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QUALIFICATIONS SUMMARY

Experienced professional with diverse background that supports JCAHO accreditation and regulatory compliance through consulting, education, and publications. Her strengths are in health care administration, including performance improvement of organizations and networks, outcome measurement, accreditation, corporate compliance, utilization, risk management, medical staff credentialing, education, and clinical information systems. Skilled in needs assessment, data analysis, and program development and training at any level. Excellent leadership, organization, communication and interpersonal skills. Past experience includes, broad based work environments, including acute care, managed care plans, home health care and ambulatory facilities, in community, university and rural settings. Excellent working relationships with administration and other employee groups; effective liaison with medical staff and governing boards. Nationally certified professional in Healthcare Quality (CPHQ) and distinguished as a Fellow in the National Association of Healthcare Quality. She is a licensed healthcare risk manager in Florida.

EDUCATION

Certificate "JCAHO-Consultant’s Conference" JCAHO, Chicago, IL September, 1999
Certificate in Teaching Statistics and Facilitating Quality Improvement,1992,The Juran Institute,Wilton, CT
Masters of Science in Nursing, 1983, with ARNP designation, University of Florida, Gainesville, FL
Bachelor of Science in Nursing, 1981, University of South FL, Tampa, FL
Associate of Science, 1976, St. Petersburg Junior College, St. Petersburg, FL

PROFESSIONAL EXPERIENCE

PRINCIPLE
Swain & Associates, providing services to healthcare. Charlotte, NC 1985 to present.

• Successfully designed and implemented facility-wide and medical staff performance improvement and regulatory compliance programs for hospitals, clinics and home care agencies.
• Developed leadership and management skills in connecting strategic objectives to daily operations for leaders and managers of hospitals, physicians offices and managed care companies.
• Coordinated review, development and revisions of organization policies and procedures to be compliant with accreditation and regulatory requirements. Compressed policies into a simplified manual that was automated with software to support change easily in community hospitals.
• Provide direction for facility-wide and service-line process evaluation, i.e., development of a committee-less organization and use of a functional approach to patient care and services.
• Provides results-oriented education to nursing staff, hospital management and administration of surveillance activities such as quality, risk, and case management in all types of facilities.
• Successfully provided staff resources to management of information efficiently, such as knowledge of data management, graphics and internet skills at community and veterans hospitals.
• Provide specialized total quality management techniques such as systems assessment and implementation strategies, training teams through the use of accelerated replication and rapid cycle project management in university settings and health systems and managed care companies.
• Training expertise in both traditional (workshops and seminars) and innovative (experiential, quality team, retreat and authored computer-based training CDs, and self-directed learning texts) techniques to achieve the desired education goals and organizational change.

DIRECTOR OF CLINICAL AND REGULATORY REVIEW
Presbyterian Healthcare, Charlotte, NC. Part of the Novant healthcare system, Presbyterian Healthcare is located in the Southern Piedmont Region of North Carolina. It is comprised of a comprehensive 593 bed hospital, a specialty orthopaedic hospital and community hospital, home care, long term care and ambulatory service settings. May, 2001 to present.

• Successfully completed JCAHO survey in 2002 having conducted preparation at all levels of the organization.
• Developed and manage JCAHO functional teams who maintain continuous survey readiness activities and will conduct required JCAHO self-assessment activities based on performance elements.
• Support the system in all external regulatory surveys and plans of correction for agencies such as Federal, State, Medicare, local, EMTALA, Nuclear Regulatory Agency, and others.
• Provide leadership for regional patient care and administrative policy and procedure management.
• Conduct education and training on all types of regulatory and accreditation issues such as JCAHO, CMS Validation and for cause surveys.

JOINT COMMISSION COMPLIANCE MANAGER
Tampa General Healthcare, Tampa, FL A regional facility that supported inpatient care including transplant, burn, neonatal intensive care as well as traditional services, long term care, ambulatory clinics, a rehabilitation hospital and children’s hospital. January to December, 2000.

• Conducted JCAHO mock survey of the facility and developed compliance strategies.
• Coordinate and integrated project teams such as, Point of Care Testing, Restraint Revisions, Sedation & Anesthesia, Open Medical Record Review methods, Patient Rights issues of Grievance, Limited English Proficiency, and HCFA issues.
• Prepared staff and supported through a HCFA Validation Survey post JCAHO with successful outcome.
• Provided education and training to all levels of management and staff on JCAHO standards changes, data management, using the internet in daily practice, and patient safety strategies with error reduction as a focus.
• Prepared senior management in how to analyze and demonstrate ORYX data to the JCAHO.
• Assisted departments and teams with data collection design and analysis.

QUALITY MANAGEMENT DIRECTOR
Morton Plant Hospital, St. Petersburg, FL A 745-bed facility that consisted of the hospital and medical staff, a nursing home, rehabilitative center and home health agency. 1985-1988

* Developed an innovative Quality Improvement and performance measurement program.

* Coordinated the integration of department and committee activities, including medical staff departmental functions to meet JCAHO accreditation requirements.

QUALITY ASSURANCE COORDINATOR
All Children's Hospital, St. Petersburg, FL A 113-bed pediatric hospital. 1980-1985

* Responsible for overall management of the Quality Assurance Department and JCAHO compliance.

* Developed, coordinated and conducted department functions including budgeting development and implementation of the QA, UR plan, and Occurrence and Risk Screening Program.

* Developed interface with PRO for QA and UR functions. Facilitated all medical staff activity from credentialing to appeals.

