Project Management Risk
Resume:
Elbert Starks 260-***-**** ******.******@*****.***
Professional Profile
• 20+ years of leadership and management experience
• 20+ years in emergency management
• 5+ years in risk management
• Project Management
• Implementation of strategic planning
• Self-starter who believes in teamwork
• Exceptional planning and organizational skills
Education
DBA, Healthcare Management – Liberty University MBA, Healthcare Management – Western Governors University BS, Occupational Safety and Health – Columbia Southern University AAS, Respiratory Care – IVY Tech State College Registered Respiratory Therapist (License-IN, IL, OH, FL, NC)
Skills
Analysis skills, Analytics, Communication skills, Conflict management, Continuous improvement, Customer service, Data analysis skills, Database management, Google Suite, Microsoft Office, Microsoft Outlook, Microsoft PowerPoint, Microsoft Project, Microsoft Word, Power BI, Project management, Quality assurance, Regulatory reporting, Relationship management, Senior leadership, Team management
Experience
Northern Path Recovery Center 1/2025-Present
Director of Quality and Performance Improvement
• Reports directly to the CEO
• Serves as the Compliance and Risk Manager
• Monitors and directs the day-to-day operations of quality management and compliance process within the organization to establish and maintain a culture of compliance and safety.
• Continually assesses the facility survey readiness. Functions as survey coordinator during any regulatory survey. In consultation with key managers, prepares responses to survey and addresses recommendations and areas needing improvement.
• Coordinates regulatory activities including licensure, certifications, and accreditation
(OHFLAC, BHHF, CMS, Joint Commission, CARF, ASAM, Office of Civil Rights, etc.). Serves as liaison to the regulatory agencies related to activities within the organization.
• Sets expectations, develops plans, and manages processes to measure, assess and improve the quality of clinical programs and/or regulatory/accreditation compliance by measurable results in assigned facilities.
• Develops, reviews, and updates internal clinical procedures, related outcomes measurement, client satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state, and other regulatory requirements and improvement of services.
• Collects and provides data for compliance requests, dashboards, and scorecards. Prepares and submits accurate and comprehensive reports as required both internally and externally
• Responsible for overall key performance indicators and quality outcomes
• Works closely with corporate quality and risk to adhere to all rules and regs associated with each position
• Reporting of the culture of safety and patient experience surveys
• Directs clinic directors in the collection and entry of quality data
• Prepares packets to report to the Medical Executive Committee and Governing Board
• Reviews policies and procedures annually
• Responsible for maintaining compliance with TJC, CMS, and state agencies
• Responsible for submitting corrective actions for any RFI's found by regulating bodies
• Responsible for identifying risks to the hospital and making recommendations based on these findings
• Report findings and solutions to immediate issues, as well as plans for future potential problems or emergencies, to hospital management
• Manage and oversee the risk management program.
• Patient Safety Coach Chairperson
• Directs overall development and implementation of performance improvement indicators
• Collaborates with providers and leadership staff to promote the quality improvement program
• Presents quality data during surveys to regulatory and accreditation bodies AYA (Currently IU Ball) 09/2023-1/2025
Registered Respiratory Therapist
• In a level 2 trauma emergency room, I provide medication, vent management, ABGs
(arterial blood gas), and patient assessments; stabilize airway innovations; complete capnography; and assist physicians with chest tube placement.
• STICU, CCU, Peds, PICU, Adult ICU, Pulmonary Rehab
• Care planning
• Serve on the rapid response team, working with ER nurses, doctors, intensivists, EKS, and lab technicians to address critical health needs immediately.
• Deliver non-invasive ventilatory support for Continuous Positive Airway Pressure ventilation (CPAP) and Bilevel Positive Airway Pressure (BPAP) ventilation.
• Oversee bronchial hygiene for chest physiotherapy and pep therapy (positive respiratory therapy).
Advantage Medical Equipment 09/2020-10/2024
Registered Respiratory Therapist
• Home health equipment set-up and patient training
• Airway education, Asthma education, Pulmonary Rehab education, Medication education
• Manage orientation of new employees (upwards of five new hires per week) and registered respiratory therapists.
Maple Heights Behavioral Health (Lutheran Health Network Affiliate) 11/2022-8/2023 Director of Risk and Performance Improvement
• Reports directly to the CEO
• Responsible for overall key performance indicators and quality outcomes
• Works closely with corporate quality and risk to adhere to all rules and regs associated with each position
• Reporting of the culture of safety and patient experience surveys
• Works closely with HIM to audit and review charts for OPPE and FPPE evaluation
• Works closely with the business office manager and the director of utilization on the appropriateness of care, readmits, and the number of unpaid days
• Directs clinic directors in the collection and entry of quality data
• Prepares packets to report to the Medical Executive Committee and Governing Board
• Reviews policies and procedures annually
• Work with HR to record and report employee injuries and workplace violence.
• Responsible for maintaining compliance with TJC, CMS, and state agencies
• Responsible for submitting corrective actions for any RFI's found by regulating bodies
• Responsible for identifying risks to the hospital and making recommendations based on these findings
• Report findings and solutions to immediate issues, as well as plans for future potential problems or emergencies, to hospital management
• Manage and oversee the risk management program.
• Patient Safety Coach Chairperson
• Directs overall development and implementation of performance improvement indicators
• Collaborates with providers and leadership staff to promote the performance improvement program
• Promote and support a culture of safety throughout the organization and departments.
