Jeanette Ellis
Rogers
Summary
Accomplished nurse and professional leader with over 23 years of diverse health care experience. Thrives on high-quality health care operations and workflows with continuous quality management, safety, performance improvement, education, integrity, and regulatory and accreditation compliance in mind. Strong track record of driving successful programs, projects and initiatives. Skilled in strategic planning, budget management, and stakeholder engagement. Known for fostering team collaboration and adapting to evolving program and project requirements, ensuring consistent achievement of objectives. Proven ability in leadership, problem-solving, and delivering impactful results. Adept at providing consultative clinical and technical support and education, as well as standards guidance in accordance with laws and regulations for workplace and health care environments requiring positive change and/or growth to remain successful.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Program Director, Practice Improvement and Quality Measures Management Support (PIQMMS)
General Dynamics Information Technology, Health Analytics Solutions, Federal Health Division
02.2025 - Current
- Remote Position: Falls Church, Virginia with home office in Rogers, Arkansas
- Serve as Program Director on the Measure and Instrument Development and Support (MIDS), PIQMMS Task Order for the Quality Payment Program (QPP)
- Senior level PMP-certified nurse and health IT professional responsible for health policy analysis, data analytics and integrity, predictive modeling, systems development, health regulation development and reviews, Congressional and clearance comments, health information exchange (HIE), and health program and quality management through the lifecycle for the QPP within the Center for Medicare and Medicaid Services (CMS), Center for Clinical Standards and Quality (CCSQ), Quality Measurement and Value-Based Incentives Group (QMVIG), Division of Clinician Quality (DCQ)
- Scheduled and supervised staff meetings to discuss new ideas and update participants on program details and milestones.
- Recruited and trained staff and volunteers to upgrade collective team skills.
- Mentored team members for professional development, resulting in increased productivity and job satisfaction.
- Provided ongoing direction and leadership for program operations.
- Collaborated with various teams to uncover issues, identify applicable solutions, and offer guidance.
- Collaborated closely with executive leadership to develop strategic plans for long-term growth.
- Delivered outstanding program results by setting clear objectives and proactively addressing potential challenges.
- Monitored program performance to identify areas for improvement.
- Established strong partnerships with internal and external stakeholders for collaborative problem solving.
- Advanced community outreach efforts by forging strong relationships with local partners.
- Coordinated budgeting, scheduling and resource allocation to facilitate smooth flow of operations.
- Evaluated program performance through comprehensive data analysis, driving continuous improvement efforts.
- Maintained and updated project related documents.
- Established program policies and procedures to comply with regulatory requirements.
- Developed and implemented program goals and objectives, establishing specific and measurable outcomes aligned with organization's overall mission.
- Led change management initiatives, fostering a positive organizational culture during periods of transition.
- Consistently exceeded key performance indicators by adapting quickly to changes in program needs.
- Implemented best practices in project management to optimize workflow efficiencies across the organization.
- Managed cross-functional teams to deliver exceptional program outcomes within budget and time constraints.
- Communicated regularly with stakeholders, updating on progress to build support for program.
- Enhanced program efficiency by streamlining processes and implementing innovative solutions.
- Negotiated program contracts and agreements to obtain cost-effective pricing.
- Improved stakeholder satisfaction through regular communication and updates on project progress.
- Utilized data-driven decision-making techniques to ensure alignment with organizational goals.
- Analyzed program data to inform decision-making and improve outcomes, leveraging advanced analytics tools.
- Developed and managed program budget, optimizing resource allocation to meet strategic objectives.
- Identified risks and developed mitigation plans.
- Led cross-functional teams to achieve project milestones, ensuring timely and within-budget delivery.
- Cultivated high-performing team by recruiting top talent and providing ongoing professional development opportunities.
Senior Clinical and Program Analyst Expert
General Dynamics Information Technology, Health Analytics Solutions, Federal Health Division
02.2024 - 02.2025
- Remote Position: Falls Church, Virginia with home office in Rogers, Arkansas
- Senior level PMP-certified nurse and health IT professional responsible for health policy analysis, data analytics and integrity, predictive modeling, systems development, health regulation development and reviews, Congressional and clearance comments, health information exchange (HIE), and health program and quality management through the lifecycle within the federal health divisions (e.g., Centers for Medicare and Medicaid Services [CMS], Indian Health Services [IHS], Department of Veterans Affairs/Veterans Health Administration [VHA], Department of Defense [DOD], National Institutes of Health [NIH], and Centers for Disease Control and Prevention [CDC]).
- Managed large-scale, complex, multi-disciplined projects within the federal health care sector.
- Responsible for the full spectrum of business development, including capture management, business partner networking, proposal development (e.g., technical and business proposals), and labor/budget forecasting.
- Served as a clinical and business liaison between customers, federal partners, interested parties and application development teams for purposes of ensuring accurate implementation of health care standards and processes through Federal rulemaking and in accordance with statutes.
- Managed and provide expertise to diverse teams in reviewing requirements, specifications, automation options, testing, support, quality assurance and training plans to ensure alignment with business objectives and standards for all program projects.
- Trusted expert on performance in quality measure evolution and implementation.
- Proven ability to mitigate risk through established risk management strategies and knowledge of changes in federal program reporting and implementation requirements.
- Developed methods for evaluating federal quality and clinical program alignment, thereby reducing burden for stakeholders. This is inclusive of the National Quality Strategy priority areas and goals (e.g., outcomes and alignments, interoperability and scientific advancement, safety and resiliency, and equity and engagement).
- Leveraged advanced techniques for efficient feedback for federal program cycles, complex quality measure analyses, and high quality deliverables.
- Led and utilized innovative machine learning tools for expeditious rulemaking and plain writing deliverables.
- Reviewed and provide guidance on Requests for Information (RFIs).
- Provided clinical and program guidance regarding document submission and dissemination.
- Provided technical expertise and presented federal health agency reports, briefing papers, Congressional actions, executive orders and memorandums.
- Supported and advised on aspects related to the Paperwork Reduction Act (PRA), including development and updating of standard operating procedures (SOPs) for the federal health and civilian division.
- Reviewed program Statement of Work (SOW) and Performance Work Statements (PWS), updating the project management plan accordingly with updates to the Schedule of Deliverables (SODs).
- Coordinated with federal agencies’ contracting and legal teams for all acquisition agreements.
- Facilitated effective communication between team members, fostering a positive work environment conducive to collaboration.
- Monitored program performance against established benchmarks, taking corrective action as needed to realign with desired outcomes.
- Trained team members on new software tools, improving overall productivity and efficiency.
- Developed detailed project plans outlining tasks, timelines, dependencies, and resource requirements for successful execution of complex initiatives.
Acting Deputy Director
Department of Health and Human Services, Centers for Medicare and Medicaid Services
11.2023 - 02.2024
- Remote Position: Woodlawn, Maryland with home office in Rogers, Arkansas
- Served as Acting Deputy Director for the Center for Clinical Standards and Quality (CCSQ), Quality Measurement and Value-Based Incentives Group (QMVIG), Division of Electronic and Clinician Quality (DEQ) (e.g., overall division operations, strategic planning, employee performance proficiencies and plans, employee and labor relations, etc.) while maintaining responsibilities as MVP Lead and MIPS Quality Measures Lead.
- Fostered a positive work environment by promoting collaboration, transparency, and open communication among team members.
- Developed strategic plans to achieve organizational goals, ensuring alignment with company's mission and vision.
- Coordinated cross-functional teams to successfully execute large-scale projects on time and within budget constraints.
- Collaborated with other department heads to ensure smooth functioning of organizational activities.
- Improved coordination and communications across organization to increase operational efficiency.
Senior Nurse, MIPS Value Pathways (MVPs) Lead
Department of Health and Human Services, Centers for Medicare and Medicaid Services
07.2023 - 02.2024
- Remote Position: Woodlawn, Maryland with home office in Rogers, Arkansas
- Served as a Senior Nurse and Merit-based Incentive Payment (MIPS) Value Pathways (MVP) Lead in CCSQ/QMVIG/DEQ providing clinical and technical consultation for the MVPs program, while maintaining responsibilities as the MIPS Quality Measures Lead.
- Oversaw the development, maintenance, and implementation of MVPs. Inclusive of quality measures, cost measures, population health measures, improvement activities, and promoting interoperability.
- Ensured quality and safety standards aligned with existing laws, regulations, and policies applicable to CMS administered programs.
- Led the MVP development team in future strategic planning and coordination.
