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Director of Quality Measures and Regulatory Compliance Resume Example

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DIRECTOR OF QUALITY MEASURES AND REGULATORY COMPLIANCE
Executive Profile

Collaborative, multi-task oriented Nurse Leader with solid experience managing all levels of patient care including budgeting, administration, and regulatory compliance.


Skill Highlights
  • Leadership/communication skills
  • Excellent interpersonal skills
  • Superior leadership, management and motivational skills
  • Project management
  • Relationship and team building
  • Staff training and development
  • In-depth regulatory compliance and quality measure knowledge
  • Executive Management Support
  • Knowledge of HMOs, Medicare, TJC, OSHA and DOH guidelines
  • Patient-focused care
  • Strong work ethic
Core Accomplishments

Leader of accreditation process resulting in TJC designation as a Primary Stroke Center.

Leading the accreditation process that will result in SCPC designation as Non-PCI Chest Pain Center.

Led the facility through a successful Triennial TJC survey with a score of 96.

Revamped the Core Measure process to include individual remediation for staff and physicians, increasing scores to an all time high of 99.79% for combined inpatient and outpatient measures.

Established and lead the hospital wide daily safety huddle.

Implemented the daily shift safety huddle process at the department level increasing near miss reporting by 45% and driving down the SSER to zero.

Implemented "Operation Decrease Falls" in collaboration with the CNO, resulting in a decrease of falls by 40%

Authored "Orchestrating a Change in Pressure Ulcer Prevention." Presented same at the ANA national conference in New Orleans January 2010 showcasing the results of a year-long QI/PI project that demonstrated a global reduction of HAPU of 65%.

Professional Experience
Director of Quality Measures and Regulatory Compliance 05/2012 to Current Moses Taylor Hospital Scranton, PA
  • Responsible for planning, administration, and monitoring of consistent readiness of all quality management, regulatory requirements, and quality improvement processes as well as coordinating all hospital efforts to monitor and maintain compliance with all regulatory, State, Federal government, and Joint Commission standards.
Assistant Director of Nursing 11/2011 to 05/2012 Moses Taylor Hospital Scranton, PA

Working in tandem with the Director of Nursing:

  • Direct supervisory and Clinical Operations Management personnel, as well as clinical nursing staff.
  • Direct, identify and resolve departmental deficiencies with implementation of correction plans.
  • Round to inpatient population and nursing staff, working toward positive outcomes.
  • Coordinate nursing services programs within the department, reviews staff performance and ensures that Department of Nursing adheres to regulatory standards.
  • Monitor nursing cost center budgets and ensures the department is functioning within predetermined guidelines.
Clinical Operations Manager 02/2010 to 11/2011 Moses Taylor Hospital Scranton, PA
  • Coordinate all patient related services in the surgical/oncology and outpatient infusion center departments.
  • Meet and exceed quality and care measure benchmarks on a high volume inpatient unit.
  • Collaborate with physicians and Case Management to properly plan unit activities in order to offer high quality, safe patient care.
  • Supervise and evaluate employees, work with patients and families to provide assistance during each health care encounter.
Clinical Coordinator 02/2003 to 02/2010 Moses Taylor Hospital Scranton, PA
  • Direct all clinical related education to both existing and new hire staff on 36 bed Telemetry unit.
  • Assist Clinical Operations Manager with day to day operation of the department.
  • Interview, hire, oriented and evaluate all clinical nursing staff.
  • Collaborate with staff development to educate licensed personnel to all mandatory, cardiopulmonary related hospital initiatives.
  • Active participant in all departmental QI/PI efforts, sitting on and chairing various QI teams; ACLS instructor.
Staff Nurse 03/1997 to 02/2003 Moses Taylor Hospital Scranton, PA
  • Render and coordinate the care of assigned patients using the nursing process and critical thinking skills to promote good health and prevent illness.
  • Educate and provide emotional support to patients and their families about various medical conditions; Followed hospital and regulatory agency set standards to promote positive outcomes; supervise licensed practical nurses (LPNs) and certified nursing aides (CNAs) to provide high quality, patient centered care.
Licensed Practical Nurse 07/1993 to 03/1997 Marian Community Hospital Carbondale , PA
  • Part of patient care team, supported the RN by passing medications, rendering bedside care, and performing prescribed treatments to an assigned group of patients.
Owner/Operator 11/1987 to 06/1993 Barbini Bridals Scranton, PA
  • Responsible for daily operations of a family owned business. Provided a high standard of customer service while managing a staff of 10 people. Purchased inventory and managed sales in excess of $250,000/year.
Education
Master of Science: Organizational Management: Healthcare Track 2016 Misericordia University Dallas, PA, USA

Expected graduation in December of 2016
Bachelor of Science: Nursing 2002 University of Scranton Scranton, PA, USA
Certificate: Practical Nursing 1993 Career Technology Center Scranton, PA, USA
Associate of Science: Health and Human Services 1988 University of Scranton Scranton, PA, USA
Personal
  • Married to Pam Shotto for 25 years, raising six children.
  • Founder and Board Member of Sweet Charity Players, an organization dedicated to the needs of chronically and terminally ill children.
  • Founder and Board member of Seasons of Love, an organization that feeds and clothes the homeless and working poor of Northeastern Pennsylvania.
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Resume Overview

Companies Worked For:

  • Moses Taylor Hospital
  • Marian Community Hospital
  • Barbini Bridals

School Attended

  • Misericordia University
  • University of Scranton
  • Career Technology Center

Job Titles Held:

  • Director of Quality Measures and Regulatory Compliance
  • Assistant Director of Nursing
  • Clinical Operations Manager
  • Clinical Coordinator
  • Staff Nurse
  • Licensed Practical Nurse
  • Owner/Operator

Degrees

  • Master of Science : Organizational Management: Healthcare Track 2016
    Bachelor of Science : Nursing 2002
    Certificate : Practical Nursing 1993
    Associate of Science : Health and Human Services 1988

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