VIVIAN “JOANNIE” STRICKLAND, BAHR, MSM, PHR

*** **** ***** *** *****, Arizona 85282

adt1by@r.postjobfree.com 602-***-****

EDUCATION

TROY STATE UNIVERSITY; Shaw AFB; Sumter, South Carolina

Master of Science in Management (Leadership & Organizational Development)

SAINT LEO UNIVERSITY; Shaw AFB; Sumter, South Carolina

Bachelor of Arts in Human Resources Management; Minor in Public Administration

PIMA COMMUNITY COLLEGE; Tucson, Arizona

Associate of Science in Nursing (incomplete)

SAINT PHILLIPS COMMUNITY COLLEGE; San Antonio, Texas

Licensed Practical Nurse

Licensure: State of Texas Licensed Practical Nurse (1987-Inactive)

Certification: Professional in Human Resources (PHR); Shaw AFB, South Carolina

Training: The Joint Commission (TJC) Changes 2019

General Acute Care Relicensing Survey (GACRLS) 2018

Changes Conditions of Participation 2017

The Joint Commission (TJC) Changes 2017

University of North Carolina Lean 200 2014

High Reliability Training 2013

Malcolm Baldrige Training 2012

ASHRM Risk Manager Training & Orientation 2011

PROFESSIONAL SUMMARY

Healthcare Executive with a reputation for achieving exceptional quality outcomes in multiple settings, including acute care hospitals, long-term care, clinics, and consulting. Experience includes utilizing successful business strategies and implementing initiatives to meet organization objectives and contributing to the bottom line. Proven ability to conceptualize solutions to a broad spectrum of management challenges. Extensive knowledge of state and federal regulations governing healthcare: Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), General Acute Care Relicensing Survey (GACHRLS), an Office of Statewide Health Planning and Development (OSHPD) and Title 22. Expertise in organizational redesign, team dynamics, leadership development, customer service, clinical quality improving patient satisfaction, and contract management. Organized and thorough; experienced technical writer for strategic, environment of care, and disaster plans. Considerable knowledge of human resources programs, training, compliance, and employee benefits. Recognized communicator and high energy relationship builder with multicultural communities. Passionate about patient safety and delivering the best possible care for patients.

PROFESSIONAL EXPERIENCE

Children’s Benioff UCSF Hospital, Oakland, CA Dec 2019-May 2020

Interim Safety Officer/Environment of Care Manager-Emergency Management Coordinator

Primary focus was on correcting the 2020 The Joint Commission mock survey’s 83 findings in the areas of environment of care, facilities, security, and fire and life safety.

Improved the fire drill program, developed a test to include PASS/RACE training that correcting a Joint Commission finding. Over 120 staff members trained in orientation and fire drills in four months.

Functioned as Environment of Care chairman. Oversaw reports, policies & procedures and improvement activities for safety, security, hazardous materials, utilities, medical equipment, fire/life safety and emergency

Served as a key member of the interdisciplinary rounding team and validated follow-up to ensure closure and monitoring.

Leadership oversight of the hospital’s safety program, ensuring adherence to OSHA, Centers for Medicare (CMS), Joint Commission, CDPH, and NFPA requirements resulting in successful hospital audits and surveys.

Chairperson for the Environment of Care Performance Improvement Committee, ensuring improvement in compliance indicators.

Led cross-functional performance improvement rounds to monitor compliance to cleanliness/infection control, corridor safety, life safety, and fire safety.

Provided monthly Hospital Safety Orientation with an average of 20 persons per class.

Managed emergency planning, including policies, procedures, and Hazardous Vulnerability Assessment (HVA) development. Implemented emergency system updates and closed out reporting processes.

Provided best practice disaster education associated with emergency planning and crisis management to hospital staff members and outside entities. Made changes due to COVID 19 for all disaster equipment and supplies for the facility.

Rebuilt the Hospital’s relationship with Oakland Fire and OSPOD, lauded by FD and OSPD.