* Successfully created physician enhancement activities for administration by the establishment of a dedicated monthly"Grand Rounds" for physicians to experience improvements made within the facility, as well as editing and publishing the medical staff newsletter dedicated to performance improvement topics.

CHARGE NURSE, Intensive Care Unit
Edward White Hospital, St. Petersburg, FL A 167-bed acute care hospital. 1978-1980 STAFF NURSE, Coronary Care Unit

St. Anthony's Hospital, St. Petersburg, FL A 415-bed acute care hospital. 1976-1978

• National Association of Healthcare Quality, member and appointment to Fellow Status

Certified Professional in Healthcare Quality (FNAHQ)

• Opus Communication, Briefings on JCAHO, editorial review board member

American Health Consultants, Hospital Peer Review, editorial review board member

• Florida Association of Healthcare Quality, lifetime member, "Outstanding Quality Professional" distinguished member award and Past President
• Licensed Healthcare Risk Manager, State of Florida
• American Society for Quality, Charter member of the Healthcare Division
• Sigma Theta Tau, Nurse Honor Society, member
• "A Hospital in Transition to QI", SunHealth/Premier Alliance Project Award
• Peer Review Organization's Contract Development Task Group, Florida Association of Home Health Care Agencies
• Pinellas County School System, Malcolm Baldridge Evaluator.

PUBLICATIONS

Authored a chapter "Guide to Continuous Survey Readiness" in The Insider’s Guide to JCAHO Survey Success: Field Tested Tips and Tools. Opus Publications, Marblehead, MA, 2001.

* Co-Authored COP Compliance – The Manual. QSG Printing, Phoenix, AZ, 2001.

* "Things That Go Bump in the Night: JCAHO’s 1999 PI Standards", Hospital Peer Review, Feb. 1999.

* Authored CDs: "All About Audit" "Manager’s Ethics", "Preparing for JCAHO Survey" and "Violence Under Control" Compact Disk for Computer-Based Training Program, Produced by Synquest Training Company , Raleigh, NC, February, 1999.

* "Developing a Corporate Compliance Plan", A Series on Fraud and Abuse, Hospital Peer Review. Oct., Nov., Dec., 1997, Jan. 1998.

* "Hospital Peer Review's Advisory Board Looks in Their Crystal Ball", Hospital Peer Review. 20th Anniversary Supplement, Feb. 1996.

* Swain, P., A Primer on Simplified Statistics, Vol 1, PSS, Inc. Publishers, St. Petersburg, FL, Revised 1998.

* Swain, P., A Team Approach: Quality of Care in Special Care Units, PSS, Inc. Publishers, St. Petersburg, FL 1993.

* "Accreditation Leading to Evolution of Alternate CQI Model", QI-TQM American Healthcare Consultants Publishers, Sept. 1992.

PRESENTATIONS

* Presented in State Conferences in Massachusetts, Indiana, Illinois, Iowa, Arizona, Florida, Michigan, North Carolina during 1999, 2001 on a variety of topics, including improvement, internet, corporate compliance, HCFA/OIG regulation, leadership and JCAHO accreditation.

"Picking Through Cyberspace – Effectively" National Assoc.Healthcare Quality, Dallas, 2000.

"Using the Internet to Facilitate Risk Management" American Association of Healthcare Risk Management, teleconference, October, 2000.

"Turning Data into Information" six teleconferences per course, long distance learning, broadcast nationally by the University of Texas, San Antonio 1999 and 2000.

* AMEDD Quality Management Conference (Department of Defense Conference). "Advanced Tools and Facilitation Skills", Fort Worth, TX, March 1996 & in August, 2000 Patient Safety Management, Data Management and Continuous Survey Readiness held in San Antonio with the 36 Army Hospitals and Clinics in attendance.

*"Leadership Essentials in the New Millennium", National Assoc. Healthcare Quality, San Diego, 1998.

* "Coming to Grips with Fraud and Abuse in Your Healthcare Organization", Florida Association Healthcare Quality Annual Conference, 1998.

* "Evaluating Clinical Path Variances", 3rd Annual Hospital Case Management Conference, American Health Consultants, 1998.

* "Case Management With Punch: Using Variance Analysis", Quorum Learning Institute, Nashville, TN. December 1997.

* National Association of Healthcare Quality, "Accreditation Decisions" Panel Moderator, Annual Conference, Orlando, FL 1997.

* MMI, Healthcare Insurance, Managing General Liability and Safety Risk Exposures, at Focus Topic Workshops, Chicago, 1989 through 1999.

* American Institute of Risk Management, Instruct two full day sessions: Two Quality Modules-Theory and Practice, Tampa, Tallahassee, 1987 through1998.

* Florida Association of Healthcare Quality, "Conditioning for the Quality Professional: Preparing for the Long Haul", Spring Conference, Orlando, 1997.

* Compliance Issues with the Functional Standards, Phoenix, May 1997.

* Indian River Memorial Hospital, Vero Beach, FL; VA Medical Center, Gainesville, FL and Munson Medical Center, Traverse City, MI, staff training in "Making Data Tell a Story: Data Management, Computerized Graphic Display and Surfing the Internet", Swain & Associates throughout 1997

* Heart of Florida Hospital, "Managing Patients Along a Path: Development Through Evaluation", February 1997.

* "Advanced QM Skills - Expand Your Expertise", Get Out of the Box, Paula Swain Seminars, Inc. presentations in Dallas, TX January 1997.