YVETTE GUERRA
El Paso,Tx
Summary
Highly accomplished and results-driven professional with extensive experience in surgical services, quality improvement, infection control, and risk management. Proven track record as a top performer, consistently demonstrating strong communication skills and in-depth expertise in nursing processes. Well-versed in managing and optimizing quality metrics, with a comprehensive understanding of CMS guidelines and Joint Commission standards. Dedicated to enhancing patient safety, improving healthcare outcomes, and ensuring compliance with industry regulations through strategic planning and meticulous attention to detail.
Patient safety professional with proven track record in ensuring compliance with healthcare regulations and implementing effective safety protocols. Known for strong collaboration skills and adaptability, consistently delivering results through teamwork and strategic problem-solving. Expertise in risk assessment, incident investigation, and staff training, combined with proactive approach to improving patient outcomes and fostering culture of safety.
Overview
29
29
years of professional experience
1
1
Certification
Work History
Patient Safety Officer
The Hospitals of Providence-Sierra Campus
El Paso, TX
07.2022 - Current
- Leads the Patient Safety Program for the hospital
- Manages the incident reporting system and works with hospital leaders to investigate events timely
- Reports Serious Safety Events to home office and/or other regulatory agencies
- Collaborates with hospital leaders to review and investigate patient grievances and ensures written patient response are completed as per CMS requirement
- Performs Root Cause Analysis using Joint Commission Framework
- Leads quality improvement initiatives to promote safe environment
- Analyze historical data to develop annual Failure Mode and Effects Analysis Projects. Most recent project was Fall TIPS program which has decreased inpatient fall rate by 7% from prior year
- Works with the Patient Safety Officers in the market to streamline patient safety practices
- Active co-chair of Fall Committee- meets with staff to conduct post-falls debriefs, participates in product evaluation, and participates in education sessions for staff
- Performs rounding to promote "just culture"
- Continually communicate with the administrative team to ensure our organizational goals are aligned
- Serve as resource for Shared Governance Council Committees
Quality Nurse Manager
Legent Hospital of El Paso
El Paso, TX
07.2021 - 07.2022
- Lead successful HFAP survey in August 2021
- Worked with hospital leaders to restructure quality metrics and reporting structure to improve QAPI program
- Acquainted with CMS, Quality Net, CART submission requirements
- Knowledgeable on CMS Conditions of Participation
- Familiar with HFAP and Joint Commission Standards
- Participates in multidisciplinary Environment of Care hospital rounds
- Manages Occurrence reports, Grievance process, and patient safety concerns
- Conducts RCA and deep dives to review and address high risk patient quality/safety concerns
- Serves as resource for staff and leadership with regulatory requirements and quality program
Unit Director
The Hospitals of Providence-East Campus
El Paso, Texas
03.2010 - 07.2021
- 2010-2014: Recovery Clinical Coordinator- Duties included managing the daily operations of the PACU department. Worked to improved staffing shortages and productivity in PACU. Collaborated with ICU and Cath Lab department to enhance staff skills to care for critical care patients and pediatric patients in the PACU setting.
- 2015-2017: Unit Director-Directed and managed operations for the preop, PAT, Endoscopy, and Recovery department with approximately 40 FTEs. Focused on patient care throughput to maximize efficiency and allocation of resources. Focused on high-quality care and regulatory compliance. Additionally, managed contracts and product evaluations for the Endoscopy Department.
- 2017-2018: Process Improvement Coordinator- Duties include handling physician peer review, serve as liaison with regulatory agencies, lead and manage performance improvement activities throughout the organization, as well as participate in interdisciplinary task teams focused on reducing readmissions, improving patient satisfaction, and meeting regulatory requirements. Assisted and supported Chest Pain Coordinator through successful Chest Pain Accreditation with Joint Commission.
- 2018-2022: Director of Infection Control and Prevention- In this role, I conduct surveillance, educate staff on infection prevention interventions, and report to National Healthcare Safety Network (NHSN). Partner with engineering department, quality, safety officer, and EVS team to ensure infection prevention practices are maintained. Work in partnership with the administrative team to lead the facility through SARS-COVID-19 pandemic safeguarding the welfare of staff and patients.
- Peer Review Committee Chair from 2011 to 2020. Focused on improving patient outcomes through the identification of process breakdowns or deficiencies in accordance with the Nursing Practice Act.
Director of Surgical Services
Physicians Hospital
El Paso, Texas
01.2004 - 01.2010
- 2004-2007: OR Circulator- Circulated multiple specialties. Prepared rooms ensuring sterility was maintained, verify patient safety, monitor sterile conditions, manage supplies, and document the procedure, ensuring a safe, efficient environment.
- 2007-2010- Director of Perioperative Services- Was in charge of all operational, clinical, and administrative aspects of a surgical department, including the OR, pre-op, post-op, and sterile processing. Supervised and managed 50 FTEs, ensure patient safety, manage budgets, and enforce compliance with regulatory standards. Collaborated with Quality department to roll out Surgical Improvement Program.
Operating Room Circulator/Relief Charge Nurse
Del Sol Medical Center
El Paso, Texas
01.2001 - 01.2004
Special Education Nurse
Socorro Independent School District
El Paso, Texas
01.2000 - 01.2002
Oncology Nurse
Columbia Medical Center-West
El Paso, Texas
01.1997 - 01.2001
Education
Masters of Science - Nursing
Western Governors University
Salt Lake City, UT01-2017
Bachelors of Science - Nursing
University of Phoenix
Phoenix, AZ01-2014
Associate of Science - Nursing
El Paso Community College
El Paso, TX01-1997
Skills
- Microsoft Office
- Excel Spreadsheets
- PowerPoint
- Healthcare regulations
- Incident investigation
- Patient safety advocacy
Affiliations
- Agency for Healthcare Research and Quality 2022- Current
- National Association of Latino Healthcare Executives 2024- Current
- American Nurses Association 2024- Current
Certification
- Registered Nurse License, State of Texas May 1997- September 2026
- Nurse Executive-Board Certified (NE-BC) 09/2024-9/2029
- Basic Cardiac Life Support 07/2023-07/2025
Languages
Spanish
Native or Bilingual
Timeline
Patient Safety Officer
The Hospitals of Providence-Sierra Campus
07.2022 - Current
Quality Nurse Manager
Legent Hospital of El Paso
07.2021 - 07.2022
Unit Director
The Hospitals of Providence-East Campus
03.2010 - 07.2021
Director of Surgical Services
Physicians Hospital
01.2004 - 01.2010
Operating Room Circulator/Relief Charge Nurse
Del Sol Medical Center
01.2001 - 01.2004
Special Education Nurse
Socorro Independent School District
01.2000 - 01.2002
Oncology Nurse
Columbia Medical Center-West
01.1997 - 01.2001
Masters of Science - Nursing
Western Governors University
Bachelors of Science - Nursing
University of Phoenix
Associate of Science - Nursing
El Paso Community College