care they deserve. My efforts prioritize customer service while also addressing the needs of interdisciplinary healthcare teams.
Results-Oriented:
From achieving stellar patient outcomes to driving staff retention and satisfaction, I consistently turn challenges into opportunities for growth and excellence.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Interim Director of Nursing Women & Children's
Samaritan Health Services
07.2024 - Current
- Interim Director of Women and Children's: 290 beds, 1,500+ annual births, Level II NICU, Pediatric Unit
- 2 Nurse Managers, 1 Clinical Nurse Specialist, 1 IBCLC, 150 Union FTE
- Developed Quality Scorecard with specified metrics to achieve goals
- Implemented the Unit Practice Council, participated in the Nursing Practice Council, and assisted in developing the Clinical Ladder Guidelines
- Developed and implemented nursing policies and procedures to ensure quality patient care
- Developed and maintained the staffing schedule in accordance with contract terms, minimum staffing guidelines, budget mandates, and accreditation standards for nursing coverage
- Developed and implemented nursing policies, procedures, and protocols to ensure patient safety
- Resolved conflicts among staff members in a professional manner while maintaining positive working relationships
- Assessed competency of clinical staff to promote quality, continuity, and safety
- Implemented strategies for improving patient satisfaction scores in the nursing department on an ongoing basis
- Administered fiscal operations for accounting, budget planning, authorizing expenditures and coordinating reporting
- Monitored changes in laws and regulations related to healthcare delivery services to ensure compliance with all applicable standards
Interim Quality and Risk Management Nurse Consultant for Maternal Child Health
HireUp Leadership
10.2023 - 06.2024
- MCH Subject Matter Expert Quality and Risk Nurse Consultant for Kaiser Permanente
- Perform deep dive chart reviews for healthcare system reported events
- Risk Management tasks involve conducting deep dive audits with events and create reports to present for all Maternal Child Health sentinel events
- Conduct investigations with patient reported concerns and prepare reports with findings
- Quality tasks involve creating and maintaining department Dashboards, Scorecards, action plans, comprising of data stats on a weekly/monthly basis, incorporate into reports for department and senior leadership
- Utilize and extract data using Tableau, Statit, CMQCC, and more
Interim Maternal Child Health Manager
HireUp Leadership
02.2023 - 10.2023
- Interim Manager at Kaiser Permanente: 216 bed, 4,000+ annual births, Level III NICU
- Manager of Labor & Delivery, 6 ANM, 150 Union FTE
- Prepare for The Joint Commission survey, identify, improve, and maintain quality metrics, provided ongoing provider and nursing support, assisting department director and staff during management leave of absence
- Rolled out AWHONN Maternal Fetal Triage Index protocol with monthly monitoring
- Improved percentage with employee conditions of employment to zero
- Quickly attained knowledge of several protocols and processes to ensure uninterrupted departmental needs
- Assisted newly onboarded Clinical Nurse Specialist with implementing measures around: newborn falls, Quantitative Blood Loss, Massive Blood Transfusion, reduction of SSI, reduction of Cesarean Section rates, and newborn head cooling
- Appropriately maintained position control
- Specifically appointed to collaborate with development of both Nurse's and Hospital Week festivities for entire facility
Independent Nurse Consultant
JJC & Associates
01.2018 - 05.2023
- Contracted to review and recommend potential venture funding and academic study project business plans
- Specifically requested as a subject matter expert for gynecologic and maternal/child work
- Past projects include permeable membrane solution for pre-adolescent cancer surgery survivors through adolescent model
- Maternal Child Health department review/update of nurse orientation, education and competency departmental program including mock drills with debriefing layout
- Review and recommendation of current policy and procedures for appropriate evidence base organizational practices
Director of Obstetrics and Gynecology
Canton-Potsdam Hospital
10.2018 - 09.2022
- Company Overview: Rural 94 Bed Non-Profit Hospital, 650+ births annually, 55+ Union FTE, reported to CNO
- Support rural health population which included local American Indian reservation population
- Increase annual births by 45% through advocating culture change
- Decreased length of stay supported by redevelopment of patient throughput while maintaining patient satisfaction, enhancing patient education and safety awareness
- HCAHPS significantly improved and maintained between 80%-90%, exceeding target goal
- Assisted with integration and model of care for nurse midwifery services
- Strategized to decrease Cesarean Section rate (PC-02) from >30% to 19% with no increase of infections
- Eliminated contract staff while simultaneously reducing nurse turnover to
- Progressively increased revenue monthly through identification of chargeable services
- Assisted with data collection for submission of $9 million grant to NY
- Co-managed implementation, tracking, and reporting data of Maternal Wrap Around Program which provides comprehensive care coordination, and recovery support services to pregnant and postpartum with a substance use disorder
- Completed EPIC EMR and fetal monitor software conversions from pre-build through optimization
- Assisted with the development of telehealth services during COVID with enhancements thereafter
- Improved staff satisfaction rates via survey; increased staff engagement on unit base council
- Achieved NY state recognition for maternal hemorrhage program
- Received NY state recognition for annual newborn vaccine rate
Interim Director Maternal Child Health
Leaders For Today
06.2018 - 10.2018
- Interim assignment prior to accepting permanent position with Canton-Potsdam Hospital.
