Quality Management

Mark A. Powell, MHA, MA, CPHQ

*** ******** ***** 612-***-****

New Prague, MN 56071 *************@*****.***

Summary of Qualifications

Energized, enthusiastic, passionate, and engaged leader with strong

intellect and creativity with over 18 years of progressively responsible in

health care management and IT experience. Demonstrated experience and

desire to effectively work with physician and in depth knowledge of state

and federal regulation programs. Proven ability to deliver substantial

productivity, and quality improvement through well-managed, on-time

projects. Particularly strong in staff development, including training,

coaching, effectively building teams and evaluation. Highly motivated and

results-oriented certified quality professional possessing exceptional

leadership skills and an extensive background in the following broad-based

competencies:

Data Integrity

DISASTER PLANNING

DATA MINING

RISK ASSESSMENT

RECOVERY

STAFF MANAGEMENT

COST BENEFITS ANALYSIS

STAFFING AND BUDGETING

CONTINGENCY PLANNING

RISK MANAGEMENT

PERFORMANCE MANAGEMENT

DATA ABSTRACTION

HR FUNCTIONS/ISSUES CLIENT RELATIONS & NEGOTIATIONS

PROJECT MANAGEMENT

UR/CASE MANAGEMENT

. DEMONSTRATED ABILITY TO STREAMLINE OPERATIONS THAT INCREASE QUALITY

AND REDUCE RISK.

. Strong background in developing priorities and providing solutions to

quality enhancement issues.

. Proven success in implementing quality and process improvement

concepts and principles, leading change in a complex environment.

Professional Experience

St. Luke's Magic Valley Twin Falls, ID

Interim Executive Director of Quality and Patient Safety 02/2013 - 03/2013

The Director of Quality & Patient Safety is responsible for leading

strategies to achieve and maintain clinical and operational excellence,

continual patient safety and infection prevention standards. In

collaboration with SLHS business intelligence leadership, they will also

provide information and analysis to support decisions throughout the

Medical Center. This position is responsible for short and long-term plans

for supporting and sustaining clinical and operational quality, achieving

high-reliability on clinical processes that achieve patient safety,

maintaining infection prevention standards and leading and facilitating

improvement initiatives throughout the Magic Valley. This position will

work collaboratively with staff, physicians, and management and collaborate

with quality staff throughout the St. Luke's Health System to achieve

organizational goals and outcomes.

. Provides direct management oversight for performance improvement,

patient safety, infection prevention, social services/case

management/utilization review, patient relations, language services

and medical staff services.

. Lead the development of performance improvement direction, philosophy,

plan and budget, in conjuction with all stakeholders at the Medical

Center.

. Supervise the development and presentation of performance improvement

reports to management, the Board and appropriate medical staff groups.

. Initiate, support and report on patient safety initatives from the

Health System for the organization.

. Coordinate and participate in the review of ad hoc and routine

performance improvement reports and work with stakeholders to identify

and prioritize opportunities for improvement.

. Ensure proper fiscal management of the department(s).

. Work closely with Committee leaders on agenda development and other

committee functions and activities.

. Participate in regulatory survey preparations in relation to quality

improvement functions; as well as other departmental areas.

. Work with appropriate staff, management and physicians in order to

facilitate evidence-based practice and benchmarking efforts.

. Manage an integrated system for all medical center entities reporting

of performance improvement data, efforts, activities and results.

. Manage and develop competencies in department personnel and

organizational leadership.

. Lead special projects as assigned.

. Develop clinical quality improvement skills and tools for use

throughout the organization.

. Support prioritization of patient safety and clinical quality

improvement efforts.

Mayo Clinic Health System (formerly- Queen of Peace Hospital) - New Prague,

Minnesota

Clinical Quality Coordinator 10/2006 - 12/2012

Strong project management and performance improvement skills. Leads,

coordinate, facilitate, and supervise projects and teams. Self-directed

and result oriented. Communicate effectively verbally and in writing.

Implement change and problem solve using critical thinking skills.

Knowledge of organization, clinical guidelines, health care standards,

regulations, and resources. Data analysis and statistical knowledge.

Future goals are the development and expansion of my skills and knowledge

by getting Certification in Medical Services Management (CPMSM).

. Mayo Quality Fellows Program - Bronze Certified equal to Lean/Six

Sigma Yellow Belt

. Responsible for Joint Commission Accreditation, CMS and all regulatory

issues/surveys.

. Oversees and/or manages clinical outcomes based on performance

measures and/or projects including data abstraction, analysis,

transmission, and communication of results to relevant groups and

individuals.

. Collaborates with provides, leadership, and staff in development of

processes and tools to provide evidence-based, standardized care and

services.

. Oversees and/or manages all processes of both internal and public

reporting of clinical measures the organization participates in.

. Partners with the regional Organizational Performance team to

coordinate and implement comprehensive clinical performance

measurement systems.