• Ensures quality outcomes and progression improvement indicators aligned with TJC and other regulatory standards associated with healthcare best practices
• Recommends peer reviews for serious safety events
• Presents quality data during surveys to regulatory and accreditation bodies
• Administrator of the risk management event reporting system
• Responsible for implementing the comprehensive risk assessments for all 15 departments
Lutheran Health Network 1/2022-11/2022
Risk Manager
• Reports directly to the CQO
• Responsible for identifying risks to the hospital and making recommendations based on these findings
• Conducts Root Cause Analysis or Apparent Cause Analysis for Serious Safety or Serious Reportable events
• Conducts Failure Mode and Effects Analysis
• Report findings and solutions to immediate issues, as well as plans for future potential problems or emergencies, to hospital management
• Manage and oversee the risk management program.
• Conducts annual building and occupancy risk assessments
• Responsible for implementing the comprehensive risk assessments for all 150 departments
• Liaison with legal to notify them of potential claims and or potential compensatory events
• Investigate and submit liability claims to corporate attorneys.
• Draft resolution letters for all grievances brought on by employees, patients, or vendors
• Develop systems and procedures to improve patient, employee, and visitor safety.
• Assist hospital trainers and department managers with educating employees about risk, liability, and risk management policies and procedures. Lutheran Health Network 9/2020-1/2022
Environment of Care Manager
• Oversee multiple facilities' Environment of Care Program (EOC)/Life Safety.
• Collaborate with facility leaders and staff to develop, implement, and manage the safety program in compliance with The Joint Commission and IDHS safety standards, rules, and regulations that impact management in the acute care environment.
• Conducts hazard vulnerability analysis
• Maintains records for EPA and NFPA compliance
• Participates in the accreditation survey and complies with federal, state, and local regulations
• Works with facilities management, infection prevention, accreditation, and standards to ensure compliance with state, local, Joint Commission, and OSHA standards.
• Assumes responsibility for fire and safety management plans
• Serves as the point of contact with fire officials and insurance inspectors
• Conducts Infection Control Risk Assessments (ICRA)
• Inspect slips, trips, and falls associated with elevated ramps and wet surfaces.
• Serves as the Environment of Care Management Committee Chairperson
• Primary contact and liaison for accreditation survey and local/state fire inspection activities
• Coordinate scheduling and documentation of off-site emergency preparedness drills. Auburn Village Nursing Home and Rehabilitation 4/2020-9/2020 Director of Respiratory Therapy
• In charge of respiratory care and laboratory services such as administering oxygen, therapeutic gas, mist inhalation, and ABG quality control under the physician's orders and the hospital's policies. Requires knowledge of medications, treatments, and their correct administration based on the age of patients and their clinical condition
• Conducts onboarding and orientation of new employees
• Responsible for a job posting and hiring of respiratory therapists
• Responsible for compliance and accreditation standards associated with the respiratory department
• Trains all department personnel
• Communicate clearly and effectively with physicians, staff, Department Directors, and administrative team; able to assist physicians with procedures such as bronchoscopy.
• Update department plans, goals, and objectives and direct the development of the department.
• Prepare an annual budget and record necessary statistical data. Parkview Regional Medical Center 9/2018-4/2020
Registered Respiratory Therapist
• Provides medication, vent management, ABG's arterial blood gas), and patient assessments; stabilizes airway innovations; completes capnography; and assists physicians with chest tube placement.
• Airway education, Asthma education, Pulmonary Rehab education, Medication education
• Hospital-Emergency Preparedness Committee member
• Serve on the rapid response team, working with ER nurses, doctors, intensivists, EKS, and lab technicians to address critical health needs immediately.
• Conduct pulmonary rehab exercises and provide high-flow therapy; deliver non-invasive ventilatory support for Continuous Positive Airway Pressure ventilation (CPAP) and Bilevel Positive Airway Pressure (BPAP) ventilation. Parkview Hospital 8/1997-4/2013
Certified Respiratory Therapist
• Works in the highest trauma level in an emergency room, completing medication delivery, vent management, and patient assessments while also providing pulmonary rehab and high-flow therapy
• STICU, CCU, Peds, PICU, Adult ICU, Pulmonary Rehab
• Airway education, Asthma education, Pulmonary Rehab education, Medication education
• Manage orientation of new employees (upwards of five new hires per week) and registered respiratory therapists.
• Conduct pulmonary rehab exercises and provide high-flow therapy; deliver non-invasive ventilatory support for Continuous Positive Airway Pressure ventilation (CPAP) and Bilevel Positive Airway Pressure (BPAP) ventilation. Fort Wayne Fire Department 2/2009-10/2018
Combat Lieutenant / Combat Captain
• Managed up to seven personnel on fire scenes, accidents, medical, and other emergency services
• Assumed control of incidents and played an essential role in incident mitigation, life safety, and property conservation
Fort Wayne Fire Department 6/2014- 4/2015
Assistant Chief-Human Relations
• Scheduled physicals and return-to-work evaluations; investigated misconduct allegations for civilians and firefighters
• Administered a risk assessment program and initiated an injury reduction program to reduce injuries and accidents by 20%
• Streamlined the medical absence policy to increase efficiencies and reduce time to return to work
Fort Wayne Fire Department 6/1997-10/2018
Firefighter
• Responded to fires, accidents, medical, and other emergency services and played a vital role in incident mitigation, life safety, and property conservation; acted as a safety officer in emergencies.
• Served as a Member of the Apparatus specifications and bid committee Professional Development
CPHRM (5436) RRT ACLS, BLS, CPR, NPR Hazmat First Responder Operations Health and Safety Officer - National Fire Academy ICS 100, 200, 700, 800 ICS 300: Intermediate ICS FOR Expanding & ICS 400: Advanced ICS for Command & General Staff - National Fire Academy Health and Safety Officer Instructor I Leadership I, II, III-National Fire Academy Safety Officer- National Fire Academy WMD/Terrorism Awareness for Emergency Responders-FEMA
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