From Silos to Synergy: Enhancing structural alignment and optimizing practices for fall with injury prevention
June 10th, 2025
Preventing patient falls with injury is a perennial problem inside hospitals. Learn how a quaternary medical system reimagined and refreshed its approach to align and coordinate improvement from the unit to system by leveraging improvement methodologies and optimizing a fall risk assessment tool.
Tracy Ou, MS, BSN, RN, CPHQ
Tracy Ou is passionate about improving systems to prevent patient and staff harm with particular interest in human factors engineering and leveraging meaningful data to drive change. She currently serves as Senior Program Manager for Nursing Quality. Tracy leads the Fall with Injury Task Force and is a subject matter expert in fall and fall with injury prevention at SHC. Tracy has 7 years of experience in guiding and coaching nursing leaders through quality improvement initiatives from the unit to hospital level at Stanford Health Care.
Tracy joined SHC in 2013 as a clinical nurse. Her clinical experience is in adult medicine and oncology. She holds a Bachelor’s in Integrative Biology from UC Berkeley, Bachelor’s in Nursing from University of Rochester, and Master’s in Healthcare Administration & Interprofessional Leadership from UC San Francisco.
She has been a coach for SHC’s Realizing Improvement Through Team Empowerment (RITE) program, CELT, completed SHC’s Advanced Course in Improvement Science (ACIS), and is a candidate for Lean Six Sigma Black Belt.
Johnathan Clevinger, DNP, RN, NE-BC
Johnathan Clevinger is an experienced healthcare leader with extensive expertise in clinical operations, quality improvement, and human-centered leadership. In his current role as Director of Operations for Inpatient Services in the SHC adult hospital overseeing Inpatient Medicine and Clinical Trials, he is committed to addressing healthcare disparities and promoting interdisciplinary collaboration, with a distinctive focus on translating research into practice.
Dr. Clevinger earned his Doctor of Nursing Practice from the University of Nevada, Reno, and holds a Master of Science in Nursing from Chamberlain College of Nursing. Throughout his career at Stanford Health Care, he has held various leadership positions, playing a pivotal role in integrating patient care services with clinical and human subjects research programs at SHC.
In addition to his clinical and operational responsibilities, Johnathan is actively engaged in professional service and leadership development. He contributes to numerous committees and task forces dedicated to enhancing quality, safety, and engagement in healthcare both. His professional contributions have been recognized through several awards, and he has shared his insights at various conferences and workshops.
