Customer Service Virtual Assistant

SABRINA R. HUGHES

**** ******* ****, ***** ******, IL 60542 630-***-**** ****************@*****.*** QUALITY, PERFORMANCE IMPROVEMENT AND COMPLIANCE LEADER

Hospital Quality Education Patient Safety System Improvement Care Management Accomplished healthcare executive and instructor with a proven track record leading quality initiatives and accreditation for complex tertiary healthcare hospitals with large primary care programs for over 20 years. Consistently improved metrics such as healthcare quality, infection control, patient safety, and productivity through evidence-based evaluations, strategy, and process improvement. Promotes a culture of quality and safety while centering on transparency and high reliability. Excels at managing and educating teams and providing leadership to drive change. Skilled in:

Education

College and High School Instruction

College Preparation Programs

Databases/computer programs for

high school and portals (for

instruction grade entries, time, and

attendance)

Microsoft Office Suite

Analytics/Data Analysis

Performance Improvement

Stakeholder Satisfaction/Surveys

Quality Control/Assurance

Utilization Management

Accreditation Readiness

Change Management

Lean & Six Sigma

Health Care Operations

Compliance and Business Integrity

Policy/Development and Execution

Budget and Contract Management

PROFESSIONAL E X P E R I E NCE

LEYDEN HIGH SCHOOL (WEST), CHICAGO, IL

Substitute Teacher (Science) 12/19-5/20

Provided direct and online classroom instruction in biochemistry, genetics, general biology, and more for seven class periods to approximately 100 students during the extended absence of a teacher. The student population consisted of biology honors students and those with educational challenges. Use data and computer systems for attendance, classroom, and online instruction. After my departure, I assisted the department chairperson and staff in developing their medical career program. Resolved issues and eliminated barriers by working with parents and students. FULL-TIME MINISTRY (GLOBAL) 03/21-12/2024

NORWEGIAN AMERICAN HOSPITAL (NAH) CHICAGO. IL

Vice President, Quality and Corporate Compliance Officer, Executive 05/17-12/18 My executive responsibilities included hospital quality, customer service, accreditation, compliance, patient safety, risk management, infection control, performance improvement, analytics, utilization management, social work, patient experience, voluntary services, and spiritual care. My role encompassed direct supervision, strategic planning, managing budgets, and leading diverse teams (inpatient and outpatient) to improve all aspects of quality customer satisfaction and healthcare operations. Managed a budget exceeding 4 M.

Managed a team of 20 (a physician, Registered Nurses, Case Managers, Social Workers, and Data Analysts).

Spearheaded and erected an integrated quality program that included a focused agenda on oversight, customer satisfaction, continued readiness, and safety linked to Centers for Medicare and Medicaid’s (CMS) Hospital Compare domains of mortality, safety, effectiveness, and timeliness of care, readmissions, and patient experience.

Designed and executed the quality operational and three-year strategic plan, resulting in 14 priority goals being achieved during my tenure. Partnered with other executives to devise and execute the hospital’s three-five-year plan.

Directed the system-wide customer service program that improved patient satisfaction scores.

Chief Liaison and point of contact to resolve external issues relating to accreditation and customer satisfaction.

Served as the chairperson of the interdisciplinary Quality and Performance Committee (QAPI) that analyzes, oversees, and directs strategies to improve patient outcomes and performance in quality assurance metrics.

Devised and facilitated a hospital-wide strategic approach to assess accreditation and formulate a performance improvement plan. Results were converted to a monthly scorecard and graphs and presented to the QAPI committee. My leadership and efforts of the teams resulted in three successful accreditation surveys in 2017-2018.

Structured a patient safety and risk program that included redesigning the Patient Safety Committee’s operational platform. Introduced and launched health care failure effect mode analyses (HFEMAs) for administrative and clinical programs. In partnership with physicians and nursing leaders, with notable improvements in six out of ten CMS Patient Safety Indicators (2nd - 4th quarter).

Erected the Compliance Committee, served as the chairperson, facilitated ethics training, and designed a risk assessment tool that led to improvements in privacy, cybersecurity, billing, coding, and internal stakeholder satisfaction.