. Collaborates with providers, leadership, and staff in the development

of criteria and indicators to monitor clinical performance.

. Designs effective and efficient systems for data collection,

aggregation, analysis, and communication of defined clinical

indicators to appropriate medical staff and/or clinical departments

and committees.

. Designs and coordinates process for display and communication of

physician-specific data related to clinical indicators.

. Collaborates with Medical Staff Office in the development and

implementation of an effective and efficient peer review process.

. Collaborates with Medical Staff Office in the aggregation of data and

information related to ongoing and focused professional practice

evaluation.

. Maintains proficiency and expertise in quality improvement

methodologies.

. Serves as a facilitator for process design and redesign efforts

related to clinical outcomes.

. Assists teams, committees, and/or individuals in the analysis of data

to identify trends and patterns for identification of opportunities

for improvement.

QUEEN OF PEACE HOSPITAL - NEW PRAGUE, MINNESOTA

Director of Quality & Patient Safety 2006 - 7/2011

Director of Patient Satisfaction 2006 - 7/2011

Queen of Peace Hospital charged me with building a Quality Program that

would lead them in positive direction with Quality and Regulatory

Standards. Daily responsibilities included management of regulatory

compliance and day to day quality issues. Also maintain and developed the

peer review database and providing statistics to medical staff, performance

improvement committees and administration. Queen of Peace Hospital named as

one of the Top 100 Critical Access Hospital in the Nation.

. Conflict management and resolution skills

. Primary Lead for setting up Patient Satisfaction Process in five areas

of the organization.

. Aggregated and analysis/interpreted Patient Satisfaction.

. Responsible for education of Leadership on Performance Improvement

Methodologies.

. Responsible for education of Leadership on Patient Satisfaction Data.

. Created process for patient complaints/concerns.

. Root Cause Analysis interpretation.

. Abstraction and review of Core Measure's, Clinic and State data.

. Ongoing working relationships with organization leadership through

participation in hospital/medical executive and department committee

meetings and the ability to work collaboratively with various cross-

level functions of the organization as well as client contacts and

business associates.

. Development and implementation of policies/procedures, bylaws and

rules/regulations to monitor and maintain ongoing compliance with all

relative accreditation and regulatory requirements.

. Development and implementation of a medical quality management/peer

review programs, and demonstrated abilities working with confidential

and sensitive information and files.

. Lead FMEA Teams for Patient Safety Issues.

. Development of online Physician Privileges via organization's

Intranet.

. Development of online of Organization's Administrative and Patient

Care Policies via Intranet.

. Development of online forms via Intranet for PI, active record review,

plan of action, and etc.

. Lead on State Safety Projects.

. Responsible for Quality of care chart reviews.

. Maintain a budget with not much variation.

. Responsible for Joint Commission Accreditation, CMS and all regulatory

issues/surveys.

o Hospital

o Four Physician Clinic's

o Two Express Care Clinic's

. Responsible for Departmental Performance Improvement Data throughout

Organization.

. Adhoc Reporting through Organization's CPSI System.

. Facilitate Performance Improvement Teams.

. An active leader in the Studer Hardwiring Excellence Program.

. Provide education to Leadership Team, Staff and Physician's

. Cambridge's Who's Who VIP member, inclusion in 2008-2009 & 2010 -2011

edition of their registry for my contribution and leadership in

Healthcare Quality.

Jefferson Regional Medical center - Pine Bluff, Arkansas 1997 - 2006

Project/Credentialing Coordinator (Manager), Quality Management/ Medical

Staff Office 2003 - 2006

Won repeated promotion due to exemplary leadership and quality and process

improvement measures working within one of Arkansas largest hospitals, with

471 beds, 6 clinics, and 1,900 employees, to oversee maintenance of medical

licenses, insurance and DEA standards.

. Promoted to oversee multi-issue, including new processes, redesign of

program and staff.

. Developed and implementation of policies/procedures, bylaws and

rules/regulations to monitor and maintain ongoing compliance with all

relative accreditation and regulatory requirements.

. Developed and implementation of a medical quality management/peer

review programs, and demonstrated abilities working with confidential

and sensitive information and files.

. Undergoing preparations for changeover to paperless system, scanning

physician and healthcare files into system, allowing physicians direct

computer access that will save time and money.

. Developed and automated initial and re-application process using

crystal reports, allowing physicians to complete applications online,

reducing paperwork and streamlining process.

. Oversaw development, beta, and launch of new online physician's

privileges via the Intranet and created icon in Eclipsis system for

nursing.

. Installed Premier's Informatics System and Cactus Credentialing

Systems that provide ability to check accuracy at anytime, data

tracking capabilities and reduces FTE's and collection time.

. Updated Physicians staff status used for billing and coding, bringing

accuracy levels from 35% to 100%.