- Reviewed and approved contractor developed deliverables in accordance with respective SOWs, PWSs and SODs. These included but were not limited to: candidate MVP reports; MVP development priorities (short-term and long-term) reports and documents; Webinar slide content; education and outreach materials (e.g., fact sheets, guides, Web page content, etc.); MVP contractor roles and responsibilities matrix; contractor responses to stakeholder inquiries; and MVP candidates published for a 30-day comment period.
- Led and facilitated the MVP development Webinars and education sessions.
- Led and facilitated the MVP development meetings, educating stakeholders and federal partners on program requirements and participation.
- Facilitated development and maintenance of MVP policies, while tracking future items for rulemaking.
- Led the broader QPP team in decision-making processes and strategic direction of the program.
- Ensured issues were discussed in a timely manner, and all consultative perspectives were included when briefing issues to the Office of the Administrator, as well as the CCSQ and QMVIG Senior Leadership Team (SLT).
- Reviewed and tracked ICD-10 code updates, as well as HCPCS/CPT II files.
- Coordinated with the APM team as needed.
- Coordinated with the MITRE and MVP development teams in data analysis and integrity, as well as preparation for policy planning.
- Led, facilitated, and participated in rules briefings to the Office of the Administrator and Secretary as needed.
- Reviewed and responded to health regulation and policy clearance comments.
- Provided sign off on the MVP Inventory pages.
- Responsible for the C-BB, F-A, F-C and C-A pages in the Physician Fee Schedule Final Rule.
Senior Nurse, MIPS Quality Measures Lead
Department of Health and Human Services, Centers for Medicare and Medicaid Services
06.2022 - 02.2024
- Remote Position: Woodlawn, Maryland with home office in Rogers, Arkansas
- Served as a Senior Nurse, MIPS Quality Measures Lead, and Quality Team Co-Lead leading and providing clinical and technical consultation to improve outcomes related to clinical standards and quality/safety oversight programs.
- Ensured quality and safety standards aligned with existing laws, regulations, and policies applicable to CMS administered programs.
- Reviewed and responded to health regulation and policy clearance comments.
- Led measure development and promotion of clinical standards that health care organizations, physician practice groups and individual physicians must meet for eligibility and continued participation in the QPP [e.g., MIPS and Alternative Payment Models (APMs), MVPs, etc.].
- Reviewed operating policies utilized in determining whether health care entities meet federal standards.
- Reviewed and tracked ICD-10 code updates, as well as HCPCS/CPT II files.
- SME for regulatory specifications, impact analyses, and responses to comments in the proposed and final rules that established or updated the Medicare/Medicaid quality and safety standards. Examples: 1) Led and provided clinical consultation and guidance regarding the 2022 Measures Under Consideration (MUC) List clearance comments posed by the Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA). 2) Led and provided clinical consultation and guidance regarding the 2022 MUC measure specifications for final review and publication. 3) Responded to Office of General Counsel’s (OGC) comments/questions on the 2023 Physician Fee Schedule Final Rule, specifically for the C-H and F-A pages. 4) Regulation writer, reviewer and SME for the 2024 Physician Fee Schedule Final Rule, specifically F-A pages.
- Provided clinical consultation and guidance regarding measure specification development. Collaborated with contractors and measure stewards to verify these measure specifications.
- Demonstrated exceptional knowledge, skills and abilities and seen as a leader within the workgroup.
- Ensured issues were discussed in a timely manner, and all consultative perspectives were included when briefing issues to QMVIG SLT. Offered well thought out mitigation strategies. Examples: 1) Led review and coordinated with contractors on matter raised by QMVIG Director and Interagency Task Force on suicide risk. This included providing clinical education and technical consultation on the subjects of suicide risk, follow-up/safety planning, and behavioral health, which were applicable to the following measures under consideration (MUC): MUC2022-127 Initiation, Review, Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior or Suicide Risk; and MUC2022-131 Reduction in Suicidal Ideation or Behavior; MUC2022-122 Improvement or Maintenance of Functioning Mental Health and Substance Use Disorder. 2) Led and provided scoring synopsis to QMVIG SLT for the updated measure QID400 One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation. Raised concerns regarding the determination of how we score the measure and provided recommendations on solution.
- Coordinated within DECQ and across QMVIG, CCSQ, CM, and CMMI to achieve consensus and reduce duplicative efforts. This included strategy, policy development and resources management. Solicited feedback from partners and external stakeholders on assigned projects or programs, and collaborated with team members to recommend and implement improvements.
- Provided clinical education and program guidance regarding document submission and dissemination, including public availability of QPP program specific activities in accordance with regulations.
- Evaluated and provided technical expertise for QPP and other health agency reports, briefing papers, Congressional actions, executive orders and memorandums.
- Supported and advised on QPP programs related to the PRA, including development and updating of SOPs in DECQ.
- Supported Executive Leadership, as well as current Administration stakeholders with strategic planning and communication of shared vision. Examples: 1) Provided clinical education, guidance and consultation to QMVIG Director regarding the MIPS quality measures and QCDR measures which could be applicable to the current administration’s Cancer Moonshot project. 2) Provided clinical education and consultation regarding the Digital Quality Measurement (dQM) transition through a RFI. Identified components missing from the dQMs definition, including differentiating between dQMs from eCQMs. Validated the value of having dQMs versus eCQMs.
Chief Nurse of Quality, Safety and Value (QSV)
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
08.2021 - 06.2022
- Responsible for the development, oversight, and effectiveness of the health care organization’s Quality, Safety, and Value (QSV) service line. Included direct supervision for the following QSV programs and personnel: Patient Safety, Risk Management, Accreditation, Systems Redesign/HRO, Performance Measures, VASQIP, Quality and Performance Management, Infection Prevention and Control, Utilization Management, Integrity and Compliance Program, Credentialing and Privileging, Lab Quality Management, Nursing Education, Nursing Quality, Primary Care Quality, Mental Health Quality, and Program Assistants.
- As a member of the executive leadership team and reporting responsibilities to the Medical Center Director, Associate Medical Center Director, and VISN 16 Network Director, led and provided consultative recommendations for overall health care operations of administrative and clinical programs based on statistical data analyses and integrity, strategic planning, policymaking, regulations and revision activities, research (quantitative, qualitative and mixed-methods), evidence-based practice, and stakeholder feedback.
- Led, facilitated and guided health care organizational operations, policy and regulation negotiations, revisions, and creation in accordance with the Veterans Health Administration business rules and initiatives.
- Collaborated with other members VHSO’s executive leadership team as well as other management staff and Network Leaders to address organizational approaches in assessing the environment, forecasting trends based on data analyses, transmitting values, communicating ideas, developing, and implementing standards and policies, initiating programs and systems, identifying gaps in quality of care, and overall management of care and resources at the facility and VISN level.
- Served as the clinical and technical advisor and educator on Incident Command during the COVID-19 Pandemic Public Health Emergency (PHE) for VHSO and VISN 16.
- Collaborated with facility multidisciplinary team to assess environment and feasibility of transition to Oracle Cerner Electronic Health Record (EHR), identifying gaps and vulnerabilities with the transition.
- Provided other members of VHSO’s executive leadership team consultative advice and led decision-making in assessing, analyzing, acquiring, and administering human, financial, material, and information resources. This included providing financial stewardship for over $500M in budgetary resources per annum.
- Responsible for over $200,000 per annum budget of the QSV service line, which was inclusive of two fund control points covering legal and consultative services, staff training, supplies, and equipment. Collaborated with VHSO’s Budget and Finance service in making operational and financial expertise decisions for the QSV service line, as well as in identifying any budget issues with regards to the overall impact of protocol amendments, timeline changes and operational changes. Prepared quarterly budget reviews by developing benchmark data and documentation of justifications.
- Oversight and coordination of internal and external legal reviews, audits, hotline cases, investigations, and/or issue briefs. Facility and VISN Lead and Point of Contact (POC) for the Office of Special Counsel (OSC), Office of General Counsel (OGC), Office of Inspector General (OIG) (health care and criminal), Office of Medical Inspector (OMI), Government Accountability Office (GAO)-Office of Inspector General (OIG) Accountability Liaison (GOAL) Office, Office of Accountability and Whistleblower Protection (OAWP), National Center for Ethics in Health Care and Office of Internal Audit and Risk Assessment, Occupational Safety and Health Administration (OSHA) and U.S. Environmental Protection Agency (EPA). Provided all requested documents by external offices. Created restricted, secure SharePoint sites for uploading confidential documents requested during reviews, audits, hotline cases, investigations, and/or issue briefs. Collaborated with specified external office contact in arranging interviews and coordinating meetings. Developed and edited issue briefs and/or investigation reports including all facts, evidence, testimonies and determination (e.g., substantiated, partially substantiated, and unsubstantiated). Developed, tracked, and monitored causation and corrective action plans (CCAPs) in accordance with findings from internal and external reviews, audits, hotline cases, investigations, and/or issue briefs. Briefed/presented investigation reports to facility, VISN and VACO executive leadership.
