Betty Poffenberger
Sarasota,Florida
Summary
Innovative, progressive, and enthusiastic healthcare leader with expertise in executing quality, regulatory and safety programs and practices that produce positive outcomes. 40 years of health care experience 21 years of education/training, quality, patient safety, risk, and leadership. Strong collaborative servant leader, proficient in assessing and reducing risk to produce high organizational reliability.
Overview
40
40
years of professional experience
1
1
Certification
Work History
Quality Specialist/Accreditation & Regulatory
Sarasota Memorial Healthcare System/ Sarasota Florida
01.2016 - Current
- Oversight of accreditation and regulatory requirements of Joint Commission and DNV & ISO 9001 for an 800+ bed hospital and 21 off-site settings. Designed, implemented, and educated eighteen audit teams for Environmental Care Rounding. Completed two DNV organizational surveys and one Joint Commission Disease Specific Survey. Lead action planning teams for IPON, Grievance /Complaints, Medication Security, Post Anesthesia Care Note and Conscious Sedation with successful closure of these citations. Directed performance improvement efforts for Suicide Screening, implementing an evidence-based screening tool for both inpatient and outpatient cites. Instrumental in driving redesign and implementation of the Workplace Violence Program. Redesigned and implemented required sedation credentialing and privileging to improve sedation fall out reporting by 20%. Collaborated with medical staff manager to design processes for student and observer on-boarding for over 150 observers and students. Reduced nuisance alarms on all telemetry units by 75% and improved suicide assessment from .8% to 2% of all patients screened. Designed and produced survey readiness tools, tips and updates for managers and staff. Precepted MSN student for graduate practicum. Lead fifteen medical students in performance improvement initiative to reduce COPD readmissions.
Personal Leave
Due to Significant Family Loss
06.2024 - 11.2025
Director of Clinical Compliance and Regulatory Affairs
Specialty Pharmacy Nursing Network
12.2021 - 06.2024
- Oversight of regulatory compliance activities for Joint Commission Accreditation and Joint Commission Certification for Home Health Care Staffing organization in all fifty states. Direct and oversee clinical standards of practice and risk assessment. Monitor patient safety activities, quality of care, grievances, and complaints. Track and trend all safety events, perform Root Cause Analysis and CAPA Corrective Action and Prevention Actions. Ensure compliance with all state and federal statues regarding the delivery of specialty nursing services for home infusion.
Senior Manager of Quality & Accreditation
Naven Health
05.2023 - 06.2024
- Oversight of daily Quality operations and performance improvement activities. Oversight of risk and patient safety activities. Same as below in previous position.
- Acquisition of SPNN by Option Care Health May 2023-June 2024
Director of Patient Safety, Risk and Equity & Compliance Coordinator
HCA/Blake Medical Center
08.2018 - 11.2021
- Management of Patient Safety program for 338 bed facility. Charged with reporting of all serious events, conducting root cause analysis and implementation of action plans. Reporting of serious events to ACHA and Joint Commission and annual risk assessment. Implemented process improvement programs to reduce falls, reduce specimen labeling errors, dysphagia screening and CIWA reporting. Improved reporting of occurrences by 20% within the organization and increased reporting of events by residents by 50%. Created a daily safety report to all leaders and implementation of daily falls report. Reduced fall rates by 10% year over year. Review of all safety occurrences and assignment of follow up and responsibility to management. Educated leaders on high reliability, process improvement and risk reduction. Conducted orientation and training for all new employees and the STAR RN program.
Quality Coordinator
Cleveland Clinic / SouthPointe Hospital
06.2012 - 12.2015
- QI led for core metrics abstraction and reporting. Reduced fall outs in stroke, CHF, and Sepsis by developing a concurrent review system and share point site for nursing units as well as educational tools. Created and reported balanced score card for core metrics and readmissions to key leaders and medical staff monthly. Trained over 150 nurses and residents in evidenced practices for core metrics and value-based purchasing. Successfully obtained, maintained Joint Commission Stroke Certification, and received the Gold Plus American Heart Award for three cycles. Lead Sepsis Task force and improved physician sepsis order usage to >90% and Sepsis measure compliance to 80%. Conducted FMEA on glucometer utilization and patient identification resulting in significant cost savings by reducing label usage improved patient identification. Lead root cause analysis cases in missed increased ICP and educated 100% of critical care staff on recognition of increasing intra-cranial pressures. Active leader for safety huddle and accreditation readiness. Assumed peer review responsibilities for emergency room and surgery cases during staff turnover. Trained several specialists for core metrics and peer review responsibilities. Monthly contributor to the Quality and Physician Newsletter. Co-mentored summer study student for research project on re-admissions and follow-up appointments for two years. Awarded the Cleveland Clinic Enterprise Nursing Excellence Award for Evidence Practice. Awarded Patient Safety Recognition for two years.
