Interim Director of Quality, Patient Safety & Accreditation | MBA | TJC & DNV Experience


Last Updated: November 21, 2020 (11 months ago)

Interim Director of Quality, Patient Safety & Accreditation | MBA | TJC & DNV Experience
Immediately
Leadership & Acute Care Experienced

A results-driven healthcare leader with over ten years of progressive hospital operations experience who thrives on challenges, is grounded in ethical decision-making principles, political sensibility, and possesses superior communication skills. Demonstrated knowledge in all aspects of healthcare delivery, including TJC, DNV, HFAP, Title 22, CMS, CAP, and ACGME. Proven ability to develop teams, redesign clinical and organizational processes and structures, implement programs, execute revenue enhancement strategies, and build relationships to achieve results. He possesses a passionate commitment to quality care and operational excellence. His leadership style builds and maintains a climate of trust and inspires commitment from others to achieve organizational goals. He recognizes the need for change, adapts to, and causes others to adapt to values, strategies, goals, and plans in response to changing business conditions.

References & Reviews

• “He has a great way of putting mission and vision into a strategic plan and then guiding the organization to achieve goals.”
• “He managed a $500,000 renovation to the ED, looking at flow and function, he brought the vendors together and managed the project, coming in under budget and ahead of schedule.”
• “In a hospital that had very little in terms of a quality program, he worked with the staff throughout the hospital to put together a plan and processes, adding risk, grievance process, the peer review process, he really brought the entire program to life at the facility.”
• “He is king of building relationships and is able to educate folks and help them understand how change positively affects patient care and safety; he is able to get people on board, he's really a change agent.”
• “He put the quality agenda together with the regulatory agenda in a formalized manner so we could address weaknesses both horizontally and vertically within the organization. He really integrated compliance into the fabric of what we did.”
• “He coordinated all quality data into a matrix with weighted scores, which was really helpful to help people see the key items driving their metrics.”
• “He came into a department in flux, needing a complete overhaul, he was able to manage a complete turn-around while still managing quality metrics.”

• Quality Reporting and Analytics
• Risk Management & Patient Safety
• Lean Six Sigma
• Environment of Care Structure and Effectiveness
• New Construction & Design Strategy
• Licensing and Accreditation
• Stroke, Sepsis and Cardiac Program Management
• Staff Training & Leadership
• Health & Safety Standards
• Clinical Excellence

Resume Content

Title:

Interim Director of Quality, Patient Safety & Accreditation | MBA | TJC & DNV Experience

Date Available:

Currently Available

Summary:

Leadership & Acute Care Experienced

A results-driven healthcare leader with over ten years of progressive hospital operations experience who thrives on challenges, is grounded in ethical decision-making principles, political sensibility, and possesses superior communication skills. Demonstrated knowledge in all aspects of healthcare delivery, including TJC, DNV, HFAP, Title 22, CMS, CAP, and ACGME. Proven ability to develop teams, redesign clinical and organizational processes and structures, implement programs, execute revenue enhancement strategies, and build relationships to achieve results. He possesses a passionate commitment to quality care and operational excellence. His leadership style builds and maintains a climate of trust and inspires commitment from others to achieve organizational goals. He recognizes the need for change, adapts to, and causes others to adapt to values, strategies, goals, and plans in response to changing business conditions.

References & Reviews

• “He has a great way of putting mission and vision into a strategic plan and then guiding the organization to achieve goals.”
• “He managed a $500,000 renovation to the ED, looking at flow and function, he brought the vendors together and managed the project, coming in under budget and ahead of schedule.”
• “In a hospital that had very little in terms of a quality program, he worked with the staff throughout the hospital to put together a plan and processes, adding risk, grievance process, the peer review process, he really brought the entire program to life at the facility.”
• “He is king of building relationships and is able to educate folks and help them understand how change positively affects patient care and safety; he is able to get people on board, he's really a change agent.”
• “He put the quality agenda together with the regulatory agenda in a formalized manner so we could address weaknesses both horizontally and vertically within the organization. He really integrated compliance into the fabric of what we did.”
• “He coordinated all quality data into a matrix with weighted scores, which was really helpful to help people see the key items driving their metrics.”
• “He came into a department in flux, needing a complete overhaul, he was able to manage a complete turn-around while still managing quality metrics.”

Qualifications & Achievements:

• Instrumental in the opening of a $3.5B new hospital
• Accountable for multiple transition strategy teams responsible for accreditation and licensing, patient safety and quality, patient transition and service line activation teams
• Point person for all accreditation and regulatory communications and correspondences
• Strong administrative leadership skills overseeing 50 + FTEs and managing Quality, Risk, Performance Improvement, Regulatory and Accreditation, Infection Prevention, Patient Experience, and Medical Staff
• Comprehensive and thorough understanding of all elements of health care delivery including regulatory and accreditation requirements to include TJC, HFAP, Title 22, CMS and CAP
• Excels in leading multidisciplinary teams of physicians, administrators, leadership, clinical and non-clinical staff to achieve top-performing status
• Proven ability to develop teams, redesign clinical and organizational processes and structures, implement programs, execute revenue enhancement strategies and build relationships to achieve results
• Extensive experience in developing and implementing policies and procedures that promote patient safety and best practice guidelines
• Successfully managed key projects to include meeting 100% of clinical safety improvement deliverables, renovation of a $1M emergency department and $2M labor and delivery patient room initiative
• Facilitated a culture of patient safety and risk prevention by implementing programs to increase reporting
• Self-driven, hard-working and energetic professional with exceptional communication skills who is committed to the quality and care of patients

Expertise:

• Quality Reporting and Analytics
• Risk Management & Patient Safety
• Lean Six Sigma
• Environment of Care Structure and Effectiveness
• New Construction & Design Strategy
• Licensing and Accreditation
• Stroke, Sepsis and Cardiac Program Management
• Staff Training & Leadership
• Health & Safety Standards
• Clinical Excellence

Experience:

• Senior Quality Operations Consultant, New Hospital Transition Strategist | 500+ Bed Academic Hospital
• Vice President of Quality | 250+ Bed Acute Care Hospital
• Director of Quality | 300+ Bed Acute Care Hospital

Education:

• Master of Business Administration (MBA)

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Testimonials

"She has been perfect for us particularly since we are in our Joint Commission survey window for both our Disease Specific Care certification reviews and our triennial accreditation.  I also believe she is the one that’s helped us identify the root cause of some of our SSI’s.

Thank you for connecting us with [her]."

"[She] is an excellent addition to our team. She was able to hit the ground running, and I am very excited to be working with her. I believe with her positive attitude, we are really going to be able to turn our little home health ship around, and get it running well."

"[She] walked into a very challenging position - technically, politically, and operationally. She inherited a disorganized and unreliable credentialing history, records, and dysfunctional staff. She has a terrific work ethic, very pleasant interpersonal and leadership style, and great fund of knowledge. She has been incredibly reliable, dedicated, focused, and industrious. Thank you for sending her to us."

"[The Galileo Interim] was well received by our hospital staff members. She built relationships and was always in an "appreciative inquiry" mode. She quickly came up to speed on the transition of the retiring Quality Manager, and effectively transferred the necessary information to the new Quality Manager.

Many among our team have said they would like her to stay? We would like to have her come back for specific projects as needed."

"[He] spent an extended time at our hospital and lay the foundation of a strong infection prevention program. He assisted with program development (including training a new IP) and with policy development. He was well-received by everybody. Very adaptable to different audiences, always professional, and approached circumstances with a goal of providing support and guidance. In my experience, he was one of the strongest infection prevention professionals I've worked with, and he has my strongest recommendation."