York Hospital, York, Pennsylvania

Interim Director of Accrediation and Compliance 02/2019-11/2019

York Hospital is a Wellspan Healthcare facility with 585 patient rooms and 62 clinics.

Led this facility thru the 2019 Triannual Joint Commission (TJC) which became one of the best outcomes of the Joint Commission Readiness (JCR) affiliated hospitals in the Pennsylvania and Triad area.

Developed and implemented continuous readiness weekly rounding surveys for hospital and clinics. Created an action plan for corrections to insure on going continuous readiness.

Developed an action plan template to document Joint Commission responses, including an opportunity to add preventive analysis if required.

Leader of the hospital’s Continuous Readiness Committee (CRC). Developed process for leaders to present their on-going action plans following weekly rounding by the hospital’s survey readiness team.

Managed the Pennsylvania Department of Health (DOH) visits for occupancy, complaints, and surveys.

Created a standard work process to use beds in out-lying units during times of overflow. The Department of Health (DOH) approved and referred other hospitals to contact me regarding this process.

Trained senior leaders on the Joint Commission Continuous Readiness processes and Centers of Medicare and Medicaid requirement focused on the Conditions of Participation (COPs).

Partnered with the patient safety officer and department of safety for management of complaints and grievances, and patient safety events. Became a key member of the root cause analysis improvement team.

Trained and mentored a newly hired director of accreditation.

St. Mary’s Medical Center: Long Beach, California

Interim Patient Safety Officer 06/2018-12/2018

St. Mary’s Medical Center is a 389 bed Dignity Health Care facility providing the full spectrum of acute care services and extended access through community benefits outreach.

Managed the California Department of Health Services (CDPH) and Centers for Medicare and Medicaid Services (CMS) visits including completion of the 2567 actions plans. Trained and assisted the directors in developing their action plans and scheduled tracking and reporting to the Quality Committee.

Team lead for the General Acute Care Relicensing Survey (GACRLS) mock survey. Lauded by the team for knowledge of the survey’s requirements and processes.

Educated on and encouraged use of the incident reporting system throughout the facility.

Wrote the 2018 Patient Safety Plan and ensured approval through the committees and hospital board of directors.

Provided leadership for sentinel/clinical event process-identification and prioritization of cases with appropriate leaders, case write up and summation, patient complaints, and complications.

Responded to all patient and family grievances and concerns per regulatory standards. Recognized by several patients for follow up with one patient contacting the California Department of Healthcare (CDPH) to compliment follow up.

Partnered with the director of quality to implement a comprehensive patient safety and regulatory program including setting up outstanding committees, serving as the team lead for hypoglycemia task force, and complaints and grievances committees.

Brookwood Medical Center; Birmingham, Alabama 01/2018 - 06/2018

Interim Patient Safety Officer

Brookwood Baptist Medical Center is a 607-bed acute care facility in metropolitan Birmingham, Alabama, with over 2,500 employees, offering a comprehensive range of clinical services.

Managed the daily Quantros daily risk information system and produced reports that guided organizational decisions related to patient safety needs and trends.

Developed and implemented organizational-wide patient safety/risk management program with focus on proactive strategies to control and reduce facility-acquired conditions.

Developed and implemented an enterprise-wide patient safety management program that effectively managed post-event analytics, adverse event disclosure, and shared learning across the organization for prevention of future events.

Led several root cause analyses, coordinating with process improvement to execute a robust process improvement and other auditing/monitoring processes as part of the Patient Safety committee.

Alameda Health System; Alameda, California Nov 2016-Nov 2017

Served in two roles in this system

Interim Systems Director of Accreditation and Risk Manager July 2017-Nov 2017 Provided oversight of regulatory and risk for a four-hospital system that includes Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, and San Leandro Hospital.

Interpreted new laws, standards, and regulations to direct the development, revision, communication, and implementation of new policies, processes, or systems to ensure ongoing achievement of external requirements.

Collaborated with other directors to understand the interrelationships between external standards and resource utilization and advised senior management on the impact.

