Jennifer M. Pekola
Rome,NY
Summary
Experienced nursing professional with more than 20 years of experience in quality management, patient safety, and regulatory compliance. Adept at leading teams, aligning quality goals with organizational strategy, and ensuring adherence to state and federal regulations. Passionate adjunct instructor assisting to create curriculum and motivate students through an online learnging platform.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Director Quality Management and Regulatory Affairs
Mohawk Valley Health System
11.2025 - Current
- Lead system wide quality improvement initiatives to improve clinical outcomes and operational efficiency.
- Facilitate Root Cause Analyses (RCA), Common Cause Analysis (CCA), and other QI methodologies.
- Facilitate quality committees and performance improvement teams.
- Mentor staff in QI methodologies including PDSA cycles and high-reliability principles.
- Coordinate event reporting systems, and safety assessments, ensuring appropriate incident investigation, analysis, and follow-up.
- Serve as the system’s primary liaison for regulatory agencies, including CMS, DNV, OSHA, state departments of health, and others.
- Lead system preparation, readiness, and response for accreditation surveys and regulatory inspections.
Manager, Quality Management
Mohawk Valley Health System - Wynn Hospital
01.2023 - 11.2025
- Collaborate with the Supervisor of Quality Management and eight Quality Professionals
- Active in Regulatory activities by leading site visits by DNV and DOH as well as reporting to NYPORTS and the Justice Center
- Work with the Patient Advocate to respond to and manage patient complaints
- Work with the CMO to coordinate physician complaints
- Verify data integrity and accuracy
- Maintain active membership on the Medication Safety Committee
- Complete insurance company, DNV and DOH complaint reviews and correspondence
- Prioritize patient safety to include review of Midas reports to identify trends and create action plans.
- Ensure compliance to the Medical Staff Bylaws related to OPPE and Peer Review
- Coordinate Peer Review activity within the Peer Review Committee
Supervisor, Quality Management
Mohawk Valley Health System
06.2018 - 01.2023
- Aligned two quality management departments to include case and peer review processes
- Assign complaints and case reviews
- Complete reviews for and follow up with insurance company complaints
- Collaborate with Risk Management with clinical complaints and responses
- Provides quality and regulatory education to Aspiring Leaders, Graduate Nurse Orientation, Charge Nurses, and through Physician Leadership Academy
- Member of the MVHS Nurse Residency Advisory Board
- Co-chair of the Nursing Quality & Performance Improvement Council (since 2011)
- Active member of the Medication Management Committee
- Advanced proficiency in electronic charting systems including Epic, Allscripts, Paragon & Midas
- Perform yearly performance evaluations and reviews for eight employees.
Lead Quality Professional
Faxton St. Luke's Healthcare
12.2014 - 06.2018
- Maintains work schedules for eight staff members
- Delegates cases for review
- Coordinates daily activities
- Complete yearly performance evaluations and competencies
- Assist with reporting cases through the NYPORTS system and complete required paperwork
- Working knowledge of CMS initiatives such as Core Measures and Value Based Purchasing
- Develop, enhance and maintain provider quality profiles and departmental dashboards
- Assist with creating organizational Quality Plans
- Lead regulatory surveys (DNV and DOH) and maintain regulatory plans of correction
- Proficient in DMAIC (process improvement methodology).
Quality Professional
Faxton St. Luke's Healthcare
10.2012 - 12.2014
- Concurrently and retrospectively monitoring and assessing the quality of care delivered by physicians, nurses and ancillary support services using specific approved criteria
- Identification and reporting of NYPORTS events to the Department of Health, and conducting Root Cause Analysis
- Data abstraction, analysis and reporting at physician department meetings and organizational meetings.
Assistant Nurse Manager Of Maternity, Nursery, & Pediatrics
Faxton St. Luke's Healthcare
11.2011 - 10.2012
- Co-managed four nursing units, both in-patient and out-patient
- Worked with the Children's Miracle Network with allocation and fundraising
- Maintained work schedules and payroll for all four units
- Allocated staff and staffing for the unique needs of each unit
- Ensured proper compliance with DNV requirements
- Attended Quality Academy: working on adhering to AWHONN staffing guidelines.
Bariatric Coordinator
Faxton St. Luke's Healthcare
10.2009 - 11.2011
- Maintain facilities designation as a Bariatric Center of Excellence
- Act as a liaison and resource to other departments in caring for bariatric patients
- Promote education about bariatric sensitivity
- Coordinates the organizations monthly support group
- Coordinates and facilitates the organizations bi-monthly bariatric meetings
- Conducts and evaluates Quality and Performance Improvement Initiatives related to bariatric care
- Promotes bariatric services to the public through health fairs.
Assistant Nurse Manager Medical/Surgical Unit And RAU
Faxton St. Luke's Healthcare
05.2007 - 11.2011
- Co-manage a 40 bed acute care unit and a 10 bed Rapid Admission Unit
- Specialize in Orthopedic and Bariatric surgeries
- Schedule staff, designate staff assignments by census, and assist with staff development and training
- Investigate Safety Reports for Quality Assurance
- Ensure proper compliance with the Joint Commission and the NYS DOH requirements.
