Quality Manager

Nancy Sharif, RN. BSN. MBA. CPHQ.

**** ********** ******, #***, *******, CA 95350

Cell- 209-***-****; *************@*****.***

Education and Professional Certifications:

• Master, Business Administration MBA- National University, San Diego, California

• BS, Nursing- BSN, College of St. Teresa, Winona, Minnesota,

• C.P.H.Q. Certification number HQO212411

• California R.N. License Number 286873; Florida R.N. License Number RN9354956

• CPR Instructor

• Six Sigma Black Belt Certification (In Process)

Overall Qualifications:

• 25 years as a RN working in acute care inpatient, including pediatrics, psychiatry, ICU, ED and outpatient settings

• 7 years as a quality/risk manager working with patient safety, and infection control

• 7 years’ experience with The Joint Commission specializing in international accreditation ( JCIA)

• 7 years working in the Middle East interfacing with a multi-cultural milieu

• 7 years as a hospital case manager incorporating Medicare, Medi-cal and insurance reviews

• 3 years of broad based experience in Managed Care dealing with HEDIS, HIPPA, HCAHPS,

• 3 years’ experience dealing with the Balanced Scorecard, patient and data tracers

• 4 years’ expertise creating and implementing hospital polices, clinical practice guidelines, and procedures

That support accreditation compliance

• Knowledge of Federal, CMS, TJC and DNV regulations

• Outstanding problem solving skills with the ability to analyze issues quickly, and develop relevant courses of action

• Strong statistical and analytical skills with expertise in continuous quality improvement concepts, implementation and

outcomes’ evaluation

• Ability to interact effectively and efficiently with physicians, nurses, and senior hospital management

• Excellent interpersonal skills, tactful and diplomatic

• Exceptional oral, written, public speaking and presentation skills

• Proficient in computer programs: Microsoft Office- Word, Excel, PowerPoint, Access database and Visio

• Languages; English- mother language, conversational in Arabic, Spanish and German

Employment History:

Central Valley Specialty Hospital, Modesto, CA March 2013 to present

Director of Quality, Risk Management & Patient Safety Department

• Interface closely with CEO in licensure process for California Center for Medicare and Medicare (CMS) which involves

establishing policies and processes for all standards relating to patient safety and quality.

• Created Policy and Procedure Manual for Quality, Risk Management and Infection Control Department

• Generated and taught the hospital staff departmental quality indicators that were in compliance with the CMS guidelines

• Directed along with CEO the processes, procedures, standards and policies needed for DNV accreditation

• Tracked and trended the hospital quality indicators for variances and performed action plans.

• Conducted classes to hospital-wide staff on topics such as: Patient Safety Goals, audits patient tracers, quality indicators, Power

Point presentations, benchmarks and the FOCUS-PDCA quality tool.

• Organized and chaired the hospital-wide six committees, such as the Quality Committee, P&T etc.

• Investigated any sentinel events through the Root Cause Analysis format (RCA)

• Supervised and counseled the RCA team on the outcomes and analysis on the sentinel events.

• Monitored and evaluated patient complaints, Incident Reports, Quality Indicators, Sentinel Events and presented outcomes to

the hospital committees on a monthly basis

• Coordinated monitored, tracked, trended the infection control quality indicators on a monthly basis.

• Developed and implemented hospital-wide direction and facilitation of Quality Management program in accordance with the

State requirements.

• Provided leadership for the hospital’s disaster preparedness, fire safety and patient safety plans

Nancy Sharif, RN. BSN. MBA. CPHQ. Page 2

Employment History Continued:

King Fahad Medical City Hospital, Riyadh, Saudi Arabia May 2010 to October 2012

Senior Quality Specialist

• Supervised, and consulted seven hospitals and clinics on their Quality Improvement projects

• Initiated six Patient Goals taskforces which encompassed creating audit tools, checklists, monitoring trends

revising policies and clinical guidelines as they related to these Patient Safety Goals

• Conducted classes to hospital-wide staff on quality topics such as: International Patient Safety Goals, audit tools, Key

Performance Indicators, FOCUS-PDCA, and other quality tools

• Initiated a hospital-wide taskforce to include all invasive surgical procedures on the “Time –Out” process and

supporting documentation accompanying it which included, checklists, audit tools, policies, and staff classes

• Was a contributory member of eight committees including: Mortality and Morbidity, Length of Stay, JCIA

Preparation Steering, and the Quality Improvement Committee

• Participated in data and patient tracers as they related to the accreditation preparation process

• Piloted the Root Cause Analysis projects for various departments throughout the hospitals

Quality Consultants Inc. Dubai, United Arab Emirates October 2007 to April 2010

Freelance Quality Consultant

• Consulted and trained companies on topics such as: International Patient Safety Goals, audit tools, Key Performance Indicators,

FOCUS-PDCA, policies, and clinical practice guidelines in preparation for Joint Commission International Accreditation

( JCIA)

• Educated companies on the core standards needed for JCIA accreditation

• Performed Gap Analysis for clients as it related to the JCIA preparation

• Conducted patient and data tracers for customers to assist them with compliance to the JCIA standards.

SAAD Specialist Hospital, AL-Khobar, Saudi Arabia May 2005 to September 2007

Performance Improvement Coordinator

• Assisted eight hospital departments on the statistical analysis and trending of their clinical outcome indicators

• Taught ongoing weekly classes on FOCUS- PDCA to the hospital staff

• Initiated fourteen Performance Improvement projects with the various departments on topics such as: Leave Against Medical

Advice, Patient Satisfaction Surveys, Leapfrog Criteria, and Turn Around Time for STAT laboratory values

• Prepared monthly reports for the Quality Council on issues such as: quality trends, hospital committees, patient satisfaction

surveys, and data/patient tracers

• Closely involved with committees for 3 hospital accreditation agencies such as: America, Canada, and Australia

• Worked closely with the Infection Control and Risk Management Departments in collaboration of their key indicators, quality

projects and root cause analysis

Tower Health Care, Long Beach, CA. ( Company filed Bankruptcy and closed 2001) January 2000 to December 2001

Manager of Grievances and Appeals/Quality Management Department

• Managed on a monthly basis, fifty health plan companies, members and providers’ grievance complaints and appeals

• Disputed members’ claims, assisted with grievance resolutions, and communicated with members as to resolution process

• Supervised up to five staff in the department which included - new employee orientations, employee evaluations and the

mentoring and professional development of the department staff

• Established new policies and implemented existing policies which complied with Department of Health Services, HEDIS and

HIPAA regulations

• Oversaw the Quality Management, and Public Policy departmental meetings on a monthly basis

Managed Care Resources, Los Angeles, CA March 1995 to Dec 1999/January 2002 to April 2005

Case Manager/Quality Manager/Utilization Review

• Performed telephonic on site utilization review for health plans’ criteria, for up to 20 adult, pediatric and psychiatric inpatients

in the hospital setting on a daily basis

• Coordinated discharge follow-up plans such as: home care, durable medical equipment and physician appointments

• Interfaced with patient’s families, physicians, nurses, social workers and other hospital staff to ensure a seamless transition from

the hospital setting to the home environment for the patients and their families

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