Interim Quality & Performance Improvement Leader | MSN, MBA, RN, CPHQ


Last Updated: January 29, 2021 (12 months ago)

Interim Quality & Performance Improvement Leader | MSN, MBA, RN, CPHQ
Immediately
Lean Six Sigma Black Belt, TeamSTEPPS Master Trainer
Leadership & Acute Care Experienced

A senior level quality & performance improvement professional with over 20 years of experience in healthcare project management. She excels in leading hospitals through successful TJC, DNV, CMS, and state surveys and specializes in creating, monitoring, and improving hospital-wide quality programs to improve patient experience and outcomes. Driven by excellence and focused on best practices and outcomes that improve customer and staff satisfaction. Adept at Leveraging Lean Six Sigma Black Belt tools to deliver results that transform healthcare organizations.

REFERENCES & REVIEWS

• “She brings a high level of clinical expertise to the quality realm, she is really able to understand situations from both sides of the coin and that makes her knowledge invaluable.”
• “She is very detail-oriented and very driven, she doesn't give up when there is an opportunity that needs correcting, she keeps working until she reaches a solution.”
• “She doesn't back down if she meets resistance, she just keeps going until she finds the "win-win" resolution.”
• “She is a consultative manager, she communicates very well, and invites input from all staff from floor to physicians to leadership to identify the best-case solution, then she utilizes her relationships to make sure change is implemented smoothly.”
• “Usually when you hire people with such a strong clinical background, they aren't as well versed in using data, and she is very data focused, helping develop dashboards to drive performance, and monitor for trends.”

QUALIFICATIONS

• Developed Scorecard Premier/Truven with Directors of Informatics and Chief of Surgical Services for monthly analysis and drill-down of data for surgical/medical process improvement
• Led Root Cause Analysis (RCA) and implemented Action Plans to improve safety culture and overall metrics
• Conducted daily surveillance for all MDROs, CAUTI, CLABSI, C-diff to report to NHSN per CDC guidelines; Daily Infection Control Risk Assessment (ICRA) rounds for building projects compliance
• Improved TJC mandatory education compliance from 40%- 95% for survey readiness
• Developed strategies to improve System-wide CMS core measure for Medication Reconciliation which led to improvement in scores from 62% to 96.5% in 1 year
• Comprehensive overhaul of hospital-wide QAPI Plan and CMS Corrective Action Plan (2567) leading to successful DNV Accreditation Survey; no conditional findings
• Led a Leapfrog Gap-Analysis to improve the system’s publicly reported data
• Led hospital through successful TJC Survey on the new SAFER Matrix Methodology, and implemented several best practices identified by the survey team
• Developed and implemented new OPPE /FPPE/ Peer Review process to include evaluation for allied health professionals, leading to physician performance improvement and accreditation compliance
• As Leader/Facilitator for the performance improvement committee, affected a 3-year continuous improvement in hospital metrics
• Improved HCAHPS scores to the threshold in all domains resulting in significant cost savings in Value-based Purchasing reimbursement from CMS

RECENT EXPERIENCE

• Interim Quality Leadership Consultant | 400 Bed Acute Care Hospital
• Interim Director of Quality | 250 Bed Acute Care Hospital
• Interim Chief Quality Officer | 35+ Bed Acute Care Hospital
• Director of Quality Management | 475 Bed Acute Care Hospital
• Senior Performance Improvement Specialist | 650 Bed Acute Care Hospital

EDUCATION

• Master of Science in Nursing (MSN)
• Master of Business Administration (MBA)
• Registered Nurse (RN)
• Certified Professional in Healthcare Quality (CPHQ)
• Lean Six Sigma Black Belt (LSBB)
• TeamSTEPPS Master Trainer

• Accreditation Expert on TJC Requirements for the New SAFER Matrix
• Healthcare Performance Improvement
• Value Stream and Root Cause Analysis
• Expert Educator/Mentor/ Facilitator
• Expert Lean Six Sigma DMAIC
• System Strategic Planning/Implementation

Resume Content

Title:

Interim Quality & Performance Improvement Leader | MSN, MBA, RN, CPHQ

Date Available:

Currently Available

Summary:

Lean Six Sigma Black Belt, TeamSTEPPS Master Trainer
Leadership & Acute Care Experienced

A senior level quality & performance improvement professional with over 20 years of experience in healthcare project management. She excels in leading hospitals through successful TJC, DNV, CMS, and state surveys and specializes in creating, monitoring, and improving hospital-wide quality programs to improve patient experience and outcomes. Driven by excellence and focused on best practices and outcomes that improve customer and staff satisfaction. Adept at Leveraging Lean Six Sigma Black Belt tools to deliver results that transform healthcare organizations.