Using change management principles, reengineered the Care Management department to comply with URAC requirements, improve work productivity, increase revenue streams, and reimbursements related to various health SABRINA R. HUGHES

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plans, Medicare, Medicaid, and self-pay. My leadership led to exceeding the 6M monthly cash collection goal in nine out of twelve months for the Fiscal Year 2018. Work productivity improved by 40% in 45 days using interrater reliability techniques and value stream mapping. Timeliness and accuracy relating to insurance verification, claim submissions, admission criteria assessments, and placements also improved.

Devised a lean/six sigma plan to improve the efficiency and effectiveness of the Interdisciplinary Plan of Care (IPOC) teams, reduce the length of stay, improve discharge planning, and reduce readmission rates. Some strategies included the use of an electronic acuity assessment tool and geometric length of stay criteria, the use of scripts during rounds, and a stronger focus on barriers to move to a lower level of care. Discharge planning improved by 30% in a quarter, as identified in the HCAHPS scores. Under my leadership, some readmission rates dropped by 10-30% in 15 Diagnosis- Related Groups for Ambulatory Sensitive Conditions by facilitating physician and nursing-led teams.

Managed a data repository and dashboard system that houses enumerable data sets used to determine performance trends over time and serve as a springboard for action.

Provided bi-monthly outcome-driven quality reports and PowerPoint presentations to the Board of Trustees, with weekly reports to the executive team and monthly reports to senior leaders and committee members. RETIRED FROM FEDERAL GOVERNMENT SERVICE 05/2017

VETERANS AFFAIRS, HINES VA HOSPITAL, CHICAGO, IL 06/15– 05/17 Chief (Director), Quality Management and System Improvement, Supervisory, Health Systems Specialist, Office of the Hospital Director (CEO)

Led daily operations and managed Quality and System Improvement that included quality oversight, survey readiness, patient safety, risk management, utilization review, and infection control for acute and ambulatory care. Managed the department budget. Created, approved, and provided oversight of policies.

Spearheaded the creation and execution of a rigorous interdisciplinary assessment process and actions to improve measures related to timely effective care, clinical outcomes, safety, and core measures linked to CMS’ Hospital Compare and CDC’s Health Safety Network System. My direction led to a VA star ranking of number two in the country.

Supervised a team of 25 (Registered Nurses, Case Managers, Program Analysts, and administrative staff).

Led the UM team to exceed collection goals and increase revenue streams for all 12 months in a two-year period and was noted as the regional high performer.

As Chairperson of both the Quality Board and Performance Measures Committee, redesigned the structure and functions of both bodies to focus on system-level performance regarding HEDIS and ORYX measures.

Designed and directed a hospital-wide continuous performance improvement and accreditation readiness process that raised TJC compliance to +95% in 90 days. My leadership led to a successful triennial Office of the Inspector General

(OIG) for FY16, three Commission on Accreditation for Rehabilitation Facilities surveys, and others.

Drove team efforts to resolve potential infectious disease outbreaks, including surveillance, risk evaluation, and enhancing infectious disease policies, resulting in no significant adverse patient outcomes.

Designed and launched a computer-based, interactive analytics program to train leadership at all levels on how to determine performance improvement priorities and opportunities using clinical data.

Provided monthly quality reports and PowerPoint presentations with graphical displays to the Regional Executive team and also provided monthly reports to interdisciplinary senior leaders and committee members. VETERANS AFFAIRS, OVERTON BROOKS VA MEDICAL CENTER, SHREVEPORT, IL 10/12– 06/15 Regional Quality Leader, Management Analyst, Office of the Director (CEO) Directed risk management and executive-level organizational performance and improvement initiatives at the regional level. Advised executive leadership and key staff in 10 VA medical facilities in five states to evaluate programs using many qualitative and quantitative analytical principles for acute and ambulatory care.

Supervised a team of 25 (Registered Nurses, Case Managers, Program Analysts and administrative staff).

Provided ongoing quality oversight and risk assessments of the Peer and Risk Programs for 10 hospitals.

Created and executed a rigorous interdisciplinary assessment process and actions to improve measures related to timely effective care, clinical outcomes, safety, core measures linked to CMS’ Hospital Compare and CDC’s Health Safety Network System. My direction led to a VA star ranking of number two in the country.