Participated in the General Acute Care Relicensing Survey (GACHRLS) and a CMS survey; surveyors commented on knowledge of the process and support: requested to be the interim directed of accrediation after this survey.

Used the Joint Commission (TJC) Safer Matrix reporting tool to document the weekly tracer findings to senior leadership for correction and preparation for a successful Joint Commission survey.

Member of the infection prevention working group to develop a high level-low level disinfection policy lauded by the Joint Commission as a best practice.

Provided in-service education on both standard basic education and complex focused topics as needed and/or requested for survey readiness for the four facilities.

Developed tracer tools to support CMS Condition of Participation, TJC, and Title 22, resulting in enhanced understanding and support of nursing staff.

Identified issues with management concerning broken equipment and storage. Implanted a new policy and process for equipment management.

Served as the team lead for the 2017 Laboratory Joint Commission survey at San Leandro Hospital with excellent results.

Lead for the 2017 Radiation Safety reporting. Corrected all but one finding from the visit within two weeks. During the return visit, was recognized by Joint Commission surveyors.

Participated in a Joint Commission mock survey. Surveyors commented on knowledge of process.

Served as a key team member for a four-day mock continuous readiness survey for John George Psychiatric Hospital, all outpatient psychiatric services, and Highland Hospital.

Interim System Risk Manager 11/2016-07/2017

Developed, implemented, and facilitated the Accrediation, Risk Management and Patient Safety (ARPS) Programs.

Responsible for all aspects of ARPS Programs to protect the facilities, patients, visitors and employees.

Implemented the integration of Continuing Quality Improvement (CQI) concepts, as determined by TJC into the monitoring of organizations systems as they relate ARPS for all campuses and problem solved quality and patient care risk issues.

Coordinated annual ARPS review, revision and approval; directed and coordinated the collection of surveillance data as recommended by the director, ARS, federal, state, county and/or licensing accreditation agencies. Evaluated ARPS statistics and practices, team lead for all onsite surveys by The Joint Commission and the reporting of all medical center departments.

Participated in committees related to ARPS, provided consultation to the medical center’s administrative team and interacted with departments for ongoing ARPS activities.

Recommended and coordinated risk assessment and departmental surveys with AHPS liability carrier. Worked with other department heads to ensure the implementation of corrective action and effective risk reduction.

Provided a comprehensive plan to identify and take corrective actions to eliminate potential risks for medical center patients, visitors, and employees.

Developed and updated ARPS policies and procedures for the medical center. Interpreted and implemented ARPS pertaining to regulatory standards practices, plans for correction, and monitored methodologies when necessary.

Designed and implemented administrative programs and projects to communicate litigation activities to appropriate medical staff.

Investigated and analyzed potential and actual professional and general liability exposures within the health system. Evaluated the extent and elements of exposure and recommended appropriate actions for risk mitigation.

St. Mary’s Hospital (St. Joseph’s Health System), Apple Valley, California 06/2016 - 10/2016

Consultant - Peer review to the Medical Staff.

Served as a Medical Staff consultant for more than 300 High Desert doctors that provide services in a multitude of disciplines including pediatrics, oncology, cardiology, family medicine, internal medicine, obstetrics and more.

Evaluated the existing peer review program and processes, and identified opportunities for improvement for the medical staff peer review program by including key essential departments in the process: Quality, Infection Prevention, and Utilization Management.

Developed a professional relationship with the director of case management to identify patient safety indicators for the utilization committee, including physician outliers for length of stay.

Reported physician outliers to the CMO and Medical Staff Chiefs and created a new process to improve the hospital’s length of stay.

Collaborated with the directors of quality, case management, and infection prevention to develop a process for sharing information and insuring the hospital met all CMS current standards and recommendations.

Created a best practice Excel spreadsheet with all indicators required for each service line, including all current CMS requirements.

Created a positive peer case review culture by recognizing physician excellence as well as identifying improvement opportunities through a clearly defined, fair, and efficient process.

Reviewed and documented the current peer review process and developed a reference booklet that others will be able to use with new requirements.

