Medical Manager
Resume:
Yvonne Shamplain, MBA, JD, BSN, RN
***** ******* ***** ***** ******, Tx. 77388
***********@*****.***
DIRECTOR QUALITY, PATIENT SAFETY/RISK MANAGEMENT & INFECTION CONTROL
Proven history of success leading and facilitating clinical staff members, along with independent practitioners, through the formation of clinical teams, structured and organized to implement and sustain proactive clinical practices, that resulted in improved clinical care and organizational efficiencies.
● Served as a change agent organization-wide handling projects for performance and process improvement, as
related to patient and employee safety.
● Designed clinical systems to facilitate improved patient-care and patient safety outcomes.
● Proven ability to facilitate the organization of teams, organizational committees and work in concert with
clinical/medical staff members and executive committees to implement and manage strategic agendas.
● Possess excellent verbal, and written communication skills.
● Proven research skills, knowledge of regulatory standards of care and practice, audit methodology and data
analysis to sustain regulatory readiness.
CAREER HISTORY
ADVANCE DIAGNOSTIC HOSPITALS/CLINICS, Houston TX
New integrated hospital system with 2 campuses housing a total 16 beds and multiple specialty clinics
Interim Director Quality/Risk Management/Infection Control/Employee Health, 12/2019-04/2020
● Assessed, identified, developed, implemented and evaluated the second hospital campus for follow-up survey
readiness of the required clinical functions needing performance improvement (PI) relative to the hospital-wide
Quality/Risk Management/Infection Control/Safety programs. Education was provided to the hospital’s clinical
and medical staff.
● Reported and communicated PI/Risk Management strategies and results to the hospital’s committees and
Board of Directors.
ASPIRUS LANGLADE CRITICAL ACCESS HOSPITAL, Antigo WI
25 bed county Critical Access Hospital with several specialty out-patient/ambulatory clinics/department that included: cardiology, respiratory, oncology, dialysis, ortho, pain management, surgery, psychiatry, and hospice
Interim Manager, Quality Resource Department, 03/2018-10/2018
⃰ Contract ended
● With 6 FTEs prepared the organization’s for regulatory compliance for TJC triennial survey. The hospital
successfully passed the survey with minimal citations and corrective actions needed;
● Assisted with patient safety events and RCAs;
● Led clinical process improvement teams for the hospital’s infection prevention and control program through the
reorganization of the hospital’s infection control program and committee;
● Served as a regulatory resource regarding process improvement to the OPPE/FPPE/Peer Review
policy/procedure revisions for the medical staff and independent practitioners;
● Developed a written plan for the management/oversight of hospital’s Case/Utilization Management
Department.
CYPRESS CREEK PSYCHIATRIC HOSPITAL, Houston, TX
92 bed acute psychiatric hospital, reported the department director
Assistant Director PI/Risk Management, 04/2017 - 1/2018
*Resigned. Corporate restructure
● Assisted with preparation for organization wide demonstration of hospital compliance to the regulatory bodies’
rules/regulations, hospital policies/procedures by the hospital staff and independent practitioners;
● Assisted with the hospital’s preparation for the hospital’s triennial Joint Commission survey November 2017
that demonstrated successful compliance to pass the survey;
● Assisted the PI/Risk Department Director with clinical investigation of a sentinel event and adverse patient
safety events, while also assisting to manage potential risk related events relating to patient and employee safety
issues;
● Assisted with Medical Staff preparation and education for TJC survey;
● Designed a Medical Staff Credentialing Tool to ensure process compliance for the Independent Practitioners’
initial appointment and/or re-appointment to the medical staff;
● Assisted with the Medical Staff and PI committee agenda organization, minutes and follow-up;
● Designed patient safety education tools and assisted with Department Directors’ and employee education
relative to patient safety;
PANAMA CITY HEALTH & REHABILITATION CENTER, Panama City, FL
125-bed skilled nursing and rehabilitation facility
Quality/Risk Manager/Safety/Infection Control Manager/Compliance Coordinator, 4/ 2014 – 2/ 2016
● Managed facility’s compliance to rules and regulations related to the health care services and practices provided
in this organization, a long-term care facility.