Led the UM team to meet or exceed collection goals and revenue streams using change management principles.

Provided ongoing instruction and consultative services regarding performance improvement and the use of analytics.

Using analytics as the key driver, partnered with the Chief of Medicine and Assistant Chief of Primary Care to improve physician productivity and performance in diabetes, blood pressure metrics, rheumatology, orthopedics, and cardiology that led to increased revenue and access to care in 2015. SABRINA R. HUGHES

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Achieved successful accreditation surveys by The Joint Commission, The OIG, and four CARF programs in 2013-15.

Provided monthly quality reports to the Regional Executive team and interdisciplinary senior leaders. VETERAN AFFAIRS, CENTRAL ALABAMA VETERANS HEALTH CARE SYSTEM (CAVHCS) 09/07– 10/12 Chief (Director), Quality Management/Performance Improvement, Office of the Director (CEO) Managed daily operations of Quality Division (Registered Nurses and administrative staff) with hospital-wide program responsibilities for quality management assessments, accreditation and external review processes, risk management, peer review oversight, performance measurement, and improvement, Administrative Investigative Boards, Controlled Substance Program, and policy management for acute inpatient and ambulatory care programs. Managed the department’s budget.

Managed a team of 12 (Registered Nurses, program analysts, and administrative staff.

Restructured and streamlined Quality Management Division, employing a standardized clinical pertinence review program that raised division accountability and fostered the production of actionable data-driven reports.

Launched integrated hospital-wide Patient Safety Program that raised accountability of health care quality and patient safety, including creation and timely completion of RCAs, HFEMAs, and aggregates.

Created and directed interdisciplinary hospital-wide continuous performance improvement and accreditation readiness process that included oversight of inpatient and outpatient metrics. My leadership resulted in zero OIG findings. Redesigned the operations of the customer service department, which improved patient satisfaction scores by 11% over the prior year, achieving a five-year all-time high, by instituting Medical Home/Patient-Centric Model approaches.

Provided monthly quality reports to the Regional Executive team and interdisciplinary senior leaders. VETERAN AFFAIRS, OFFICE OF QUALITY AND PERFORMANCE (OQP), DC/NC 04/03 – 09/07 Executive Officer/Chief Operating Officer

My chief responsibilities were leading operations that supported the oversight of national clinical outcomes, managing Fiscal Operations, Human Resource Management, logistics, contracting, and physical plant oversight, and managing a budget of 8 M.

Designed and implemented financial plans and a budget process to project, prioritize, and track resource spending according to strategic priorities, resulting in a 25% reduction in operational and contractual costs.

Worked with a national VA team to develop healthcare performance measures for all VA hospitals based on metrics in the public domain, such as CMS, HEDIS, ORYX, and clinical practice guidelines that were included in performance plans of executives and senior leaders throughout the Veterans Health Administration.

Devised national responses for customer satisfaction concerns

Provided monthly presentations to Washington, DC leadership. UNIVERSITY OF PHOENIX – Taught healthcare operations, analytics, and quality. 01/05– 01/06 College Professor

VETERAN AFFAIRS, VA TENNESSEE VALLEY HEALTHCARE SYSTEM (TVHCS) 10/01 – 03/03 Staff Assistant to the CEO, Health Systems Specialist Laboratory Manager, Supervisory Medical Technologist 12/96 – 10/01 Medical Technologist 06/93 – 12/96

UNITED STATES ARMY MILITARY INTELLIGENCE COMMAND, FIELD STATION KUNIA, HAWAII 08/79 – 04/87 Electronic Cryptographic Warfare Interceptor/Analyst (Far East Specialist)

Conducted interception and analysis of far eastern intelligence. I received Combined Services Accommodation. EDUCATION, CREDENTIALS & A F F I L I A T I ONS

Master of Science, Management of Technology, Murray State University, Murray, KY Bachelor of Science, Medical Technology, Austin Peay State University, Clarksville, TN Certified Professional of Healthcare Quality (CPHQ), Cert. ID. 309687 Lean and Six Sigma Green Belt Certification, Johns Hopkins University Licensed Medical Technologist Generalist (National Certification) Cert. ID. 192784 Licensed Substitute Teacher, (Illinois) IEIN# 1267003

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