Reviewed all risk incident reports to evaluate the need for peer review; improved the current peer review requirements by 20%.

Cape Cod Health System, Falmouth Hospital; Falmouth, Massachusetts 02/2016 - 06/2016

Interim Manager of Quality and Regulatory Department

Cape Cod Healthcare is the leading provider of healthcare services for residents and visitors of Cape Cod with two acute care hospitals, Hyannis and Falmouth. Falmouth hospital has 90 beds.

Managed the day-to-day processes of the quality department at Falmouth Hospital.

Performed data measure analysis, service line activities, and special projects to support safe patient care and compliance with pay for performance, regulatory, patient safety, process and systems improvement, public and internal reporting, and peer review requirements.

Worked closely with risk management and case management departments.

Served as overseer of the Medical Staff Peer Review program.

Managed the continuous readiness program for the facility.

Demonstrated a high level of expertise for utilization review, health care finance and requirements. Reviewed one-day readmissions for quality of care and discharge planning issues.

Developed the readmissions review program for 30-day readmissions with a primary focus on 24-hour readmissions.

Developed a peer review tracking tool to manage the program throughout the continuum from entry to closure. Reorganized the quality office peer review/medical staff quality files.

Identified opportunities for improvement in the cleaning of equipment during readiness rounding. Shared a best practice for cleaning of equipment.

Started a weekly Survey Readiness rounding program, partnering with staff closest to the point of care as the hospital prepared for an upcoming survey.

Lawrence General Hospital; Lawrence, Massachusetts 06/2015 - 12/2015

Director of Risk Management and Medical Staff Quality Peer Review

Led the risk management program with emphasis on customer satisfaction, risk reduction, and delivery of high quality, safe patient care.

Assisted with safety inspections and security for all facilities to ensure that safety measures were in place at all times.

Identified noncompliant issues related to the Joint Commission standards, rationales, elements, or performance for the environment of care (EOC), emergency management (EM), infection control and medical equipment, and recommended corrective actions as needed.

Developed and implemented policies and procedures for the risk management department, working closely with other hospital departments on issues relating to risk management and safety.

Improved the risk program by developing one-on-one relationships with directors and managers, changing the perception of risk being punitive to positive through focusing on patient safety.

Developed hospital-wide risk assessments to reduce medical errors and improve patient safety.

Updated the occurrence reporting and complaints & grievance policies to comply with CMS and TJC standards.

Reorganized the risk program patient folders, improving the ability to track and manage all legal notifications

Oversight and management of the Medical Staff Peer Review program; provided education around quality and risk, ensuring compliance with CMS and TJC standards, with accurate reviews and documentation

Organized the root cause analysis process with key personnel to identify issues with the new infant security system. Helped the team create action plans to correct testing, usage, and implement training for nursing and security.

Reorganized the Medical Staff peer review committee process and developed templates to be used to follow up with physicians.

Developed templates for business associates agreements to be used for external peer review physicians.

Developed spreadsheets for all risk and peer review cases, ensuring accurate tracking and monitoring.

St. Mary’s Hospital; Madison, Wisconsin 09/2014 - 06/2015

Interim Director of Quality Management Services, Risk Management and Patient Safety

Provided support for the development and implementation of a comprehensive system-wide quality and patient safety program.

Oversaw quality performance improvement, infection control, risk management, and peer review.

Promoted an environment of continuous improvement as measured by the Center for Medicare and Medicaid Services, The Joint Commission (TJC), and other regulatory and quality organizations.

Collaborated with senior leadership to ensure the Regulatory Compliance Program met TJC, resulting in excellent results during the hospital’s 2015 Joint Survey and CMS validation survey.

Conducted tracers with the administrative directors, managers and team leads using the CMS standards. During the tracer methodology, trained and educated participants on requirements.

Developed a workbook of questions for TJC visit for the following hospital areas: medical staff, leadership, infection prevention, pharmacy, care management, and suicide tracers.

Worked with corporate legal, the VP of Medical Affairs/ Chief Medical Officer to support the medical peer review process.

