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Quality/Performance Improvement, Risk Management, Patient Safety

Henderson, Nevada, United States
February 05, 2018

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Kathleen Marie Nelson, R.N., M.P.A.

**** ********* *****

Henderson, Nevada 89044

650-***-**** Cell


*/**-**/** ********, National Risk Management & Patient Safety

(retired early) Kaiser Permanente

Oakland, California

Kaiser Permanente is one of the nation’s largest non-profit HMOs with 11.8 million members residing in 10 different states.

Began in the role of National Leader and was promoted to Director. Set national Risk Management/Patient Safety priorities for strategically focused areas via data analysis (lawsuits, potentially compensable events, sentinel events, unusual occurrence reports, industry trends etc.) Specific areas of expertise include Perinatal Patient Safety, Risk & Safety Education, HealthCare Ombudsman/Mediator, Second Victims/Care for Caregivers, Suicide Prevention and Patient & Family Centered Care programs. Provided national leadership and expert consultation on the design, development and implementation of systems, processes and programs related to practice areas.

Led large scale process redesign/improvement efforts designed to facilitate key organizational objectives. Collaborated with leaders nationally to direct, guide, and support clinical Risk Management & Patient Safety activities. Represented the national offices at all levels of the organization. Fostered a customer oriented work environment with emphasis on dedication to helping customers, respect for individuals, highest standards of quality, innovation, empowerment, and teamwork. Supervised a department of 7 – 10 staff at the national level as well as oversight of 27 – 29 HealthCare Ombudsman/Mediators out in local medical centers. Presented to and trained thousands of physicians and staff in Risk Management & Patient Safety performance, both internally and at external conferences. Recruited and trained Patient & Family Advisors and Advisory Councils.

9/03-5/06 HealthCare Ombudsman/Mediator

Kaiser Permanente

Diablo Service Area/Walnut Creek, California

Served as the internal neutral to help surface healthcare issues and resolve conflicts associated with unanticipated adverse outcomes. Successfully implemented the new HealthCare Ombudsman/Mediator (HCOM) program in the Diablo Service Area. Consistently received excellent provider and patient/family satisfaction. Demonstrated ability to develop collaborative relationships, facilitate fair and open mediations, coach providers and staff in Communicating Unanticipated Adverse Outcomes (CUAO), identify opportunities for improvement and inform upper management of patterns and trends affecting patient care. Served as faculty for “CUAO” training – including “train the trainer” sessions. Assisted in the redesign of the HCOM database. Mentored six of the new Northern California HCOMs, lead reflective practice sessions and acted as a liaison between the HCOMs and National Risk Management & Patient Safety Offices. 5/01-9/03 Director, Quality Outcomes

Kaiser Permanente

Hayward/Fremont, California

Responsible for the operations of the Quality Outcomes, Accreditation, Regulation & Licensing and Risk Management/Patient Safety Departments. Experienced in conducting root cause analysis, failure modes and effects analysis, rapid cycle improvement teams, chairing quality committees, continuous survey readiness, HIPAA and Corporate Compliance Training, Perinatal Patient Safety Project, Operating Room “Pause/Briefings”, Executive Walk-Arounds, Responsible Reporting and conducting and interpreting quantitative and qualitative analyses. Served as liaison between the Quality Service Leaders (QSLs) peer group and the East Bay Service Area when the QSL position was vacant.

12/98-5/01 Chief Operating Officer

Institute for Medical Quality

* A Subsidiary of the California Medical Association 221 Main Street, Suite 210 San Francisco, California 94105 Complete operational responsibility for the following programs: Consolidated Accreditation and Licensure Survey Program (CALS) – a California program in which the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Department of Health Services (DHS), and the Institute for Medical Quality (IMQ) jointly survey acute care hospitals for accreditation and licensure; Ambulatory Accreditation Survey Program – a program providing education, consultation and accreditation of outpatient settings, including those facilities that are seeking compliance with AB-595;

Independent Review Entities Program – a national program which accredits and performs on- going monitoring of independent review entities which evaluate coverage decisions made by health plans regarding experimental, investigational and medical necessity therapies; Continuing Medical Education Accreditation Program – the California Medical Association

(CMA) is designated by the nationally recognized agency for continuing medical education

(CME), the Accreditation Council for the Continuing Medical Education (ACCME), to accredit healthcare organizations to offer their own CME programs. IMQ administers this program for the CMA;

Health Plan Survey Program – IMQ contracted with the Department of Corporations

(DOC)/Department of Managed Health Care (DMHC) in partnership with JCAHO to evaluate health plans for compliance with Knox-Keene regulations; Peer Review Consultation Program – a program providing objective peer review of the clinical practice of one or more physicians with a focus on education and consultation; Medical Staff Consultation Program – a program providing assistance, guidance and evaluation of medical staff issues and functions;

Educational Programs – IMQ offers a wide variety of educational programs each year which address the current and relevant issues faced by healthcare providers and organizations. In addition to managing the above-mentioned programs, responsible for strategic planning, budgeting/financial operations (including the installation of a complete internal financial software system), business development and human resources. 3/97 – 1/99 Director, Quality Management Services

Alexian Brothers Hospital

225 N. Jackson Avenue San Jose, California 95116

Member of the Senior Management Team/Administrative Council. Began in the role of Director of Service Improvement and was promoted to Director of Quality Management after four months. Responsible for Quality/Performance Improvement, Risk Management, Patient Safety, Regulatory Compliance & (Customer) Service Improvement for this 204-bed medical/surgical facility. Concurrently, provided interim management for the Medical Staff Office while director position was vacant.