- Led and directed VHA OIG investigation regarding secondary pathology lookback, a high-profile, multijurisdictional case. Led and directed review of Level 2 and Level 3 pathology reading errors. Developed process for tracking and conducting quality reviews for disclosures of pathological errors in diagnosis(es), the impact on care, and amendments of the EHR documentation.
- Led and facilitated integrity and compliance program (formerly known as compliance and business integrity) effectiveness at the facility and VISN level in collaboration with the Compliance Officer. Included evaluation of Business Associate Agreements (BAAs) and payer contracts. Conducted and facilitated third-party audits in collaboration with Compliance Officer. Conducted HIPAA/Privacy and Whistleblower investigations.
- Led and facilitated 80% of QSV service line team members in becoming HRO trainers and CTT trainers in CY2021 for VHSO’s HRO program.
- Led and facilitated the organization’s monthly Joint Commission (TJC) mock surveys, Tracer Methodology, Commission on Accreditation of Rehabilitation Facilities (CARF [behavioral/mental health, residential rehabilitative treatment, intensive outpatient program, medical rehabilitative services, psychosocial rehabilitation and recovery centers, employment and community services, substance use disorders]) and continued readiness meetings with organizational leaders and stakeholders.
- Served as key personnel on Professional Standards Boards, reviewing new personnel credentialing and privileging as well as Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE).
- Provided recommendations and guidance regarding survey readiness and external review issues to VHSO’s Executive Leadership Team (Pentad) and organizational stakeholders.
- Led interviewing and hiring processes of vacancies and newly created positions in QSV. Made selections and uploaded applicable documents in USA Staffing.
- Led, collaborated and consulted with employee and labor relations regarding workforce complaints and priorities within the health care system, inclusive of managerial reassignments and promotions, disciplinary action and EEO complaints.
- Assessed, rated, and approved employee performance proficiencies and plans in ePerformance.
- Mentored junior nurses, fostering professional growth and clinical competence within the team.
- Championed quality improvement initiatives focusing on enhancing the safety of patients under our care unit''s supervision.
- Evaluated new medical equipment before purchase ensuring that it meets regulatory requirements as well as being compatible with existing infrastructure.
- Coordinated patient care services and managed clinical cost control.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
Associate Chief Nurse of QSV/Accreditation Coordinator
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
08.2019 - 12.2021
- Direct supervision for the following programs: Accreditation, Quality and Performance Management, Infection Prevention and Control, and Utilization Management.
- Indirect reports were Patient Safety, Risk Management, Systems Redesign/HRO, Performance Measures, VASQIP, Integrity and Compliance Program, Credentialing and Privileging, Lab Quality Management, Nursing Education, Nursing Quality, Primary Care Quality, Mental Health Quality, and Program Assistants.
- Assessed, rated, and approved employee performance proficiencies and plans in ePerformance.
- Designated facilitator and educator for VHA Safety Standdown as directed by the Acting Under Secretary for Health.
- Led, facilitated, and negotiated strategic planning for realignment of Nursing, Primary Care and Mental Health Quality programs under QSV service line. Strategic planning also included expansion/creation of new Sterile Processing Services and Social Work Quality programs, as well as OIG readiness program under QSV service line.
- Designated Chief Nurse of QSV as needed.
- Served as the clinical educator and technical advisor on Incident Command during the COVID-19 Pandemic Public Health Emergency (PHE) for VHSO and VISN 16.
- Facilitated and guided health care organizational operations, policy and regulation negotiations, revisions, and creation in accordance with the Veterans Health Administration business rules and initiatives.
- Collaborated with facility multidisciplinary team to assess the infrastructure environment and feasibility of transition to Oracle Cerner EHR, identifying gaps and vulnerabilities with the transition.
- Provided education, consultative advice and guidance regarding evidence-based practice, quality management, performance improvement and accreditation and regulatory practice standards to stakeholders.
- Disseminated information to stakeholders regarding current standards, elements of performance and compliance for TJC and CARF.
- Collaborated with the Performance Measures Coordinator in identifying key performance indicators, including analyzing and validating measurable data as well as identifying trends and opportunities for improvement (e.g., ORYX, HEDIS, SAIL, etc.).
- Led, facilitated, and negotiated contract management and quality monitoring to assist with external accreditation compliance.
- Developed, published, and conducted organizational tracers, observations, and audits to ensure compliance and survey readiness. Compliance metrics were as follows for these accreditation tracers and observations: *FY19 (prior to transitioning into the role): Only 322 tracers and observations were conducted with 93% compliance. *FY20 (after transitioning into the role): 730 tracers and observations with 96% compliance. *FY21: 573 tracers and observations with 97% compliance.
- Led and facilitated the organization’s monthly TJC mock surveys, Tracer Methodology, CARF (behavioral/mental health, residential rehabilitative treatment, intensive outpatient program, medical rehabilitative services, psychosocial rehabilitation and recovery centers, employment and community services, substance use disorders) and continued readiness meetings with organizational leaders and stakeholders.
- Led and facilitated random audits of the Veterans’ claims review process, ensuring claims were reviewed and paid correctly in accordance with VHA Directive.
- Provided recommendations and guidance regarding survey readiness issues to VHSO’s Executive Leadership Team (Pentad) and organizational stakeholders.
- Analyzed and trended statistical data and deficiencies within TJC Resources Portal Illuminate Analytics. Reported in QSV Committee with recommended corrective actions for improvement.
- Monitored overall effectiveness of organizational tracers, observations, and audits making modifications as necessary in accordance with VHA program, and accreditation standards and regulatory updates.
- Served as key personnel on Professional Standards Boards, reviewing new personnel credentialing and privileging as well as FPPE and OPPE.
- QSV representative along with facility Suicide Prevention Coordinators on the VA Suicide Risk ID and SPED Technical Assistance group.
- QSV representative on the High Risk for Suicide Patient Record Flag (HRS-PRF) Review Committee, supporting facility Suicide Prevention Coordinators and facility stakeholders in determining the activation and deactivation of flags.
- Facilitated and guided organizational policy negotiations, revisions, and creation in accordance with the Veterans Health Administration business rules and initiatives.
- Led, facilitated, and protected the confidential nature and integrity of Administrative Investigation Boards (AIBs) along with the Risk Manager and Chief Nurse of QSV as directed by VHSO’s Executive Leadership Team (Pentad).
- Conducted formal and informal Fact Findings as directed by VHSO’s Executive Leadership Team (Pentad).
- Oversight and coordination of internal and external investigations. Lead and POC for the OSC, OGC, OIG, OMI and GAO-OIG legal reviews, audits, hotline cases, investigations, and issue briefs. Conducted legal reviews and analyses of Veteran EHRs. Provided all requested documents by external offices conducting investigations. Collaborated with specified external office contact in arranging interviews, and coordinating meetings prior to investigations.
- Co-led interviewing and hiring processes of vacancies and newly created positions in QSV. Made selections and uploaded applicable documents in USA Staffing.
- Led, collaborated and consulted with employee and labor relations regarding workforce complaints and priorities within the health care system, inclusive of managerial reassignments and promotions, disciplinary action and EEO complaints.
- Coordinated and collaborated with VHSO stakeholders in completing the Network Director and Medical Center Director Fiscal Year Performance Plan addressing strategic intent, demonstrated performance, and integrity within each of the five critical elements reflected in the executive core qualifications.
- Demonstrated commitment to continuous learning through participation in relevant conferences, workshops, and seminars related to nursing leadership trends or issues impacting the field at large.
- Streamlined processes to improve efficiency in daily nursing operations, reducing overtime hours required by staff members.
- Developed and delivered training programs for nursing staff to enhance their skills and knowledge.
- Implemented innovative strategies to reduce hospital-acquired infections, resulting in improved patient outcomes.
- Discussed patient care and treatment with care team members to optimize intervention plans and care delivery.
- Designed and implemented standards of care for nursing and patient care.
- Established strong relationships with physicians and other healthcare professionals for optimal collaboration and patient care coordination.
- Coordinated seamless transitions between departments during times of patient transfers or discharges, enhancing overall patient experience.
- Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Quality and Performance Management Specialist
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
01.2018 - 10.2019
- Provided education, analyzed data, and developed reports to identify opportunities for improving compliance in accreditation standards and elements of performance.
- Led and facilitated home-based primary care, behavioral health, outpatient surgery, endoscopy, and surgery team members in providing safe, quality Veteran care, and facilitate initiatives/projects to ensure quality improvement and staff performance.