Project Coordinator (Manager), Quality Management

2002 - 2003

Received merited promotion to provide operational leadership of JCAHO and

CMS related priorities. Accepted responsibility for analyzing outcome

data, educating nursing staff on documentation improvements, developing

priorities and objectives, creating Physician Profile Reports and running

queries for peer review process for the purpose of improving scores.

. Investigated and implemented strategies for improving publicly

reported data on TJC and CMS websites, leading administrators,

physicians and staff training sessions targeting low score data and

improvement methods.

. Negotiated sensitive vendor agreements, and managed $300,000 budget.

. Fundraise for the Employee Benevolence Fund (8 Years).

. Major team player in reorganization and creation of new reporting

system for Quality Management Department.

. Held weekly conference calls and meetings to track and troubleshoot

progress, frequently creating multi-layered contingency plans.

. Developed comprehensive training programs for all projects that led to

overall improved teams capabilities.

. Monitored data and formulated solutions for AMI, Heart Failure,

Pneumonia, Hip & Knee Surgeries and CABG that enabled hospital to meet

quality standards.

. Increased departmental performance through addition of two monitors

per terminal, allowing for review of EMR and data simultaneously and

increasing daily record review from 20 to 50.

. Undertook a major project of Performance Improvement Fair for entire

hospital.

. Recognized with two Quality Awards in 2005.

Team Leader (Supervisor), Quality Management 1997 - 2002

Brought on to lead Quality team charged with increasing productivity levels

and to serve as a facilitator for process improvement teams. Daily

responsibilities included management of 12 employees including two licensed

practical nurses, two data entry clerks, one registered nurse reviewer and

seven nursing students, developing and administrating database and

providing statistics to medical staff, performance improvement committees

and administration.

. Successfully transitioned data abstraction process from manual to data

entry system that streamlined report creation process and improved

data collection, winning Platinum Measure Award in 2003.

. Created new Cross-Functional Team department that led to 100%

permanent elimination of overtime work.

. Collected and analyzed quality control data that identified trends

associated with hospital performance, allowing for development of

training activities and initiatives that addressed product quality and

reliability.

. Honored to participate in the development of TJC Survey, contributing

expertise in the areas of performance improvement and medical staff

leadership.

. Developed and implemented departmental training manuals that increased

reliability scores from 90% to 99% - 100% per quarter.

. Setup centralized Quality Control process and developed a system that

reducing errors 75% improving quality of workflows and outcomes.

. Chosen to serve as one of eight Customer Service Trainers due to

successful development of training initiative within Quality

Management.

Lifeworks Services, Inc. - Edina, Minnesota

Personal Care Provider 03/2008 - 02/2013

Assist patient with activities of daily living including bathing, dressing,

eating and transferring in and out of bed. They also measure vital signs,

change bed linens and report changes in the patient's condition to the

patient's provider.

. Administer medications and treatments, such as catheterizations,

suppositories, irrigations, enemas, massages, and douches, as directed

by a physician or nurse.

. Bathe, groom, shave, dress, and/or drape patients to prepare them for

surgery, treatment, or examination.

. Clean rooms and change linens.

. Feed patients who are unable to feed themselves.

. Prepare, serve, and collect food trays.

. Provide patient care by supplying and emptying bed pans, applying

dressings and supervising exercise routines.

. Provide patients with help walking, exercising, and moving in and out

of bed.

. Transport patients to treatment units, using a wheelchair or

stretcher.

. Turn and re-position bedridden patients, alone or with assistance, to

prevent bedsores.

. Collect specimens such as urine, feces, or sputum.

. Deliver messages, documents and specimens.

. Explain medical instructions to patients and family members.

. Maintain inventory by storing, preparing, sterilizing, and issuing

supplies such as dressing packs and treatment trays.

. Observe patients' conditions, measuring and recording food and liquid

intake and output and vital signs, and report changes to professional

staff.

. Perform clerical duties such as processing documents and scheduling

appointments.

Early Career History

CNA Health Partners; Little Rock, Arkansas; Computer Operator (8/1996 -

6/1997)

AeroTech; Tennessee; Computer Technician; (6/1996-11/1996)

Stream International; Dallas, TX; Computer Support Technician (01/1996 -

07/1996)

. Technical support via phone in a call center environment

Associates National Bank; Irving, Texas; Customer Sales/Service Manager in

call center environment (2/1992 - 3/1996)

Technical Skills

o FrontPage

o Microsoft Office Suite

o Microsoft Visio

o MediQual's Atlas Outcomes

o Cactus Credentialing

o Premier's Informatics

o CPSI

o HCPro's Physician Profiler

Education

Webster University Jacksonville, Arkansas

Master's in Computer Resource and Information Management 2005

Webster University Little Rock, Arkansas

Master's in Health Administration (MHA) 2002

DeVry University Irving, Texas

Bachelor of Science in Business Administration 1994

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