Director Maternal Child Health
Southeastern Regional Medical Center
08.2016 - 05.2018
- Company Overview: 452 Bed Non-Profit Hospital, 1400+ births annually, 80+ FTEs, 2 Managers, reported to CNO
- Support rural health population which included local American Indian reservation population
- Infant mortality rates decreased from 14.8% to 6.2% through redeveloping the level of care and provider collaboration
- Assisted in NICU renovation project while arranging appropriate training needs for all nursing staff
- Network with Lumberton Treatment Center on co-management of prenatal care; Partnered with Project ECHO
- Developed NICU Cuddler Program for newborns
- Decreased Early Elective Deliveries (PC-01) from 5.3% to 0
- Decreased Cesarean Section rate (PC-02) from 30% to 25%
- Increased Exclusive Breast Milk rate (PC-05) from 50%
- Re-evaluated Couplet Care model to include 100% success of cross training staff - reducing staff needs
- Implemented a well-defined mentoring program to support new staff and enhance growth of staff
- Eliminated contract staff while simultaneously reducing nurse turnover
- Progressively increased revenue monthly through identification of chargeable services
- Outsourced Newborn Hearing Screening while reducing annual labor and supply cost by >50k
- Provided oversight with EPIC EMR build while concurrently integrating PeriCALM fetal monitoring software for conversion at 'Go-Live'
- Earned the Breastfeeding-Friendly Business and Breastfeeding-Friendly Workplace awards by the NC Breastfeeding Coalition for establishing an environment within the hospital for employees and visitors to privately breastfeed and/or pump
- Participated in the statewide Perinatal Quality Collaborative of NC, a postpartum hemorrhage initiative to improve morbidity and mortality rates of pregnant patients
- Maintain/negotiate new and existing vendor contracts
- Survived Hurricane Matthew with assistance of the Mobile One Unit on site for several weeks
Interim Director Maternal Child Health
The First String Healthcare
03.2016 - 07.2016
- Interim assignment at Howard University Hospital in Washington, D.C.
Director Family Birth Center
Bon Secours Maryview Medical Center
01.2014 - 01.2016
- Company Overview: 346 Bed Academic Hospital, 1200+ births annually, 75+ Union FTEs, reported to CNO
- Administratively and clinically responsible for 5 Labor Rooms, 1 Operating Room, 3 Triage Rooms, 13 Postpartum/GYN Rooms and NICU
- Manage service line budget of over $8 million - 3 cost centers
- Successful Joint Commission survey in 2015 for the Family Birth Center with no direct findings
- Successfully crossed trained RNs and implemented Couplet Care
- Recently awarded one star toward Virginia's 'Breast Feeding Friendly' designated hospital - 1st facility within Bon Secours Hampton Roads to apply and achieve this recognition
- Promote a supportive leadership environment that encourages active team involvement to bring about evidence based change
- Lead team with strategies to improve HCAHPS; Nurse Communication average increased to > 90% during leadership
Nurse Manager L&D Family Birth Center
Bon Secours Mary Immaculate Hospital
04.2014 - 12.2014
- 482 Bed Academic Hospital, 1200+ births annually, 75+ Union FTEs, reported to CNO
- Promoted to Director of the Family Birth Center; see above position.