- Evaluated accreditation standards relating to clinical practice, service line, and program policies/procedures to ensure local directives were following standards of practice. This was inclusive of Veterans Health Administration Directives and Handbooks, Medical Center Memorandums (MCMs), Medical Service Memorandums (MSMs), Nursing Service Memorandums (NSMs), Standard Operation Procedures (SOPs), employee competencies, and functional statements.
- Demonstrated expertise in developing effective monitors for gathering, analyzing, and trending data to ensure continued compliance with external mandates (e.g., National Patient Safety Goals [NPSG], Nurse Practice Acts, American Nurses Association [ANA], OIG, Office of Nursing Service [ONS], National Surgery Office [NSO], TJC, CARF, etc.). Made quality improvement decisions based on professional standards, patient safety, quality health care information.
- Facilitated Medicine SAIL workgroup, focusing on analysis of Ambulatory Care Sensitive Conditions, Readmissions, and Mortality (SMR, SMR 30). Provided clinical and technical expertise to drive improvement initiatives.
- Led and participated as a member of professional and/or health related groups within the community, facility (VHSO), and Veterans Integrated System Network (VISN).
- Developed standard operating procedures to facilitate data collection, aggregation, and presentations that enhanced data utilization to drive care improvement initiatives.
- Facilitated collection of reports from service lines for the monthly QSV Committee reviews.
- Collected and input data into IPEC and other databases within the required reporting dates.
- Supported the Associate Chief Nurse of QSV/Accreditation Coordinator role by entering assigned assessments into TJC, OIG, CARF, and other external review sites as needed.
- Designated Associate Chief Nurse of QSV/Accreditation Coordinator as needed.
- Designated VASQIP RN as needed.
- Served on AIBs as needed.
- Conducted clinical reviews for pathology lookback (34,000+ cases) as part of the VHA OIG health care and criminal investigations into oversight failures.
- Conducted formal and informal Fact Findings as directed by Executive Leadership.
- Responded to OIG hotline cases and issue briefs as needed.
- Led and participated in interview panels as needed.
- Reduced operational costs by identifying areas for improvement and implementing cost-saving measures.
- Delivered successful projects within deadlines through effective time management and resource allocation.
- Developed strong relationships with stakeholders, ensuring clear communication and alignment on project objectives.
Registered Nurse, Outpatient Surgery
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
10.2015 - 01.2018
- Direct care nurse for all phases of care in Outpatient Surgery (Preop, PACU, Phase II).
- Demonstrated leadership skills, utilized problem solving methodologies, and maintained a professional working relationship with all team members.
- Managed unit resources which resulted in decreased waste, improved efficiencies and decreased liabilities while enhancing care and practice.
- Cross-trained and assisted as circulating nurse in the operating room, and endoscopy nurse as needed.
- Updated the SOPs for outpatient surgery, endoscopy, and the operating room.
- Led designated team members in updating SOPs and competencies for Sterile Processing (SPS) Department, as well as Outpatient Surgery and Operating Room.
- Functioned as the nurse educator for the operating room staff.
- Developed and implemented surgical services nursing orientation manual, objectives, and competencies.
- Completed Yellow and Green Belt LEAN training. Received LEAN Green Belt certification.
- Received approval for implementation and facilitation of AORN’s Periop 101 program (e.g., online modules, simulations, etc.) for Outpatient Surgery and Operating Room staff members.
- Led and facilitated systems redesign project in preventing patient harm and promoting best outcomes among cataract surgery patients.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Administered medications safely according to established guidelines while closely monitoring for side effects or adverse reactions requiring intervention.
- Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.
- Prevented the spread of infections by consistently adhering to strict infection control protocols and educating patients on proper hygiene practices.
- Participated in ongoing professional development opportunities to stay current on best practices in nursing care and emerging trends in healthcare delivery.
- Collaborated with interdisciplinary teams to develop comprehensive treatment plans for complex patients with multiple comorbidities.
- Facilitated patient transitions between different levels of care, ensuring continuity of services and minimizing disruptions in treatment plans.
- Implemented evidence-based fall prevention strategies, resulting in a significant decrease in patient falls within the unit.
- Collaborated with interdisciplinary teams to develop comprehensive care plans for complex cases.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Equipped patients with tools and knowledge needed for speedy and sustained recovery.
- Investigated and resolved issues affecting hospital operations and patient care.
- Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Served as a preceptor for nursing students during their clinical rotations, providing valuable real-world experience and guidance to foster professional growth.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Improved patient outcomes by implementing evidence-based nursing interventions and individualized care plans.
- Promoted a culture of safety within the healthcare facility by participating in quality improvement initiatives, identifying potential hazards, and advocating for best practices in nursing care delivery.
- Educated family members and caregivers on patient care instructions.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Registered Nurse, Operating Room and PACU
Mercy Northwest Arkansas
10.2014 - 10.2015
- Served as circulating nurse and surgical scrub nurse (as needed) in all specialty areas.
- Delegation of authority as charge nurse as needed.
- Developed staffing methodology/labor mapping and clinical workflows for surgical services anticipating growth and surgical complexity of the operating room, as well as effect on other hospital department needs.
- Preceptor and mentor for new nurses in an accredited nurse residency program.
- Updated surgical services nursing curriculum and competencies according to accreditation requirements.
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Served as a preceptor for nursing students during their clinical rotations, providing valuable real-world experience and guidance to foster professional growth.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Improved patient outcomes by implementing evidence-based nursing interventions and individualized care plans.
- Promoted a culture of safety within the healthcare facility by participating in quality improvement initiatives, identifying potential hazards, and advocating for best practices in nursing care delivery.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
- Educated family members and caregivers on patient care instructions.
- Evaluated patient histories, complaints, and current symptoms.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
Registered Nurse, GI/Endoscopy
Mercy Northwest Arkansas
06.2013 - 10.2014
- Direct care nurse for all phases of care.
- Collaborated with other health care professionals to provide safe, quality patient care.
- Streamlined medication administration processes for increased safety and accuracy during busy shifts.
- Managed patients recovering from medical or surgical procedures.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Monitored patient reactions after administering medications and IV therapies.
- Observed and documented patient factors such as diets, physical activity levels, and behaviors to understand conditions and effectively modify treatment plans.
- Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
- Recorded details regarding therapies to keep patient charts updated.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
- Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
- Led teams in driving successful patient outcomes by prioritizing standard of care and best practices.
- Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.
- Prevented the spread of infections by consistently adhering to strict infection control protocols and educating patients on proper hygiene practices.
- Participated in ongoing professional development opportunities to stay current on best practices in nursing care and emerging trends in healthcare delivery.
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Assisted in the training and mentorship of new nursing staff members, contributing to a positive work environment and high-quality patient care.
- Served as a preceptor for nursing students during their clinical rotations, providing valuable real-world experience and guidance to foster professional growth.
- Promoted a culture of safety within the healthcare facility by participating in quality improvement initiatives, identifying potential hazards, and advocating for best practices in nursing care delivery.
- Contributed to interdisciplinary team meetings by presenting relevant clinical data about patients'' progress toward reaching established goals of care.
- Improved patient outcomes by implementing evidence-based nursing interventions and individualized care plans.
- Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.
- Collected core quality measures (health indicators), and disseminated data to the unit, members of the leadership and management group, and Quality Council.
- Participated in the interview process of new employees.
- Developed and implemented a new GI/Endoscopy nursing curriculum and competencies.
Clinical Nurse III/IV, Unit Nurse Educator and Supervisor (Perioperative Services) and Quality Outcomes Coordinator (Quality, Safety and Research)
University of Kansas Health System (Hospital)
04.2011 - 05.2013
- Co-Supervisory responsibility for staffing methodology/labor mapping for Perioperative Services.
- Co-Supervisory responsibility for overall operations of Perioperative Services.
- Co-Supervisory responsibility, including annual performance evaluations and scheduling for 200+ employees in the main operating room area.
- Led and facilitated staff training sessions for 200+ employees on specific products and equipment used in the operative setting.
- Developed and implemented perioperative nursing curriculum and competencies according to accreditation requirements.
- Facilitated and updated accredited nurse residency program including seminars, large group settings with fellow new graduate nurses, and small group settings with unit specific nurses each month for the 12-month residency program (starting months of January and June).
- Conducted weekly conferences with new employees to track progress in orientation.
- Collected core Surgical Care Improvement Project (SCIP) measures and presented data to other members of the Perioperative Leadership and Management team, the Department of Nursing, and Perioperative staff members.