● Oversaw risk identification data systems that identify clinical trends toward medical errors, and implement
corrective actions that are designed to limit exposure to such risk.
● Diligently investigated exposure incidents and the rates of risky healthcare practices by the facility’s staff,
implemented and manage practice improvements; The rate of the residents’ falls has been reduced by 40%.
● Analyzed key clinical functions, systems, and intervention that are designed to provide a safe environment for
facility residents and staff members.
● Reported to regulatory agencies in timely manner facility exposures to allegations of resident abuse, neglect,
exploitation and/or adverse events, along with the corrective action(s) that were implemented.
● Coordinated the training in risk prevention and performance improvement interventions for the facility staff.
VALLEY VIEW MEDICAL CENTER, Fort Mojave, AZ
120-bed acute care hospital with 2 direct reports, while reporting up to both the CEO and CNO
Director Quality/Risk Management, 2011 – 2013
⃰ Left to care for critically ill mother
● Coordinated the successful passage of the Joint Commission Survey.
● Oversaw development, implementation and evaluation of performance improvement (PI) processes, monitored
and evaluated all outcome activities related to the hospital-wide Quality/Risk Management Program for the
hospital’s clinical and medical staff.
● Reported and communicated PI/Risk Management strategies and results to the hospital’s committees and Board
of Directors.
● Reduced over-utilization of antibiotic by working closely with Pharmacy Director and Infection Control
Medical Director by focusing monthly on trends of antibiotics ordered by individual physicians.
● Wrote hospital patient and family’s complaint/grievance policies and procedures, physician performance and
improvement policies and procedures, (OPPE/FPPE), occurrence reporting/risk identification and assessment
policies and procedures.
● Re-wrote hospital EMTALA policies and procedures as an authority that was compliant with federal
regulations, corporate policies/procedures, and the hospital’s Performance Improvement Plan.
● Implemented patient safety strategies that included defined benchmarks, continuous monitoring and evaluation
of process compliance criteria through data presentation at the hospital’s multidisciplinary monthly Performance
Improvement Committee.
● Improved medication errors from 60% success to 85% success.
● Improved patient fall rates from 3% to 1%.
● Implemented corrective actions to document the identification and presentation of community pressure ulcers,
and infections upon admission to improve the nosocomial and iatrogenic rates.
● Facilitated the organization of joint medical and clinical staff committees for the surgery department and
medicine department intended to discuss transparently departmental patient safety issues. The committees’
agendas were designed to have constructive, nonpunitive, proactive, problem-solving communications between
the hospital’s clinical staff and the independent practitioners, while designing safer, measurable corrective
actions required of the medical an clinical staff members within each department.
● Used verbal and written communication skills, to provide information-laden reports, organization-wide and to
other audiences as indicated, that addressed performance improvement issues and corrective action
opportunities taken within the hospital’s clinical environment to reduce medical errors.
SELECT SPECIALTY HOSPITAL, Cincinnati, OH
Director of Quality, Risk, Infection Control, Employee Health, Patient Satisfaction, 2010 – 2011
● Coordinated the development and evaluation of all outcome activities including but not limited to: Risk
Management, Performance Improvement, Survey Readiness, Infection Control, Employee Health/Education
and the Patient Satisfaction Surveys (patient/family).
● Facilitated the reduction of fall rates from 8% to 3%
● Wrote policy/procedures that defined the hospital’s Nursing Peer Review committee, designed
to facilitate a process that was a non-punitive, proactive focused review, while identifying corrective actions as
related to preventing fall incidents, medication errors, skin break down and increased rates of nosocomial
infections.
● Facilitated the reduction of over-utilization of physicians’ antibiotic orders by working closely with the
Pharmacy Director and
the Infection Control Medical Director as data was presented monthly that analyzed the trends of antibiotics
ordered by individual physicians, as related to specific microorganisms.