Received accreditation in April 1998 Cals Survey with no Type 1 recommendations in all areas of responsibility.

6/96 – 3/97 Nelson Consulting Services/4 NURSES/Airports International 2811 Garfield Street San Mateo, California 94403

Consulted in the start-up of three new companies; one providing comprehensive financial services, one providing continuing education to nurses over the Internet, and one providing Internet kiosks & web page development to airports internationally. Developed comprehensive strategic business/marketing plans and secured new business contracts. Completed numerous Request for Proposals (RFP’s). Designed marketing materials, including logos and web sites. 2/95 - 6/96 Chief Executive Officer/Vice President, Board of Trustees Charter Medical Corporation/Magellan Health Services Charter Behavioral Health System of Northern California/San Jose 455 Silicon Valley Boulevard San Jose, California 95138 Began in the role of Chief Operating Officer and was promoted to Chief Executive Officer. Responsible for the entire operations of this 80-bed, free-standing psychiatric facility. Successfully recruited and retained over 130 employees and 125 Medical/Professional Staff members. Managed an aggressive budget through strategic planning, business development, customer service, cost containment, quality clinical services and outcomes monitoring. Negotiated numerous managed care contracts, tripled the number of admissions and referrals to the facility and successfully passed a HCFA unannounced validation survey and random (18 month) unannounced JCAHO Survey (with no Type 1 recommendations). Accountable for Bay Area Network Development. Additionally, functioned as the Director of Clinical Services/Director of Nursing for 10 months.

4/90 - 2/95 Administrator - in - Training (10/92 - 2/95) Director, Marketing & Business Development (1/93 - 2/95) Director, Psychiatric Assessment Services (4/90 - 1/93) Community Psychiatric Centers (CPC)

CPC Belmont Hills Hospital

1301 Ralston Avenue Belmont, California 94002

First two years spent directing all intake/admission, emergency triage, assessment & referral, critical incident stress debriefing and mobile crisis team functions for adults, adolescents and children.

Supervised a clinical team comprised of R.N.’s, MFCC’s, LCSW’s and Ph.D’s throughout the SF Bay Area region.

Completed a two-year training program for Chief Executive Officers while managing all marketing, business development, strategic planning, patient/customer satisfaction and public relations for this 84-bed, free-standing psychiatric facility. 12/83 - 3/90 Charge Nurse

Mills - Peninsula Corporation

1783 Trousdale Boulevard Burlingame, California 94010 Coordinated all nursing aspects of the adult and adolescent Alcohol and Drug Rehabilitation Centers. Developed detox protocols, co-facilitated group therapies, conducted emergency assessments and participated in development of program design and marketing. 1/83 -12/83 Intern/School Nurse

Carlmont High School

1400 Alameda De Las Pulgas San Carlos, California

Responsible for emergency first aide, vision and hearing screening, psychological counseling, drug prevention education, etc.

Classroom Aide

Children's Health Council

700 Sand Hill Road Palo Alto, California

Provided educational support utilizing behavior modification techniques for children five to seven years of age with emotional & personality disorders. 6/79 - 12/82 Certified Nursing Assistant

Mills - Peninsula Corporation

1783 El Camino Real Burlingame, California

Clinical experience included: medical-surgical, telemetry, pediatrics, newborn nursery, and post partum units.

6/77 – 6/79 Certified Nursing Assistant

Hillsdale Manor Convalescent Hospital

Norfolk Street San Mateo, California


Registered Nurse G 371044

Public Health Nurse 37980


2014 Executive Leadership Program, Harvard School of Business 2010 Video Ethnography Training, Kaiser Permanente 2010 Advanced Mediation Practice – Institute for Dispute Resolution, Pepperdine University 2008 Certified Professional in Healthcare Risk Management (CPHRM) 2007 Institute for Healthcare Improvement (IHI) Patient Safety Officer Program 2003 HealthCare Ombudsman Training (40 hours), Kaiser Permanente 2003 Mediation Training (40 hours), San Diego Mediation Center/Kaiser Permanente 2001 Certified Professional in Healthcare Quality (CPHQ) 1997 Certified Facilitator, The Customer Program, Integrity Services, Nashville, Tennessee 1997 Management Action Program (MAP), Newport Beach, California 1995 Masters, Public Administration/Health Services Administration University of San Francisco, San Francisco, California

1989 Graduate, Dale Carnegie Course ~ Effective Speaking and Human Relations, San Mateo, California

1983 Bachelor of Science, San Jose State University - School of Nursing, San Jose, California. Minor, School of Psychology, San Jose State University, San Jose, California 1981 Associate of Science, College of San Mateo, San Mateo, California

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