- Collaborated with the Nursing Quality and Research Team to analyze and disseminate: 1) NDNQI’s quality measures and comparisons to national benchmarks; 2) NDNQI’s practice environment and job satisfaction survey results; 3) Press Ganey Perioperative patient satisfaction measures and comparisons to national benchmarks; and 4) HCAHPS quality measures, surveys, and comparisons to national benchmarks. Provided clinical and technical expertise to drive improvement initiatives.
- Conducted tracers, observations, and audits to ensure compliance with TJC and CMS standards and ongoing survey readiness.
- Prepared regulatory specifications and data analyses in accordance with TJC and CMS quality and safety standards.
- Collaborated with Hospital Administration, the Department of Nursing, and other members of the Magnet® Steering Committee to gather evidence related to nursing excellence for the organization’s redesignation process. Evidence focused on empirical outcomes; exemplary professional practice; new knowledge, innovations, and improvements; structural empowerment; and transformational leadership.
- Updated and facilitated medical student and resident orientation program for all areas within Perioperative Services.
- Led and facilitated the Department of Nursing Nurse Residency and Nurse Academy Programs.
- Administrator for AORN Periop 101 program.
- Led and facilitated the interviewing and hiring processes of new employees to Perioperative Services.
Clinical Nurse II/III, Unit Coordinator Supervisor
University of Kansas Health System (Hospital)
08.2010 - 04.2011
- Charge nurse responsible for staffing assignments. Included staffing methodology across shifts.
- Maintained strong working relationships with physicians and ancillary staff, fostering a collaborative approach to patient care delivery.
- Responded to patient emergencies to provide prompt and correct intervention .
- Educated patients and families to increase understanding of condition and best ways to manage.
- Collaborated with interdisciplinary teams for optimal patient outcomes and efficient care coordination.
- Mentored new nursing staff, fostering professional growth and team building within the unit.
- Acted as a clinical resource for colleagues seeking guidance on best practices or challenging cases, contributing to a supportive learning environment within the unit.
- Stayed current with health system initiatives and incorporated evidence-based practice and research into care routine.
- Promoted a culture of safety by maintaining strict adherence to infection control protocols and reporting potential hazards.
- Coordinated seamless transitions between levels of care by effectively communicating with multidisciplinary team members throughout the process.
- Streamlined workflow processes, improving overall efficiency within the unit.
- Handled patient transfers, following safety protocols to prevent injuries.
- Responded to medical emergencies with prompt and decisive action, minimizing patient risk and improving outcomes.
- Coordinated with multidisciplinary teams to ensure cohesive patient care and treatment strategies.
- Participated in continuous professional development, staying abreast of latest nursing practices and standards.
- Improved team efficiency by mentoring new nurses, sharing expertise and fostering supportive work environment.
- Led health promotion initiatives within community, raising awareness on critical health issues and prevention methods.
- Conducted research on patient care practices, integrating evidence-based approaches to improve care quality.
- Facilitated and attended interdisciplinary meetings to discuss patient care.
- Handled confidential patient information with discretion, adhering to HIPAA regulations to protect privacy rights.
- Trained new Unit Coordinators on unit-specific protocols, contributing to overall team proficiency in delivering exceptional patient care experiences.
Clinical Nurse I, Circulator/Scrub RN-PACU-CTS ICU
University of Kansas Health System (Hospital)
06.2009 - 08.2010
- Circulator and scrub RN for all surgical specialties, transplants, trauma, and CVOR/Hybrid.
- Float RN to Cath Lab, Interventional Radiology, Preop, PACU, and Cardiothoracic Surgery (CTS) ICU.
- Maintained strong working relationships with physicians and ancillary staff, fostering a collaborative approach to patient care delivery.
- Administered medications and treatments to manage patient's condition.
- Utilized evidence-based practice to assess and provide care for patients.
- Participated in quality improvement initiatives to improve patient care outcomes.
- Demonstrated knowledge of technical procedures and proper equipment use.
- Utilized advanced assessment skills to identify early indications of deterioration in a patient''s condition, enabling prompt intervention when needed.
- Developed strong rapport with patients and families, promoting open communication channels for effective collaboration in treatment plans.
- Ensured accurate documentation of all patient records, contributing to improved quality assurance measures.
- Maintained patient confidentiality by protecting unauthorized access to personal information.
- Monitored patients, evaluated results, and recommended further courses of treatment to quickly improve patient outcomes.
- Increased patient satisfaction scores through consistent delivery of compassionate and culturally competent care.
- Maintained accurate and comprehensive patient records in line with regulatory standards.
- Served as a patient advocate, ensuring individual needs were met and concerns addressed promptly.
- Participated in hospital-wide initiatives aimed at reducing medication errors and improving patient safety practices.
- Utilized technology to improve patient care, integrating electronic health records and telehealth services.
- Managed patient records with meticulous attention to detail, ensuring accuracy and confidentiality.
- Advocated for patients' needs and preferences, ensuring their voices were heard in treatment decisions.
- Participated in quality improvement initiatives to improve patient care.
- Evaluated patient progress, assessed outcomes and provided follow-up care.
- Monitored and maintained clinical supplies, materials and inventory.
- Assessed effectiveness of clinical nursing interventions and programs.
- Created educational materials for staff and patients.
- Conducted research and developed evidence-based clinical guidelines.
- Demonstrated adaptability by quickly adjusting to new technologies or procedures in the rapidly evolving healthcare industry.
- Ensured a sterile environment for surgeries by adhering to strict protocols and guidelines.
- Assisted surgical teams with seamless communication, resulting in a well-coordinated and successful procedure.
- Supported surgical teams to achieve successful patient outcomes by providing critical assistance during complex surgeries.
- Facilitated patient education on post-operative care, promoting quicker recoveries.
- Promoted positive working relationships within the surgical team through open communication and collaboration on best practices.
- Supported patient recovery by assisting with post-operative care plans and providing appropriate discharge instructions.
- Streamlined workflow in the operating room through effective communication with surgeons, anesthesiologists, and other staff members.
- Improved patient care by efficiently preparing operating rooms and ensuring all necessary supplies were readily available.
- Reduced patient anxiety and increased comfort with compassionate pre-operative communication and care.
Licensed Practical Nurse
Craig Homecare
08.2008 - 03.2009
- Part-tim LPN for critically ill children, specifically oncology, cerebral palsy, and spina bifida.
- Improved patient outcomes by administering medications, monitoring vital signs, and documenting relevant information.
- Cared for wounds, provided treatments, and assisted with procedures.
- Assisted with admissions, appointments, transfers, and discharges.
- Collaborated with interdisciplinary healthcare teams to ensure continuous quality improvement in patient care delivery.
Freelance Technical Writer
Self-employeed
10.2002 - 06.2009
- Contract technical and grant writer, specifically working with local and regional health care entities.
- Proved successful working within tight deadlines and a fast-paced environment.
- Managed version control and timely updates of documents through effective project tracking and organization skills.
- Conducted thorough document reviews to identify inaccuracies, inconsistencies, or areas needing clarification.
- Followed policies and editorial guidelines of companies to craft thorough, well-written content.
- Coordinated with subject matter experts to ensure the accuracy of technical content in documentation projects.
- Ensured regulatory compliance by keeping abreast of industry standards and updating documentation accordingly.
- Enhanced user experience by simplifying complex technical concepts into easy-to-understand documentation.
- Adapted documentation style to suit different platforms, from print to online formats.
- Ensured all documentation complied with industry standards and legal requirements.
- Managed documentation projects from concept to completion, meeting all deadlines.
- Reviewed and edited technical documents for clarity, grammar, and accuracy before publication.
Medical Information Specialist, Clinical Researcher and Writer
University of Kansas Health System (Medical Center for Research)
06.2004 - 12.2006
- Member of team earning NCI designation for the health care system.
- National Cancer Institute (NCI) at the University of Kansas Health System (Heartland Office)
- Conducted regular audits of internal documentation systems for accuracy and completeness while maintaining strict adherence to regulatory requirements.
- Streamlined database management through consistent data entry and organization, facilitating easier access to critical information when needed.
- Improved overall customer satisfaction by promptly addressing inquiries from patients, caregivers, and healthcare providers.
- Collaborated with pharmacovigilance teams to ensure seamless reporting of adverse events related to company products.
- Enhanced patient care by providing accurate and timely medical information to healthcare professionals.
- Served as a subject matter expert on specific therapeutic areas, offering guidance and insight when required by team members or external parties.
- Participated in industry conferences and workshops as a representative of the company, staying current on relevant trends and advancements within the field.
- Conducted thorough literature reviews to support the creation of evidence-based responses for complex inquiries.
- Supported clinical trial teams by providing medical expertise during study design phases, contributing to more efficient trials with improved outcomes.
