Accomplished Quality Manager overseeing two hospitals and twelve satellite emergency departments, reporting directly to the Market Quality Manager. Following a promotion within the organization successfully developed and implemented a comprehensive quality and risk program for a new hospital, then integrated both hospital quality departments and initiatives into a unified framework. Proven track record in leading transformative initiatives that improve clinical outcomes through strategic data analysis. Demonstrates strong leadership in project management and cross-functional collaboration, leveraging health data analytics to drive performance excellence, and ensure compliance with regulatory standards, while ensuring organization and regulatory compliance.
· Leads the Quality Department, driving high reliability in clinical performance through comprehensive assessments and strategic prioritization of improvement activities.
· Guides data-driven integrated care across multiple hospitals and twelve satellite emergency departments.
· Facilitates performance improvement projects and ensures successful clinical project implementation across operating entities, aligning with system and local targets.
· Collaborates closely with system and operating entities to enhance the quality and outcomes of clinical care.
· Partners with senior leadership to identify and allocate appropriate resources for Peer Review investigations and other operational/clinical priorities.
· Directs improvement teams in the integration of regulatory initiatives to achieve financial objectives, including, CMS, ADHS and The Joint Commission.
· Collaborates with administrators, physicians, clinical leaders, and staff to identify improvement opportunities using qualitative and quantitative data analysis and systems thinking.
· Strategizes with entity leadership to plan local Quality Councils/QAPIs for implementation of evidence-based Clinical Practices and standardized processes for hospital-wide initiatives.
· Provides expertise in performance and process improvement, project management, and change management methodologies for clinical quality initiatives.
· Manages, coaches, and oversees facilitation of improvement activities related to patient safety, harm reduction, clinical performance, peer review, and regulatory compliance.
· Upholds quality infrastructure, protects privileged/confidential information, and promotes interprofessional collaboration for efficient, effective, and safe patient care.
· Leverages organizational analytic environments to guide data-driven decision-making and inform opportunities for improvement..
· Oversees collaboration with process owners for data acquisition and integration from internal and external benchmarking sources.
· Employs statistical and visualization techniques to inform administrative and clinical decisions.
· Provides oversight of ongoing performance assessment, analyzes clinical outcome data, and identifies improvement opportunities and trends.
· Performs clinical documentation review and collaborates with coding professionals to ensure that clinical documentation is accurate, thorough, and complete.
· Partners with Risk Management to analyze patient safety risks and events, facilitating teams to improve processes impacting patient and team member safety.
· Participates in safety investigation results to coach entity leaders on safety improvement activities.
· Guides teams in improvement activities in preparing for, participating in, and following up with Regulatory Surveys.
· Collaborates and leverages results from regulatory opportunities into sustainable action plans.
· Serves as a subject matter expert in compliance with voluntary, mandatory, and contractual reporting requirements for data acquisition, analysis, reporting, and process improvement.
· Oversees current and emerging payment models related to quality performance outcomes, developing and communicating measurement requirements.
· Facilitates medical staff peer review meetings, data and activities.
· Manages the department budget and productivity.
· Facilitates Patient Care and Safety, Quality, and Medical Peer Review Councils.
· Collaborates with the coding department to resolve discrepancies identified through clinical documentation reviews.
· Develops, implements, and approves quality and risk management policies and procedures.
· Educates department managers on compliance documentation.
· Coordinated all aspects of patient care, ensuring safe, compassionate, patient-centered, and evidence-based nursing practices. BLS, ACLS, and PALS certified.
· Demonstrated expertise in assessing, triaging, obtaining telephonic medical histories, critical thinking, and managing patient care within fast-paced critical care environments.
· Exhibited excellence in organizational, communication, and teaching skills for staff, students, and patients.
· Utilized effective communication, team-building, and shared leadership skills to cultivate positive and collaborative relationships.
· Served as a team leader for multidisciplinary teams, safety coach, and Co-Chair patient care council.
Compact Registered Nurse License, Arizona
Certified Professional Healthcare Quality (CPHQ)