Performed root cause analyses and action planning for sentinel events and near misses.

Provided legal-healthcare consultation, troubleshooting and education for staffing in conjunction with general and defense counsel.

Conducted investigations, implemented corrective action plans, and resolution of risk and issues from the Riskmaster reporting system.

Interviewed and hired an interim risk manager to assist with restructuring and building of the risk program.

Consulted with professional staff on high risk/high exposure issues, customer service, and communication and quality improvement initiatives.

Worked with the administrative director surgical to implement and correct issues that were identified prior to our tenure. Implemented an audit system to monitor action plans resulting in meeting St. Mary’s 95% results requirement.

Augusta Health; Fishersville, Virginia 03/2014 - 09/2014

Interim Direct of Quality Management Services, Medical Staff and Risk Management

Assured maintenance of the incident reporting system and that data was trended and reported to senior management, the medical executive committee, and the hospital’s board.

Educated new and existing staff in risk management and other legal topics.

Worked closely with legal counsel to provide support communications with insurers, insurance brokers, and senior management, including notice of claims/lawsuits.

Worked closely with the medical staff coordinator to provide required training and education for medical staff.

Initiated hospital risk assessments, FMEA, and RCA activities.

Delivered quality improvement initiatives.

Developed and implemented policies and procedures for quality and risk management

Team Lead for mock survey visit by Joint Commissions Continuous Medical Readiness surveyor. Developed policies and procedures for compliance for federal and state regulatory requirements.

Educated leadership and staff on regulatory issues, new statutes and guidelines on safety, quality and performance improvement activities.

Developed training on risk reduction to obtain and maintain regulatory compliance. T aught at all employee orientation, nursing committees, and other staff meetings.

Directed and coordinated accreditation, policy, and regulatory compliance affairs initiatives.

Provided strategic oversight for patient safety and quality committee, with accountability for distribution of organizational communication.

Developed and managed the departmental budget and determined the fiscal requirements.

Completed Lean 200 training and served as a team member for patient throughput on an admissions Lean project

Initiated and facilitated several root cause analyses and the 2014 Failure Mode Effect Analysis (FMEA) for clinical alarms and safety.

Evaluated the risk management program; accomplished a SWOT analysis and recommended an action plan for correction to include hiring a director of risk management.

Kingman Regional Medical Center; Kingman, Arizona 10/2013 - 03/2014

Interim Direct Quality Management Services and Infection Prevention, and Patient Safety Officer

Developed and implemented a comprehensive system-wide quality and safety program for the hospital, rehab center, and all clinics.

As the System Director for Quality Improvement, had oversight for performance improvement, infection prevention, clinical abstractors, and peer review process.

Promoted an environment of continuous improvement as measured by the Centers for Medicare and Medicaid Services, DNV and other regulatory and quality organizations.

Coordinated the regulatory compliance program to meet the standards identified by DNV, Arizona State, and CMS.

Supported the medical peer review process in collaboration with the CMO.

Notified the Medical Staff office of findings and prepared the peer review and quality improvement committees, and the hospital’s board of directors.

Led the Infection Prevention program to insure practice was consistent with regulating agencies.

Quality lead for a core measure team and evidence-based practice team.

Worked with individual department managers for development of department-specific quality projects and monitoring related to regulations management and licensure.

Led root cause analysis and peer review encounters related to patient quality, safety, and risk issues and concerns.

Sutter Center Valley Region Memorial Hospital; Los Banos, California 10/2012 - 10/2013

Sutter Tracy Community Hospital

Interim Director Quality Management Services, Infection Prevention, Risk Management, Case Management

Directed the activities of planning, coordinating, and guiding the integrated functions of quality assessment and improvement within the functions of quality improvement, risk management, infection control, regulatory compliance, and case management for the Central Valley Regional Executive of Integrated Quality Services.

Directed a total of 14 FTEs.

Assimilated information to develop quality activities aligned with Memorial Hospital Los Banos (MHLB), Sutter Tracy Community Hospital (STCH), and Central Valley Region (CVR) strategies and values.