- Developed comprehensive medical information materials for distribution to external stakeholders, such as healthcare professionals and patients.
- Participated in cross-functional projects to optimize information-sharing processes across various departments.
- Maintained up-to-date knowledge of industry regulations, ensuring compliance with all relevant policies and procedures.
- Upheld HIPAA regulations and standards for protecting patient information.
- Catalogued patient data in clinical databases and registries according to regulatory practices.
- Assisted with analysis of research data in collaboration with research department.
- Supported publications of research findings in peer-reviewed journals by preparing well-organized manuscripts that adhered to submission guidelines.
Program Manager and Grant Writer
University of Kansas Health System (Medical Center for Research)
06.2002 - 06.2004
- Managed and supervised administrative and daily program operations, complying with policies and regulations.
- Established strong relationships with key stakeholders, ensuring support for program initiatives.
- Developed strategic plans, setting clear objectives and achievable milestones for the team.
- Managed cross-functional teams for successful project completion within deadlines and budgets.
- Conducted comprehensive program evaluations, identifying areas for improvement and recommending actionable solutions.
- Facilitated workshops and conducted one-on-one training to educate team members.
- Utilized data-driven decision-making approaches to inform strategy development and optimize outcomes.
- Met with project stakeholders on regular basis to assess progress and make adjustments.
- Delivered high-quality results by setting performance metrics and monitoring progress against targets.
- Interacted with internal partners and obtained detailed information about organization's mission and goals to form solid foundation for grant applications.
- Supported capacity building initiatives within the organization by providing training on grant writing best practices to staff members.
- Maintained compliance with funder requirements by diligently monitoring project progress and submitting timely reports.
- Enhanced collaboration within the organization by providing regular updates on grant activities and progress toward goals.
- Streamlined the grant application process by creating templates and tools for consistent proposal content.
- Tracked in-process and previously submitted grant applications to obtain status updates.
- Generated monthly grant writing activities reports and submitted documentation to director to promote funding program transparency.
- Contributed to a positive organizational culture by promoting open communication, teamwork, and shared success in fundraising efforts.
- Wrote, reviewed and edited proposals for grants, gifts, and contracts.
Education
Doctor of Nursing Practice - Healthcare Leadership and Quality Performance Improvement
University of Missouri-Kansas City
Kansas City, MO05.2019
Master of Science in Nursing - Healthcare Quality Management
MidAmerica Nazarene University
Olathe, KS12.2015
Master of Science in Nursing - Family Nurse Practitioner
Frontier Nursing University
Hyden, KY08.2013
Bachelor of Science - Nursing
MidAmerica Nazarene University
Olathe, Kansas12.2011
Associate Degree in Nursing -
Park University
Parkville, Missouri05.2009
Licensed Practical Nurse, Practical Nursing Diploma -
Cass Career Center
Harrisonville, Missouri06.2008
Bachelor of Science - Professional/Technical Writing
Missouri State University
Springfield, Missouri05.2002
Skills
- Program management and leadership
- Effective leader
- Staff development and education
- Relationship building and partnership development
- Policy implementation
- Operations oversight
- Budgeting and financial management
- Compliance management
- Innovation and creativity
- Curriculum development
- Policy and procedure improvements
- Quality assurance
- Coaching and mentoring
- Recruitment and hiring
- Performance evaluation
- KPI tracking
- Resource allocation
- Performance standards and analysis
- Organizational skills
- Multitasking Abilities
- Attention to detail
- Staff hiring and evaluations
- Teamwork and collaboration
- Decision-making
- Educational program planning
- Strategic planning
- Regulatory compliance
- Microsoft Office 360
- Microsoft Project Professional
- Windows and Mac OS
- Adobe Acrobat Pro and Reader
- Confluence
- Slack
- Box
- WebEx
- Zoom and Zoom Pro
- MS Teams
- AWS
- Tableau
- Plain Writing and 508 Compliance
- ORSOS Intraoperative Charting
- EPIC (including OpTime)
- Cerner
- CPRS and VISTA
- Stedman’s Plus
- Style Guides (APA, AMA, etc)
- CAMS (contract management) and Federal Acquisition Regulation (FAR) System
- Completion of CMS HL7 FHIR Training
- ORYX
- HEDIS
- Coding Systems (eg, HCPCS, CPT, ICD-10, SNOMED)
- SharePoint
- Introduction to Pyramid Analytics (Business Intelligence Office, Office of Information Technology)
- Reporting with Data Discovery (Business Intelligence Office, Office of Information Technology)
Accomplishments
- 2023 Honor Award, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, awarded September 2023
- 2022 Performance Award for Contributions to QMVIG/DECQ Mission, awarded Spring 2023
- NOLA U Quality Professional Pathways, awarded August 2021
- Department of Veterans Affairs, Certificate of Admiration and Gratitude, Outstanding Support and Contributions to the HFMEA Team “Suicide Risk Screening for all Veterans and Identifying Vulnerabilities with Environment,” Veterans Healthcare System of the Ozarks, awarded July 2020
- Department of Veterans Affairs, Certificate of Admiration and Gratitude, Outstanding Support and Contributions to the “Aggregate RCA for VHSO’s Leroy Pond Residential Rehabilitation Treatment Program Events from October 1, 2018 through July 22, 2019,” Veterans Healthcare System of the Ozarks, awarded August 2019
- Department of Veterans Affairs, Certificate of Appreciation for Time, Commitment and Dedication to the Pathology Lookback, Veteran’s Healthcare System of the Ozarks, awarded September 2018
- Department of Veterans Affairs, Certificate of Commitment, Exhibition of the Core Value of Commitment working diligently to serve Veterans and other beneficiaries, Veteran’s Healthcare System of the Ozarks, awarded April 2018
- Department of Veterans Affairs, Secretary’s Award for Nursing Excellence, Registered Nurse of the Year, Veteran’s Healthcare System of the Ozarks, awarded May 2017
- Department of Veterans Affairs, Medical Center Director’s and VISN 16 Network Director’s Commendation Award, Exceptional Service and Leadership, awarded October 2016
Affiliations
- General Dynamics Information Technology, Federal Civilian Division, Health Analytics Solutions
- National Quality Forum (NQF), Leadership Consortium, 2024-Present
- Ability First, Aspire, Honor and ForWARD ERG Communities, 2024-Present
- Department of Health and Human Services, Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality, Quality Measurement and Value-Based Incentives Group, Division of Electronic and Clinician Quality
- MVP Framework Meeting (Lead/Facilitator), 2023-2024
- MVP Dedicated Discussion (Facilitator), 2023-2024
- QPP/MVP Small Workgroup (Lead/Facilitator), 2023-2024
- HCD/Policy Bi-Weekly Touchbase (Facilitator), 2023-2024
- American Medical Association (AMA) meetings (as needed), 2023-2024
- CY PFS Proposed Rule Webinar (every Summer), 2023-2024
- CY PFS Final Rule Webinar (every November/December), 2023-2024
- MVP Development and Maintenance Kick Off Webinar (every Spring), 2023-2024
- Promoting Quality Cancer Care Outcomes (PQCQO) Workgroup (Cancer Moonshot), 2023-2024
- QMMS Weekly COR Meeting, 2022-2024
- Data Aggregation Weekly Meeting, 2022-2024
- Quality Team Weekly Meeting (Lead), 2022-2024
- ACIO Data Aggregation Concerns and eCOM Reporting, 2022-2024
- PIMMS Rulemaking Weekly Touchbase, 2022-2024
- QMMS Weekly Staff Meeting with Contractors, 2022-2024
- MIPS Weekly Staff Meeting with Contractors, 2022-2024
- QMTF Weekly Meeting, 2022-2024
- PIMMS COR Meeting, 2022-2024
- QMMS Measure Stewards Meeting, 2022-2024
- MIPS Meeting, 2022-2024
- Yale CORE and CMS Outpatient MIPS Measure Workgroup (Pilot 1 and 2), 2022-2024
- CMS Cross-Component Alignment Workgroup, 2022-2024