REFERENCES & REVIEWS

• “She brings a high level of clinical expertise to the quality realm, she is really able to understand situations from both sides of the coin and that makes her knowledge invaluable.”
• “She is very detail-oriented and very driven, she doesn't give up when there is an opportunity that needs correcting, she keeps working until she reaches a solution.”
• “She doesn't back down if she meets resistance, she just keeps going until she finds the "win-win" resolution.”
• “She is a consultative manager, she communicates very well, and invites input from all staff from floor to physicians to leadership to identify the best-case solution, then she utilizes her relationships to make sure change is implemented smoothly.”
• “Usually when you hire people with such a strong clinical background, they aren't as well versed in using data, and she is very data focused, helping develop dashboards to drive performance, and monitor for trends.”

QUALIFICATIONS

• Developed Scorecard Premier/Truven with Directors of Informatics and Chief of Surgical Services for monthly analysis and drill-down of data for surgical/medical process improvement
• Led Root Cause Analysis (RCA) and implemented Action Plans to improve safety culture and overall metrics
• Conducted daily surveillance for all MDROs, CAUTI, CLABSI, C-diff to report to NHSN per CDC guidelines; Daily Infection Control Risk Assessment (ICRA) rounds for building projects compliance
• Improved TJC mandatory education compliance from 40%- 95% for survey readiness
• Developed strategies to improve System-wide CMS core measure for Medication Reconciliation which led to improvement in scores from 62% to 96.5% in 1 year
• Comprehensive overhaul of hospital-wide QAPI Plan and CMS Corrective Action Plan (2567) leading to successful DNV Accreditation Survey; no conditional findings
• Led a Leapfrog Gap-Analysis to improve the system’s publicly reported data
• Led hospital through successful TJC Survey on the new SAFER Matrix Methodology, and implemented several best practices identified by the survey team
• Developed and implemented new OPPE /FPPE/ Peer Review process to include evaluation for allied health professionals, leading to physician performance improvement and accreditation compliance
• As Leader/Facilitator for the performance improvement committee, affected a 3-year continuous improvement in hospital metrics
• Improved HCAHPS scores to the threshold in all domains resulting in significant cost savings in Value-based Purchasing reimbursement from CMS

RECENT EXPERIENCE

• Interim Quality Leadership Consultant | 400 Bed Acute Care Hospital
• Interim Director of Quality | 250 Bed Acute Care Hospital
• Interim Chief Quality Officer | 35+ Bed Acute Care Hospital
• Director of Quality Management | 475 Bed Acute Care Hospital
• Senior Performance Improvement Specialist | 650 Bed Acute Care Hospital

EDUCATION

• Master of Science in Nursing (MSN)
• Master of Business Administration (MBA)
• Registered Nurse (RN)
• Certified Professional in Healthcare Quality (CPHQ)
• Lean Six Sigma Black Belt (LSBB)
• TeamSTEPPS Master Trainer

Qualifications & Achievements:

People and Careers Perfectly Aligned

Expertise:

• Accreditation Expert on TJC Requirements for the New SAFER Matrix
• Healthcare Performance Improvement
• Value Stream and Root Cause Analysis
• Expert Educator/Mentor/ Facilitator
• Expert Lean Six Sigma DMAIC
• System Strategic Planning/Implementation

Experience:

• Interim Quality Leadership Consultant | 400 Bed Acute Care Hospital
• Interim Director of Quality | 250 Bed Acute Care Hospital
• Interim Chief Quality Officer | 35+ Bed Acute Care Hospital
• Director of Quality Management | 475 Bed Acute Care Hospital
• Senior Performance Improvement Specialist | 650 Bed Acute Care Hospital

Education:

• Master of Science in Nursing (MSN)
• Master of Business Administration (MBA)
• Registered Nurse (RN)
• Certified Professional in Healthcare Quality (CPHQ)
• Lean Six Sigma Black Belt (LSBB)
• TeamSTEPPS Master Trainer

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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."