Built strong teams and business relationships, both internally and externally.

Responsible for working with the organization to pursue operational improvements and efficiencies; supporting strong teams and business relationships, both internally and externally.

Served as a resource and subject matter expert (SME) on all aspects of the quality program to develop and influence improvement strategies and development, and implementation of clinical assessment/process improvement and redesign.

Pursued opportunities that added value and eliminated waste and redundancy for the organizations to help achieve and retain optimal quality outcomes.

Led both facilities through biannual Lab Joint Commission surveys. Sutter Tracy received their best results to date.

Led Sutter Tracy through their 2013 Triennial Joint Commission hospital survey resulting in their best results to date.

Organized and presented at eight nurses’ forums principles of tracers, finding policies, and credentials on Joint Commission readiness. Received 245 surveys, with high five reviews.

Assisted the medical staff department’s leadership teams in determining criteria for conducting ongoing professional practice evaluation (OPPE), triggers indicating need for focused professional practice evaluation (FPPE), and ongoing clinical monitors.

Implemented core measures. Both facilities received full compliance in meeting their goals for the first time and became leading Sutter Health facilities during tenure.

Member of the Severe Sepsis/Septic Shock task force. Sutter Tracy Community Hospital received the Beacon Award for Excellence and national recognition.

Reorganized and relocated case managers at Sutter Tracy into patient care areas, ensuring presence on the units and improving communications with physicians.

Implemented the IHI risk program at both facilities.

Self Regional Healthcare (SRH); Greenwood, South Carolina 01/2011 - 09/2012

Director of Quality Management Services, Emergency Preparedness, Environment of Care, and Patient Safety Officer

Self Regional Healthcare is and independent, not-for-profit system providing care to the 300,000 residents of the rural, seven counties in the Lakelands Region of western South Carolina. The regional health system is anchored by 414 bed Medical Center.

Directed the operational, financial management and personnel resources for infection prevention, environment of care, safety, emergency preparedness, performance improvement, core measures, and risk management for 15 FTEs.

Responsible for planning, administration, and monitoring of consistent readiness of all quality management, regulatory requirements, and quality improvement processes.

Managed the oversight of environment of care, safety, and emergency management activities within various standing hospital committees.

Restructured the Quality Management department, eliminating two FTEs with a savings of over $150,000.

Developed and coordinated the Performance Excellence committee activities to ensure proper reporting of performance improvement process; established a yearly calendar for departments to report quarterly.

Developed the risk management program to ensure risk-related activities hospital-wide to prevent and minimize loss associated with identifiable risks and to minimize and prevent claims of general and professional liability against the hospital.

Started the Patient Safety Committee; primary focus to improve patient safety hospital-wide.

Established the Fall Prevention program. Decreased patient and visitors’ falls.

Changed perception of root cause analysis from punitive to very successful opportunities for improvement.

Led the hospital through the 2012 TJC, receiving their best survey results to date.

Infection prevention risk assessment was lauded as the one of the most thorough and best seen to date.

Rewrote the Emergency Management Plans and Hazardous Risk Vulnerability (HVA) Assessment; the HVA was lauded during The Joint Committee emergency management session.

Worked with Vice President of Medical Affairs to improve physician reappointment and peer review process; attended the Peer Review Committee.

Developed and implemented the OPPE/FPPE program for the medical staff.

Developed a core-measure training program for physicians, residences, and new nurse hires. Core measure scores increased compliance in all categories.

Reviewed and revised the State Radiology Support Plan, correcting outdated information from 2007.

Requested to serve as a member of a state team to develop the Volunteer Disaster Training Plan for physicians and allied professionals.

Member of the Malcolm Baldrige core team; assigned to categories 4, 6, and 7.

Tulare Regional Medical Center; Tulare, California 09/2010 - 12/2010

Independent Consultant - Interim Director of Medical Staff

Provided overall management of activities and resources of the Medical Staff Services department, responsible for planning, organizing, staffing, directing, monitoring, and coordinating the work efforts of all functions, including oversight of credentialing of

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