- ECQM Standards Status Meeting, 2022-2024
- QPP Performance Year Policy Planning, 2022-2024
- DECO Monthly Staff Meeting, 2022-2024
- EC eCQM Measure Finalization Meeting, 2022-2024
- SDOH Screening Measures Meeting, 2022-2024
- MVPs and APM Alignment, 2022-2024
- CMS Quality Workgroup (includes strategic planning), 2022-2024
- NQF MAP Coordinating Committee Quarterly Meeting, 2022-2024
- QIO 13th SOW Bi-Weekly Workgroup (includes strategic planning), 2023-2024
- CMS ACOE’s Health Equity Data Workgroup, 2023-2024
- Department of Veterans Affairs, Office of Quality and Patient Safety
- Office of Quality Management, Quality Professionals Community of Practice, 2020-2022
- Department of Veterans Affairs, Office of Nursing Service
- VA Nursing Excellence Collaborative, 2018-2020
- Field Advisory Committee (FAC) task force, RN Transition to Practice (TTP), 2017-2020
- Department of Veterans Affairs, Government Accountability Office (GAO) Office of Inspector General (OIG) Liaison Program
- OIG CHIP Survey Readiness, National Repository for Action Plans Workgroup, 2021-2022
- OIG CHIP Survey Readiness, Checklists and Standardized Action Plans Workgroup, 2020-2022
- Department of Veterans Affairs, VISN 16
- VISN 16 Accreditation/Continuous Readiness Community of Practice Council, 2020-2022
- VISN 16 CARF Community of Practice Council, 2020-2022
- VISN 16 OIG Book Club, 2020-2022
- VISN 16 QSV Committee, 2019-2022
- VISN 16 Quality Chief Council, 2019-2022
- VISN 16 Performance Measures, 2019-2022
- VISN 16 Planning Member and Development of Annual Chief of Staff and Quality Management Officer Face to Face Conference, 2019-2020
- VISN 16 Surgery Workgroup Planning Member and Development of Annual Surgical Face to Face Conference, 2018-2022
- VISN 16 Surgical Workgroup, 2018-2022
- VISN 16 Surgical Face to Face Annual Conference, 2018-2022
- VISN 16 Surgical Service Community of Practice, 2018-2022
- VISN 16 Staffing Methodology, Nursing Clinical Services, 2018-2022
- Department of Veterans Affairs, Veteran’s Health Care System of the Ozarks
- Facilitator and Lead for VHA Safety Standdown, June 14-30, 2021
- VA Suicide Risk ID and SPED Technical Assistance, 2021-2022
- High Risk for Suicide Patient Record Flag (HRS-PRF) Review Committee, 2021-2022
- Incident Command, 2020-2022
- Integrated Ethics Council, 2020-2022
- Strategic Planning, 2020-2022
- HRO Trainer Planning Committee, 2020-2022
- HRO Trainer, 2020-2022
- Executive Leadership Board, 2019-2022
- EOC/ARB, 2019-2022
- Quality, Safety and Value Committee, 2018-2022
- Research and Development Committee, 2018-2022
- Medical Executive Council, 2018-2022
- ICU Committee, 2018-2022
- Nursing Service Quality Committee, 2018-2022
- Baldridge Governor’s Award writing team, 2019-2022
- Governance Structure Reorganization and Alignment, 2019-2022
- Medical Center Director’s Performance Plan, 2019-2022
- Fayetteville Inpatient Behavioral Health Activation Team, 2020-2022
- Fort Smith CBOC Activation Team, 2019-2022
- Springfield CBOC Endo Activation Workgroup, 2019-2022
- Community of Care Oversight Committee, 2019-2022
- Tissue and Transfusion Committee, 2019-2022
- Out of Operating Room Procedure Tracking Workgroup, 2019-2022
- Antimicrobial Stewardship Committee, 2018-2022
- Pharmacy and Therapeutics Committee, 2018-2022
- Super Tuesday SAIL Collaborative, 2018-2022
- Emergency Department Committee, 2018-2022
- Leroy Pond Residential Rehabilitation Treatment Program Workgroup, 2018-2022
- Goals of Care Training and Implementation Committee, 2018-2022
- Evidence-Based Practice Inculcating Planning, 2018-2022
- Accreditation Readiness and Tracer Methodology, 2018-2022
- Evidence-Based Practice Committee, 2017-2022
- Operating Room Committee, 2018-2022
- Facility Surgical Workgroup, 2018-2022
- Life Sustaining Treatment Decisions Initiative Subcommittee, 2018-2022
- SAIL Workgroups, 2018-2022
- VISN 16 Supervisor Training: Cornerstones, 2019
- ANCC Pathway to Excellence Conference, 2019
- ANA Quality and Innovation Conference, 2019
- ANCC Pathway to Excellence Steering Committee, Leader and Coordinator, 2018-2020
- ANCC Pathway to Excellence Shared Decision-Making Workgroup, Leader, 2018-2020
- Central Arkansas Veteran’s Healthcare System IRB member, 2018-2020
- Inpatient Nursing Collaborative, 2018-2020
- Focused Review, 2018-2020
- Veteran’s Experience Committee, 2018-2020
- Veteran’s Advocacy Council, 2018-2020
- National Tele Stroke Program Committee, 2018-2019
- Interdisciplinary Care Committee, 2018-2019
- Patient Centered Care Steering Committee, 2018-2019
- Right Start Sponsor New Employee Orientation, 2017-2019
- Barriers to EBP Process Development, 2017-2019
- Other Affiliations
- American Nurses Association, 2015-Present
- Arkansas Nurses Association, Membership Assembly Representative, 2015-Present
- Sigma Theta Tau, Pi Theta Chapter, President Elect, Board of Directors, 2019-2021
- Sigma Theta Tau, Pi Theta Chapter, Programs Committee Member, Board of Directors, 2019-2021
- Sigma Theta Tau, Pi Theta Chapter, Nurse Leader, 2018-2022
- Arkansas Nursing Research Alliance Evidence Based Practice Forum, 2018-2019
- Association of periOperative Registered Nurses (AORN), Razorback Country Chapter, 2013-2017
- Missouri Nurses Association (MONA), 2009-2013
- AORN, Greater Kansas City Chapter, 2009-2013
- Mercy Northwest Arkansas
- Quality Council (Chairman), 2013-2015
- Unit-Based Practice Council (Chairman), 2014-2015
- University of Kansas Health System
- IHI Expedition: Engaging Frontline Teams, 2013
- Member and Facilitator, Nursing Peer Review Committee (Department of Nursing), 2011-2013
- ANCC Magnet Steering Committee (Department of Nursing), 2011-2013
- ANCC Magnet Conference and Designee, 2009-2012
- Quality Team, Safety and Strategic Planning Team (Department of Nursing), 2011-2013
- Quality Council (Department of Nursing), 2011-2013
- Quality Outcomes Coordinator Liaison (Department of Nursing), 2011-2013
- Facilitator, Quality Safety Investigator Program (Divisional), 2011-2013
- Facilitator, Nurse Residency Program (Department of Nursing), 2011-2013
- 5 Star Symposium Planner, 2011-2013
- Practice Council (Unit, Divisional and Department of Nursing), 2009-2013
- New Employee Preceptor, 2010-2013
- Competency Steering Team, 2011-2013
- Laser Safety Nurse, 2010-2013
- KU Nurse’s Association, 2009-2013
Certification
- Registered Nurse – State of Arkansas, Expires 02/28/2026
- Project Management Professional – Project Management Institute, Credential # 3856045, Renewal 6/17/2027
- Federal Acquisition Certification Contracting Officer’s Representatives (FAC-COR) Level 1 – Completion April 2023
- LEAN Green Belt Certification – VA Center for Applied Systems Engineering, 02/15/2017
Languages
English
Native or Bilingual
Interests
- “CY 2025 Physician Fee Schedule Proposed and Final Rule,” Published by the Centers for Medicare and Medicaid Services, Baltimore, Maryland, November 2024
- “CY 2024 Physician Fee Schedule Proposed and Final Rule,” Published by the Centers for Medicare and Medicaid Services, Baltimore, Maryland, November 2023
- “CY 2023 Physician Fee Schedule Proposed and Final Rule,” Published by the Centers for Medicare and Medicaid Services, Baltimore, Maryland, November 2022
- DHHS/CMS/CCSQ/QMVIG/DECQ, Presenter and Representative – “Team-based Care Approach through Traditional MIPS and MVPs,” US Health Resources and Services Administration (HRSA), Council on Graduate Medical Education (COGME) a Federal Advisory Committee, September 2023
- DHHS/CMS/CCSQ/QMVIG/DECQ, Contributing Subject Matter Expert and Clinical Workgroup Member (not writer) – “Aligning Quality Measures across CMS – The Universal Foundation” Collaborative Black Belt Project between Veterans Healthcare System of the Ozarks (VSHO) and Michael E DeBakey VAMC – “Suicide Risk Identification and Management in VHSO’s Emergency Department,” April-October 2021
- Veterans Healthcare System of the Ozark – HFMEA Team “Suicide Risk Screening for all Veterans and Identifying Vulnerabilities with Environment,” closeout July 2020
- Veterans Healthcare System of the Ozarks – “Aggregate RCA for VHSO’s Leroy Pond Residential Rehabilitation Treatment Program Events from October 1, 2018 through July 22, 2019,” closeout August 2019
