Project and Risk Management, Patient Safety, Accreditation Compliance
Resume:
Summary of Qualifications
Experienced healthcare compliance and quality management professional with over 20 years of expertise in regulatory compliance, risk management, patient safety, and strategic planning. Demonstrated success in leading cross-functional teams, developing educational programs, and improving organizational processes within various healthcare settings. Skilled in accreditation preparation, regulatory interpretation, and performance improvement with a proven ability to drive high-quality standards and continuous readiness.
Areas of expertise include:
Healthcare Compliance and Accreditation
Risk Management and Safety
Quality Management and Performance
Strategic Planning and Leadership
Regulatory Documentation and Training
Project Management and Consulting
Professional Experience
Compliance Program Manager Defense Health Agency (DHA), Remote November 2021- January 2024
Developed the first educational curriculum for the Army Nurse Rotator Program.
Provided detailed instructions and processes for projects related to patient safety, regulatory compliance, and accreditation.
Updated all TJC Standards for implementation within Military Treatment Facilities (MTFs), ensuring compliance, sustainment, and accreditation for TRICARE beneficiaries.
Prepared MTFs for the accreditation process, which takes approximately 18-24 months.
Developed strategic plans for improved compliance with high-quality standards and continuous readiness for beneficiaries.
Managed regulatory compliance standards for 131 Networks and Markets, including MTFs OCONUS and CONUS, preparing, reviewing, and revising patient safety reports for TJC.
Interpreted regulation, accreditation standards, and compliance regulations for MTFs.
Conducted training sessions, such as webinars and classes, on regulatory documentation to support DHA policies and procedures.
Provided leadership and mentoring to Quality Points of Contact and TJC Coordinators for correct submission and compliance with all new, revised, and updated standards.
Identified gaps in safety standards, provided analysis for mitigation, and implemented safety changes within MTFs.
Reviewed patient safety incidents and provided corrective actions and recommendations.
Served as a subject matter expert (SME) for TRICARE beneficiaries, improving patient safety and quality plans.
Reviewed all TJC corrective action plans from MTFs for Triennial Survey Accreditation.
Vice President of Quality and Risk Management HealthLinx, LLC Healthcare Transitional Leader, Anchorage AK October 2018- December 2019
Ensured the alignment of systems and processes to improve organization planning, accreditation, and monitoring of safety processes.
Coordinated core business group development and provided the implementation of approved initiatives.
Developed strategies to improve the efficiency of the care delivery processes.
Provided leadership, coaching, and mentoring to staff of 27 professionals,
Improved communication within Quality Department and Risk Management.
Director of Quality and Patient Safety B.E Smith, AMN Healthcare Company, Atlanta, GA May 2018- December 2018
Achieved The Joint Commission (TJC) Triennial Accreditation Gold Seal 2018-2021, at both WellStar AMC Hospital Campuses, Downtown and South
Lead and directed 25 direct reports at both campuses.
Developed, implemented goals and objectives for all hospital staff.
Served as the hospitals’ expert consultant for all regulatory and accreditation standards.
Completed and submitted National Quality Forum (NQF) data metrics for Leapfrog Survey 2018 and Hospital Grade Reports for improved Hospital Score Card
Improved Quality Score with CMS.
RN Unified Case Management, Clinical Nurse Reviewer IBM Global Business Services-Centers for Medicare & Medicaid (CMS) January 2018- April 2018
Served as Clinical Subject Matter Expert (SME) for CMS’s Unified Case. Management (UCM) 2018 Medical Record Review (MRR) Project.
Consultant to Technical Personnel for migration of project for medical review.
Developed detailed MRR Data Elements Dictionary for IBM CMS UCM Project.
Developed On Boarding and Orientation Program for new IBM CMS technical personnel.
Reviewed and Approved IBM design workflow details for screen markups for MRR all clinical personnel.
Vice President of Quality and Risk Management B.E Smith, AMN Healthcare Company, Lenexa KS January 2017- January 2018
Served as Interim Quality & Safety Leader at Jewish Hospital.
Developed new templates and tools for Risk Management Program for Risk Mitigation.
Provided resources, information, guidance, and assistance to the Quality Director for the Quality Department.
Provided the Quality Department with leadership for identified quality and safety projects on gap analysis.
Formulated, executed, and monitored Performance Improvement Projects establishing benchmarking data and analysis.
Prepared and trained the Quality Staff on TJC Hospital Accreditation Survey Process Changes and Readiness (HAP) 2017, standards, requirements, new measures, etc.
Provided leadership and direction for the Risk Management Program.
Served as Project Director for CMD Core Measures and Special Projects including Infection Prevention Standards.
Performance Improvement Coordinator HealthLinx, LLC Healthcare Transitional Leader, Remote April 2016- June 2017
Conducted Peer Review for Anesthesia, OB, Medical, and Surgical Committees.
Performed detailed Peer Review Chart Review for Performance Improvement.
Provided summarization of retrospectively reviewed cases.
Utilized EPIC Electronic Health Medical Record System (EHR) and MIDAS System for chart data reporting.
Executive Project Director TJC for Regulatory Compliance, Infection Preventionist Consultant HealthLinx, LLC Healthcare Transitional Leader, Nashville General Hospital November 2015- March 2016
Submitted all Corrective Action Plans (CAP’s), Policies and Procedures, approved by TJC.
Submitted all Safety Events, Measures of Success Reports and Evaluation Methods, approved by TJC.
Successfully conducted Centers for Medicare and Medicaid Services (CMS) Audit Survey.
Composed Plans of Corrections and other state, and federal documents.
Prepared and monitored 16 Audit Tools for Clinical and Environment of Care (EOC’s)
Improved compliance rate from 37%-99% on 4 clinical monitoring audits.
Oriented and educated executive leadership on TJC and CMS standards for hospitals’ accreditation compliance and provided status up to date reports.
Additional Leadership Career Positions:
Chief Quality Officer (CQO), Senior Director Quality Management - Amer-Health and Chartered Health Plans
Director of Quality, Safety & Services Johns Hopkins Healthcare System and Johns Hopkins Community Physicians
Johns Hopkins Healthcare, Managed Care Organization-Clinical & Policy Specialist
Director of Risk Management, Director of Quality Improvement, Chief Safety Officer (CSO), Program Manager for Pharmacy and Durable Medical Equipment, for District of Columbia DC Department of Health Medical Assistance Administration (DCMAA)-DC Medicaid Office,
Education
Central Michigan University MSA 1997
Hunter College BSN 1984
Bronx Community College AASN 1980
Active Secret Clearance
LICENSURE, TRAINING and CERTIFICATIONS:
Registered Nurse (RN) Licenses State of Alaska, Georgia, Maryland, District of Columbia, (Inactive) and New York State (Retired)
US Government Contractor Secret Security Clearance DoD CAC 2021
IBM Cybersecurity & Privacy Training-03/13/2023
HIPAA Privacy Rand Privacy Act Training 03/15/2024
Annual Security Refresher 03/15/2024
DHA Employee Safety Course 02/01/2024
DOD Mandatory Controlled Unclassified Information (CUI) 01/04/23
TJC Annual Conference 08/14-16/23
Microsoft Office Suite and Windows Workgroups
NIST Framework
Microsoft SharePoint (SAAS)
HIPAA
MS Project
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