Interim Nurse Manager Obstetrics & Gynecology
Olean General Hospital
10.2013 - 03.2014
- 186 Bed Hospital, 1100+ births annually, 55 FTEs, reported to CNO
Staff RN
Hospitals
01.1999 - 09.2013
- Hospital and clinic nurse positions: Women & Infants Hospital - performs over 8,500 births annually; Cranston & Warwick Community Health Centers - clinic and home visits performing prenatal and postpartum care
Franchise Owner
Dippin' Dots, LLC
01.2005 - 01.2010
- 100+ employees; 2 District Managers, 10 Managers, 5 Assistant Managers
- Received 'Sphere of Merit Award' for 2006 and 2007 for excelling operationally and overall in business
- Elected by fellow franchisees as President for Eastern Region, in addition to being elected Vice President for the franchise system for CY 2006 thru 2009
- Requested by corporate to represent Eastern Region on Marketing Advisory Committee from 2007 2009
Education
MS - Data Analytics
Clarkson University Graduate School
06.2024
MBA - Healthcare Management
Clarkson University Graduate School
08.2023
BSN - Registered Nursing/Registered Nurse
Rhode Island College
01.1999
Skills
- Workload Prioritization
- Project Leadership
- Needs Assessment
- Interpreting Data
- Data Management
- Analytical skills
- Risk management
- Subject matter experts
- Collaborative Leadership
- Multidisciplinary team collaboration
- Accreditation management
- Healthcare regulations compliance
- Programs development
- Process improvements
- Interdepartmental collaboration
- Verbal and written communication
- Staff recruitment and retention
- Budget management
- Effective multitasking
- Quality improvement initiatives
- Employee coaching
- Process improvement
- Professional development
- Clinical operations management
Certification
- Obstetric and Neonatal Quality and Safety (ONQS), The National Certification Corporation
- Neonatal Resuscitation Program, American Academy of Pediatrics
- Basic Life Support for Healthcare Providers (BLS), American Heart Association
- Advanced Fetal Monitoring Course, Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
- Registered Nurse - State of California
- Registered Nurse - State of New York
- Registered Nurse - State of Oregon
Honors & Awards
- Sphere of Merit, Dippin' Dots Corporate: 2006 - 2007
- President for the East Coast Region, Dippin' Dots Franchisee Advisory Council
- Marketing Representative, Dippin' Dots: 2007 - 2009
- Improve Experience Pillar - Southeastern Health
Timeline
Interim Director of Nursing Women & Children's
Samaritan Health Services
07.2024 - Current
Interim Quality and Risk Management Nurse Consultant for Maternal Child Health
HireUp Leadership
10.2023 - 06.2024
Interim Maternal Child Health Manager
HireUp Leadership
02.2023 - 10.2023
Director of Obstetrics and Gynecology
Canton-Potsdam Hospital
10.2018 - 09.2022
Interim Director Maternal Child Health
Leaders For Today
06.2018 - 10.2018
Independent Nurse Consultant
JJC & Associates
01.2018 - 05.2023
Director Maternal Child Health
Southeastern Regional Medical Center
08.2016 - 05.2018
Interim Director Maternal Child Health
The First String Healthcare
03.2016 - 07.2016
Nurse Manager L&D Family Birth Center
Bon Secours Mary Immaculate Hospital
04.2014 - 12.2014
Director Family Birth Center
Bon Secours Maryview Medical Center
01.2014 - 01.2016
Interim Nurse Manager Obstetrics & Gynecology
Olean General Hospital
10.2013 - 03.2014
Franchise Owner
Dippin' Dots, LLC
01.2005 - 01.2010
Staff RN
Hospitals
01.1999 - 09.2013
MS - Data Analytics
Clarkson University Graduate School
MBA - Healthcare Management
Clarkson University Graduate School
BSN - Registered Nursing/Registered Nurse
Rhode Island College
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