Dora Ratcliff
RN
Salinas,CA
Summary
Executive Leader in Compliance, Operations & Mission-Driven Program Oversight
Healthcare and nonprofit-aligned leader with 20+ years of experience strengthening organizational systems, improving safety and compliance, and guiding multidisciplinary teams through complex operational and regulatory environments. Known for a steady, composed leadership style and a deep commitment to serving vulnerable populations with dignity, respect, and accountability. Passionate about ensuring Veterans receive the support and care they are owed for their service to our country.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Accreditation & Regulatory Compliance Director
Salinas Valley Health
Salinas, CA
01.2024 - Current
- Directed accreditation and regulatory readiness for CMS, CDPH, and Joint Commission, leading corrective actions, education, and audits following EMTALA, CDPH, and CAP findings.
- Strengthened organizational safety culture through National Patient Safety Goals initiatives and policy management.
- Partnered with senior leadership and medical staff to evaluate program effectiveness, address operational gaps, and drive continuous improvement.
- Advanced cross-department collaboration to support safe, equitable care for diverse and vulnerable populations.
Accreditation, Regulatory & Licensing Director
Kaiser Foundation Hospital
Downey, CA
01.2016 - 01.2023
- Directed accreditation and regulatory compliance activities for TJC, CMS, CDPH, NCQA, and CAP.
- Identified vulnerabilities and implemented corrective actions in collaboration with physician and administrative leaders.
- Developed educational programs to support staff competency, new standards adoption, and survey readiness.
- Advised leadership on regulatory risk, operational gaps, and performance improvement priorities.
- Strengthened organizational accountability through transparent communication and structured follow-through.
Assistant Director, Perioperative Services
Western Medical Center
- Oversaw OR, Endoscopy, Pre/Post-Op, and Sterile Processing operations for 100+ staff.
- Earlier Leadership Roles (Condensed)
Kaiser South Bay Medical Center
01.2000 - 01.2016
- Supervised 200 employees across perioperative services, achieving 97% on-time surgical starts and 100% SCIP compliance for 18 months.
- Built compliance databases and led annual training programs to strengthen operational performance.
- Conducted sensitive investigations involving privacy breaches, inappropriate conduct, equipment and supply loss, and staff or leadership misconduct, partnering with HR, Legal, and executive leaders to ensure objective review and timely corrective action.
- Supported major system transitions, including HealthConnect EHR implementation and surgical research initiatives.
Operating Room Nurse
Harbor UCLA Medical Center
- Served in trauma, general surgery, and open-heart teams, mentored new staff.
- Earlier Leadership Roles (Condensed)
Education
MS - Health Care Administration
American InterContinental University
BBA - Business Administration
American InterContinental University
ADN - Nursing
Harbor College
Skills
- Accreditation
- Regulatory Compliance
- Patient Safety
- Risk Management
- Policy Development
- Leadership
- Team Development
- Process Improvement
- Communication
- Electronic Health Records
- Continuous Improvement
Certification
- Healthcare Accreditation Certification Professional (HACP)
- Kaiser Compliance Officer Education
- Advanced Leadership & Management Program 2.0 – USC Marshall School of Business
- Kaiser Permanente Middle Management Program
CORE LEADERSHIP STRENGTHS
- Organizational Leadership
- Program Oversight
- Compliance & Accreditation
- Operational Performance
- Staff Development
- Policy Implementation
- Risk Management
- Sensitive Investigations
- Community & Stakeholder Engagement
- Budget Stewardship
- Continuous Improvement
Timeline
Accreditation & Regulatory Compliance Director
Salinas Valley Health
01.2024 - Current
Accreditation, Regulatory & Licensing Director
Kaiser Foundation Hospital
01.2016 - 01.2023
Kaiser South Bay Medical Center
01.2000 - 01.2016
Assistant Director, Perioperative Services
Western Medical Center
Operating Room Nurse
Harbor UCLA Medical Center
MS - Health Care Administration
American InterContinental University
BBA - Business Administration
American InterContinental University
ADN - Nursing
Harbor College