● Facilitated the reduction of nosocomial pressure ulcer rates from 9% to 4% by working closely with the Medical
Director for Wound Care and the wound care nurse, by coordinating the completion of all training methods to
prevent pressure ulcer and become more competent in understanding pressure ulcer staging, thus reducing the
the patient’s risk of acquiring pressure ulcers by frequent turning, assessment, monitoring and documentation
TYNDALL AIR FORCE BASE (AFB), Panama City, FL
Contracted Wounded Warrior (WW), RN Case Manager, 2008 – 2010
● Coordinated required healthcare services to address the needs of post-deployed military personnel.
● Wrote WW program for the entire air force base.
● After writing and designing the WW program, case managed over 100 post-deployed service personnel and
their families.
● Coordinated psychiatric healthcare services for the PTSD and TBI personnel with the TBI case management
program at the VA hospital in Tampa, FL
● Coordinated and case managed pain management services within the local healthcare community for those post
deployed military service persons.
TOM P. HANEY VOCATIONAL SCHOOL, Panama City, FL
Nursing Instructor, 2006 – 2008
V-CHEL HOME HEALTHCARE QUALITY CONSULTATION SERVICES, Panama City, FL
Provided consulting expertise to support compliance efforts in a home healthcare organization
Quality Consultant for Home Care Agencies, 2002 – 2006
HEALTHSOUTH HOUSTON REHABILITATION INSTITUTE, Houston, TX
90-bed rehab hospital
Director of Quality & Risk Management, 1998 – 2002
● Directed clinical operations conducive to regulatory compliance that focused on minimizing exposure to
legal liability and improving patient and employee safety.
● Organized and presented quality management and performance improvement reports to numerous hospital
committees including the Board of Directors and Medical Executive Committee.
● Oversaw the operation of the medical staff’s credentialing department performance improvement indicators,
peer review along with the Environment of care and plant operation.
● Utilized organizational skills to prepare briefs and case presentation as a basis for the successful appeal of
previously denied Medical claims; recovered over $300K in reimbursements
● Facilitated and coordinated a successful patient fall prevention program resulting in a 75% reduction in fall
rates.
● Managed risk reduction and patient safety improvement activities of the Risk Management Program that
included: occurrence reporting, trending and analysis; root cause analyses; and claims management,
investigation of patient complaints, patient care and safety issues
ROSEWOOD MEDICAL CENTER, Houston, TX
350-bed acute care hospital
Risk Manager, Infection Control Coordinator, 1997 – 1998
* Facility closed.
● Oversaw Investigational Review Board processes and compliance; collaborated with hospital attorneys;
performed interrogations, obtained productions, prepared clinical staff for depositions, and represented
administration in mediations.
● Managed risk reduction and patient safety improvement activities of the Risk Management Program that
included: occurrence reporting, trending and analysis; root cause analyses; and claims management,
investigation of patient complaints, and safety issues.
TWELVE OAKS HOSPITAL, Houston, TX
300-bed acute care hospital
Quality Improvement Coordinator & Risk Manager, 1995 – 1997
Managed risk reduction and patient safety improvement activities of the Risk Management Program that included: occurrence reporting, trending and analysis; root cause analyses; and claims management, investigation of patient complaints, patient care safety issues, performance improvement, infection control reports, psychiatric patients’ issues, and regulatory issues.
RIVERSIDE GENERAL HOSPITAL, Houston, TX
Nurse Manager Out-Patient Chemical Dependency Unit, 1992 – 1995
STAFFORD MEADOWS HOSPITAL, Houston, TX
Charge Nurse & UR Nurse In-Patient Chemical Dependency Unit, 1987 – 1992
EDUCATION & LICENSURE
MBA, Masters of Business Administration, 2010, University of Phoenix, Phoenix, AZ
JD, Juris Doctorate, 1991, Thurgood Marshall School of Law, Houston, TX
BSN, Bachelors of Science in Nursing, 1976, Tuskegee University School of Nursing, Tuskegee, AL
RN, currently actively licensed in Texas
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