Staff Registered Nurse
Faxton St. Luke's Healthcare
07.2005 - 05.2007
- Practice Relationship Based Care and Primary Nursing
- Accurately obtained information to complete the Admission Database and Medication History
- Patient advocate
- Effectively prioritized assignments, executing care based on each patient's relative condition and delegating tasks to available personnel deliver safe and efficient care
- Reviewed patient charts and performed standard assessments to identify care needs
- Promoted quality patient care by providing guidance and training on organizational practices and policies for new nurses including nursing students
- Precepted new graduate nurses and students from the local colleges.
Education
Master of Science - Nursing Informatics
Walden University
Minneapolis, MN01.2015
Bachelor of Science - Nursing
Keuka College
Keuka Park, NY01.2009
Associate of Applied Science - Nursing
Mohawk Valley Community College
Utica, NY01.2005
Bachelor of Science - Cytotechnology
SUNY Upstate Medical University
Syracuse, NY01.1999
Associate of Applied Science - Liberal Arts And Science
Mohawk Valley Community College
Utica, NY01.1998
Skills
- Strong presentation skills
- Professional and articulate
- Experienced with regulatory compliance
- Leadership/Management
- Student Engagement
- Online Teaching
- OPPE/FPPE
- Physician peer review
- Patient safety focused
- Process improvement methodologies
Teaching Experience
Adjunct Nursing Instructor (Online)
Utica University - Utica, NY
September 2019 - current
NUR 588 Organizational Leadership & Role Development
NUR 603 Quality Improvement & Safety in Healthcare
NUR 609 Nursing Research & Evidence Based Practice
NUR 613 Health Policy and Advocacy
- Adjunct Instructor for Master's level Nursing classes
- Contributes educational and clinical expertise to help optimize the course and boost student learning
- Utilizes APA and extends this knowledge to assist students
- Strives to continuously update course strategies and content based on current trends and technological advancements in healthcare
- Updated media and resources for NUR 603 in August 2024
- Assisted with course updates for NUR 609
- Communicates frequently with the students to provide feedback and discuss assignments and expectations
- Shares additional resources and real-life experiences in the class synchronous sessions
Adjunct Nursing Clinical Instructor
Mohawk Valley Community College - Utica, NY
August 2007 - May 2009
- Mentored student projects
- Practiced all the fundamentals of nursing with the students in a hospital setting
- Provided continuous instruction to students with skill building
- Graded/critiqued weekly care plan assignments.
Affiliations
- National Association for Healthcare Quality (NAHQ)
- Association for Nursing Professional Development
Certification
- Certified Professional in Healthcare Quality, CPHQ, 2025
- Micro-Credential Data Health Analytics (NAHQ), May 2025
- Incident Command System FEMA training
- Internal Auditor for ISO 9001:2015
- NYS Registered Cytotechnologist, 1999
Licensures
- Registered Nurse in New York, License number 565729 (2005)
- Registered Nurse in Florida, License number RN9518946 (2019)
Accomplishments
- June 2025, CITI Program - Faculty Teaching Research Course, 9 modules
- December 2024 - current, Volunteer NAHQ member. Micro-Credentials Committee. Advise and assist with publishing new micro-credentials.
- July 2024 - current, Women in Leadership Certificate Program advisor, Mercy University.
- October 2024 - IHI CPPS exam course completion in preparation for the CPPS certification exam.
- June 2022 - October 2024, Volunteer NAHQ member, Intelligence & Profession Advancement Strategic Advisory Council. Reviewed and edited 2022 NAHQ Workforce Report. Advisory council to CEO of NAHQ.
Publications
December 2015, Co-authored a published article titled "Staff-led innovations reduce falls in high-acuity patients" in Nursing Management (The Journal of Excellence in Nursing Leadership)
Personal Information
Title: MS, RN, CPHQ
Timeline
Director Quality Management and Regulatory Affairs
Mohawk Valley Health System
11.2025 - Current
Manager, Quality Management
Mohawk Valley Health System - Wynn Hospital
01.2023 - 11.2025
Supervisor, Quality Management
Mohawk Valley Health System
06.2018 - 01.2023
Lead Quality Professional
Faxton St. Luke's Healthcare
12.2014 - 06.2018
Quality Professional
Faxton St. Luke's Healthcare
10.2012 - 12.2014
Assistant Nurse Manager Of Maternity, Nursery, & Pediatrics
Faxton St. Luke's Healthcare
11.2011 - 10.2012
Bariatric Coordinator
Faxton St. Luke's Healthcare
10.2009 - 11.2011
Assistant Nurse Manager Medical/Surgical Unit And RAU
Faxton St. Luke's Healthcare
05.2007 - 11.2011
Staff Registered Nurse
Faxton St. Luke's Healthcare
07.2005 - 05.2007
Bachelor of Science - Nursing
Keuka College
Associate of Applied Science - Nursing
Mohawk Valley Community College
Bachelor of Science - Cytotechnology
SUNY Upstate Medical University
Associate of Applied Science - Liberal Arts And Science
Mohawk Valley Community College
Master of Science - Nursing Informatics
Walden University