- DNP EBPQI Project Publication, manuscript submission – “Standardizing code blue documentation and leader-driven team debriefing to improve Veteran outcomes and self-efficacy performance: A quality improvement initiative,” Journal of Emergency Nursing, May 2019
- Veteran Health Administration, National RN TTP Residency Program Presentation, Office of Nursing Service and Stakeholders – “RN TTP Curriculum: Performance Improvement and Evidence-Based Practice,” Office of Nursing Services, May 2019
- Pathway® to Excellence Journey Poster – “Standard Two: Leadership,” Representative for Veteran’s Health Care System of the Ozarks (VHSO), 2019 VA Nursing Excellence Collaboration, Orlando, Florida, April 2019
- DNP EBPQI Project Dissemination – “Implementation of a standardized process review for code blue events at the Veteran's Health Care System of the Ozarks (VHSO),” Arkansas Nurses Research Alliance’s 5th Annual EBP Forum, Little Rock, Arkansas, November 8, 2018
- DNP EBPQI Project – “Implementation of a standardized process review for code blue events at the Veteran's Health Care System of the Ozarks (VHSO),” University of Missouri-Kansas City, August 2017-present, closeout May 2019
- National Surgery Office, Veteran’s Health Care System of the Ozarks, Enhanced Recovery After Surgery (ERAS) – “Implementing an ERAS program for Colon Resection Patients at the Veteran’s Healthcare System of the Ozarks (VHSO),” VHSO, September 2018
- Enhanced Recovery After Surgery (ERAS) Program Presentation – “Implementing an ERAS program in the Facility: The standards and recommendations for implementation,” VISN 16 Surgical Face to Face, Biloxi, Mississippi, June 2018
- Veteran’s Health Administration, FAC RN TTP Mentoring Task Force, Deep Dive – “RN TTP Program Facilitator Guide,” Office of Nursing Services, June 2017 to June 2020 Veteran Health Administration, FAC RN TTP Modules/Curriculum Task Force – “RN TTP Curriculum: Performance Improvement and Evidence-Based Practice,” Office of Nursing Services, June 2017 to June 2020, modules published March 2018
- AORN Periop 101 Program – “Online Modules and Simulation Scenarios for Outpatient Surgery and Operating Room,” Veteran’s Health Care System of the Ozarks, June 2017
- VHSO Systems Redesign Initiative – “Medication Management for Cataract Surgical Patients,” Veteran’s Health Care System of the Ozarks, January 2017
- Capstone/Thesis/Pilot Study – “Use of Exparel (liposomal bupivacaine) in total knee arthroplasty patients,” MidAmerica Nazarene University and the University of Kansas Hospital, Capstone August 2015-October 2015, Thesis presented December 2015, Pilot Study January-September 2016
- Abstract – “PSN reports spur OR and Pharmacy safety changes,” University of Kansas Hospital Headlines, March 2013
- Abstract and Podium Presentation – “Take ACTION: A collaborative approach to creating a culture of safety,” 40th Annual National Conference on Professional Nursing Education and Development, October 2013 Facilitator and Presenter – “Culture of Safety, Facilitator and Presenter – Four-part series incorporating the Harvard Institute’s First Do No Harm videos within the Perioperative Division,” University of Kansas Hospital, January 2013-February 2013
Awards
2023 Honor Award, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, awarded September 2023, 2022 Performance Award for Contributions to QMVIG/DECO Mission, awarded Spring 2023, NOLA U Quality Professional Pathways, awarded August 2021, Department of Veterans Affairs, Certificate of Admiration and Gratitude, Outstanding Support and Contributions to the HFMEA Team “Suicide Risk Screening for all Veterans and Identifying Vulnerabilities with Environment,” Veterans Healthcare System of the Ozarks, awarded July 2020, Department of Veterans Affairs, Certificate of Admiration and Gratitude, Outstanding Support and Contributions to the “Aggregate RCA for VHSO’s Leroy Pond Residential Rehabilitation Treatment Program Events from October 1, 2018 through July 22, 2019,” Veterans Healthcare System of the Ozarks, awarded August 2019, Department of Veterans Affairs, Certificate of Appreciation for Time, Commitment and Dedication to the Pathology Lookback, Veteran’s Healthcare System of the Ozarks, awarded September 2018, Department of Veterans Affairs, Certificate of Commitment, Exhibition of the Core Value of Commitment working diligently to serve Veterans and other beneficiaries, Veteran’s Healthcare System of the Ozarks, awarded April 2018, Department of Veterans Affairs, Secretary’s Award for Nursing Excellence, Registered Nurse of the Year, Veteran’s Healthcare System of the Ozarks, awarded May 2017, Department of Veterans Affairs, Medical Center Director’s and VISN 16 Network Director’s Commendation Award, Exceptional Service and Leadership, awarded October 2016, Dean’s List and Honors Graduate, MidAmerica Nazarene University Graduate Nursing Program, May 2014, December 2014, May 2015 and December 2015, Dean’s List and Honors Graduate, MidAmerica Nazarene University Nursing Program, December 2011, Dean’s List and Honors Graduate, Park University, December 2008 and May 2009, Honors Graduate, Cass Career Center Practical Nursing Program, June 2008, Outstanding Graduate, Cass Career Center Practical Nursing Program, June 2008
Licensure
- Registered Nurse – State of Arkansas, Expires 02/28/2026
- Project Management Professional ® – Project Management Institute, Credential # 3856045, Renewal 6/17/2027
- Federal Acquisition Certification Contracting Officer’s Representatives (FAC-COR) Level 1 – Completion April 2023
- LEAN Green Belt Certification – VA Center for Applied Systems Engineering, 02/15/2017
Timeline
Program Director, Practice Improvement and Quality Measures Management Support (PIQMMS)
General Dynamics Information Technology, Health Analytics Solutions, Federal Health Division
02.2025 - Current
Senior Clinical and Program Analyst Expert
General Dynamics Information Technology, Health Analytics Solutions, Federal Health Division
02.2024 - 02.2025
Acting Deputy Director
Department of Health and Human Services, Centers for Medicare and Medicaid Services
11.2023 - 02.2024
Senior Nurse, MIPS Value Pathways (MVPs) Lead
Department of Health and Human Services, Centers for Medicare and Medicaid Services
07.2023 - 02.2024
Senior Nurse, MIPS Quality Measures Lead
Department of Health and Human Services, Centers for Medicare and Medicaid Services
06.2022 - 02.2024
Chief Nurse of Quality, Safety and Value (QSV)
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
08.2021 - 06.2022
Associate Chief Nurse of QSV/Accreditation Coordinator
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
08.2019 - 12.2021
Quality and Performance Management Specialist
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
01.2018 - 10.2019
Registered Nurse, Outpatient Surgery
Department of Veterans Affairs, Veteran’s Healthcare System of the Ozarks
10.2015 - 01.2018
Registered Nurse, Operating Room and PACU
Mercy Northwest Arkansas
10.2014 - 10.2015
Registered Nurse, GI/Endoscopy
Mercy Northwest Arkansas
06.2013 - 10.2014
Clinical Nurse III/IV, Unit Nurse Educator and Supervisor (Perioperative Services) and Quality Outcomes Coordinator (Quality, Safety and Research)
University of Kansas Health System (Hospital)
04.2011 - 05.2013
Clinical Nurse II/III, Unit Coordinator Supervisor
University of Kansas Health System (Hospital)
08.2010 - 04.2011
Clinical Nurse I, Circulator/Scrub RN-PACU-CTS ICU
University of Kansas Health System (Hospital)
06.2009 - 08.2010
Licensed Practical Nurse
Craig Homecare
08.2008 - 03.2009
Medical Information Specialist, Clinical Researcher and Writer
University of Kansas Health System (Medical Center for Research)
06.2004 - 12.2006
Freelance Technical Writer
Self-employeed
10.2002 - 06.2009
Program Manager and Grant Writer
University of Kansas Health System (Medical Center for Research)
06.2002 - 06.2004
Bachelor of Science - Professional/Technical Writing
Missouri State University
Doctor of Nursing Practice - Healthcare Leadership and Quality Performance Improvement
University of Missouri-Kansas City
Master of Science in Nursing - Healthcare Quality Management
MidAmerica Nazarene University
Master of Science in Nursing - Family Nurse Practitioner
Frontier Nursing University
Bachelor of Science - Nursing
MidAmerica Nazarene University
Associate Degree in Nursing -
Park University
Licensed Practical Nurse, Practical Nursing Diploma -
Cass Career Center