Clinical Instructor Nursing Education
Cleveland Clinic/South Pointe Hospital
06.2012 - 03.2010
- Designed and implemented a Cleveland Clinic System wide PCNA orientation model with clinical rotation. Designed class competency and clinical test outs for PCNA’s. Designed competency training and test out for safe medication administration, environmental safety, glucose monitoring and restraint usage. Created on-line learning modules for stroke, geriatric medications, code blue documentation & Professional Boundaries. Improved over all understanding of Professional Boundaries for Nurses by 50%. Serviced customers for Behavioral Medicine, Subacute, Rehab, Oncology and Case Management. Member of Code Blue, Fall and Safety Committees. Designed and executed training programs for; Code Blue, Rapid Response, Behavioral Medicine IV Skills, Team Nursing and SBAR h a n d
- F f . Created multiple on-on line videos for hand-off and defibrillator use and on-line learning modules. BLS Coordinator responsible for scheduling, organizing instructors, conducting classes, and remediating students. Poster presentation at National Staff Development Conference on Professional Boundaries for Nurses.
Human Resource Development Specialist
Cleveland Clinic / South Pointe Hospital
06.2003 - 03.2010
- Educator and facilitator for Departments of Nursing, Case Management, Diabetes Education, Behavioral Health, Critical Care and Rehabilitation Services. BLS Instructor and program coordinator. Assisted managers to develop and execute performance improvement assessments and plans for employees. Developed classes for Geriatric Nursing Assessment, Diabetes Medication Management and Pain Management. Introduced and trained nursing leadership on Evidenced Based Practice & Outcomes Management.
Human Resource Development Specialist Home Health Care
Cleveland Clinic Home Care Services
01.2000 - 06.2003
- Direct reporting to the Director of Organizational Learning and Performance for the Eastern Regions. Facilitator, educator, and management consultant for home care clinical staff of RNs, LPNs, and NAs. Developed and conducted orientation and field training for two hundred staff nurses. Rolled- out new computerized charting laptops and software system for OASIS. BLS Coordinator for all clinical staff, planned class schedules, hired, and monitored instructors. Instrumental in on-boarding of staff for acquisitions of Marymount Home Health Care and Lakewood Home Health Care. Managed and trained all Home Health Aides for monthly annual competencies required by CMS Participated in on-site CMS and Joint Commission inspection reporting. Created several self – learning modules for continuing education credit.
Training and Development Specialist
Elyria Memorial Hospital
01.1996 - 01.2000
- Direct reporting to the Vice President of Human Resources. Instrumental in implementing a pre-hire testing for nursing assistants and nurses. Developed competency modules, test and posters for competency assessment and environmental safety. Developed and conducted on-boarding orientation classes for nursing, secretaries, and nursing assistants. BLS Coordinator and ACLS instructor. Designed and conducted courses for; Clinical Assessment and Care of the Neuro patient, Care of Geriatric, Principles of Adult Learning and Conscious Sedation. Ohio Nursing Association (ONA) program manager for contact hour and educational offerings. Provided over 120 contact hour offerings in classes and self-directed modules. Sustained program with annual audits and no deficiencies. Created an educational committee to monitor and organize offerings. Created Code Blue committee to review and analyze performance issues during codes. Introduced PBDS program patient for nursing competencies.
Program Development Coordinator
Cleveland Clinic DBA /EMH Home Health Care
04.1994 - 01.1996
- Direct reporting to the President of EMH and Director of Sub-Acute Services of the Cleveland Clinic. Developed and marketed home health services for a DBA of the Cleveland Clinic for Elyria Memorial Hospital. Increased referral base by 75% within 3 months of hire. Hired and trained three home health coordinators for acute care. Developed a specialized home care program for “disease state management” for heart failure and diabetes and pre-screening program for all total joints. Coordinated in house and alternative site care. Transitioned DBA Home Care Agency to MSO of EMH. Served as supervisor and functioned as manager for twenty-five field staff. Ensured compliance and participated in Joint Commission and CMS on-site surveys.
Director of Adult Services
Hillmed Home Medical
04.1989 - 04.1994
- Direct reporting to the President of Operations. Lead effort to achieve first time Joint Commission Accreditation for Home Infusion/Home Health. Developed policies and procedures as well as designed training manual for staff. Managerial responsibility for home infusion, oncology and DME clinical services. Trained and supervised field staff which included registered nurses, respiratory therapist, and delivery staff. Conducted a wide variety of clinical home visits, assessment and treatments for patients when needed. Maintained on-call coverage. Prepared clinical home care organization for accreditation by developing and writing a policy and procedure manual and conducting home visits with the surveyors. Created patient educational materials for care of central lines, PICC and midline catheters.
Critical Care Traveling Nurse
Nurse Finders
01.1989 - 09.1989
- Employed in various clinical settings critical care. Assumed charge responsibilities. Awarded nurse of year.
Neuro-surgical Critical Care Nurse
University Hospitals of Cleveland
06.1985 - 01.1989
- Fifteen bed Neuro-surgical ICU and fifteen bed step down unit. Clinical bedside nurse, functioned as preceptor and charge nurse.
Education
MSN: Master of Science in Nursing - Healthcare Systems Management
Loyola University New Orleans
New Orleans01.2016
BSN: Bachelor of Science in Nursing - undefined
Kent State University
Kent, Ohio01.1985
Skills
- Regulatory & accreditation for Joint Commission & DNV/ISO 9001
- Quality management and performance improvement
- RCA & FMEA, Patient Safety
- Facilitation, training & staff development, and coach
- Supervisory and management
- Mentoring and coaching
- In class and on-line training
- Word, Excel, Power Point
Affiliations
- NAHQ National Association of Healthcare Quality – Member since 2014.
- Florida Society of Heath Care Risk Management (FSHRM member 2019).
- American Society for Healthcare Risk Management (ASHRM member 2020).
- Florida Association of Healthcare Quality – Member since 2016.
- Sigma Thea Tau 1985
Certification
- CPPS Certified Professional Patient Safety
- CPHQ Certified Professional Healthcare Quality
- Certified ISO 9001 Auditor (2016)
- Yellow Belt Six Sigma (2014)
- Certificate in Evidenced Based Practice- Case Western Reserve
- Team Steps Master Trainer (2015)
Recognitions
Enterprise Nursing Excellence Award for Evidenced Based Practice 2013, Patient Safety Award 2012, 2013, Stroke Committee Service Excellence Award 2015, Poster presenter at National Nursing Staff Development Conference 2011 (Professional Boundaries), Poster presenter at Ohio Association for HealthCare (Core Measures) Quality 2014.
Timeline
Personal Leave
Due to Significant Family Loss
06.2024 - 11.2025
Senior Manager of Quality & Accreditation
Naven Health
05.2023 - 06.2024
Director of Clinical Compliance and Regulatory Affairs
Specialty Pharmacy Nursing Network
12.2021 - 06.2024
Director of Patient Safety, Risk and Equity & Compliance Coordinator
HCA/Blake Medical Center
08.2018 - 11.2021
Quality Specialist/Accreditation & Regulatory
Sarasota Memorial Healthcare System/ Sarasota Florida
01.2016 - Current
Quality Coordinator
Cleveland Clinic / SouthPointe Hospital
06.2012 - 12.2015
Clinical Instructor Nursing Education
Cleveland Clinic/South Pointe Hospital
06.2012 - 03.2010
Human Resource Development Specialist
Cleveland Clinic / South Pointe Hospital
06.2003 - 03.2010
Human Resource Development Specialist Home Health Care
Cleveland Clinic Home Care Services
01.2000 - 06.2003
Training and Development Specialist
Elyria Memorial Hospital
01.1996 - 01.2000
Program Development Coordinator
Cleveland Clinic DBA /EMH Home Health Care
04.1994 - 01.1996
Director of Adult Services
Hillmed Home Medical
04.1989 - 04.1994
Critical Care Traveling Nurse
Nurse Finders
01.1989 - 09.1989
Neuro-surgical Critical Care Nurse
University Hospitals of Cleveland
06.1985 - 01.1989
BSN: Bachelor of Science in Nursing - undefined
Kent State University
MSN: Master of Science in Nursing - Healthcare Systems Management
Loyola University New Orleans