Karen Baggett
Healthcare Management
Millbrook,Alabama
Summary
Results-driven Registered Nurse with 18 years of progressive leadership in accreditation, regulatory compliance, infection prevention, and performance improvement. Proven track record in designing and executing enterprise-wide compliance programs for The Joint Commission, CMS, OSHA, and state agencies across acute-care, outpatient, behavioral health, and hospice settings. Skilled in risk assessment, data analytics, strategic action planning, and staff education. Recognized for reducing survey deficiencies, driving quality outcomes, and leading large-scale operational change.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Accreditation Coordinator
Baptist Medical Center South
07.2023 - Current
- Lead enterprise-wide compliance planning for Joint Commission, CMS, and state surveys across a 492-bed tertiary hospital, two cancer centers, behavioral-health facility, hospice, and a network of outpatient clinics
- Translate evolving standards into operational policies, workflows, and training programs; onboard new managers to compliance and risk-management responsibilities
- Maintain centralized documentation repositories and real-time dashboards to inform executive leadership of quality, risk, and operational metrics
- Coordinate Joint Commission Primary Stroke Certification and serve as liaison for unannounced inspections by the Alabama Department of Public Health, CMS, and other agencies
- Work with individual department managers to review performance, strengths, and provide coaching
- Suggest additional training that will assist department managers’ performance development
- Key Achievements:
- Achieved full survey readiness for all entities within 12 months
- Reduced hospital survey findings by 30%, hospice findings by 70%, and attained zero findings at outpatient locations
Director of Nursing Quality
Jackson Hospital & Clinics
05.2022 - 05.2023
- Directed nursing quality initiatives, ensuring compliance with Joint Commission Provision of Care standards and other regulatory requirements
- Collaborated with VP of Patient Care Services to develop patient-care delivery systems, set performance targets, and monitor nurse-sensitive indicators
- Oversaw audit programs, data analysis, and scorecard reporting to nursing leadership and hospital administration
- Designed and launched the Nursing Quality Strategic Plan, revitalized staff recognition programs
- Key Achievements:
- Achieved a 30% reduction in inpatient falls
- Developed and implemented the Nursing Quality Strategic Plan
Director of Infection Control & Employee Health
Jackson Hospital & Clinics
05.2018 - 05.2022
- Directed infection surveillance, prevention programs, and OSHA-mandated COVID-19 compliance for a 346-bed hospital, 30+ clinics, wound-care center, and imaging center
- Conducted gap analyses for CDC, IDSA, APIC, and SHEA guidelines, chaired HAI Committee, Pandemic Preparedness, and multiple task forces
- Created and implemented the hospital’s COVID-19 Response Plan, respiratory protection, TB control, and sharps-injury prevention programs
- Managed all aspects of Employee Health: pre-employment screenings, annual evaluations, and exposure incidents
- Key Achievements:
- Established a centralized Employee Wellness Center for employee COVID-19 testing, vaccination, and return-to-work coordination.
- First hospital in Alabama surveyed by the Joint Commission to achieve 90% staff COVID-19 vaccination compliance
Research & Development Director
The Compliance Store
09.2017 - 05.2018
- Developed web-based regulatory tools and templates for long-term care customers for all 50 states
- Led research team on CMS and state survey requirements
- Key Achievements:
- Created “Binder Basics” educational resource binders
Centers of Excellence Stroke & Trauma Coordinator
Jackson Hospital
05.2014 - 09.2017
- Maintained Primary Stroke Center certification, performed chart reviews, data analysis, and corrective-action planning
- Key Achievements:
- Built the primary stroke program
- Achieved 100% compliance on all stroke core measures
Risk Manager / Director of Quality & Safety / Director of Medical Records
Capitol Hill Healthcare Facility
05.2012 - 05.2014
- Managed liability exposures, peer-review programs, and CMS audits (RAC, CERT, PERM)
- Established OSHA compliance program; led fall-prevention and safety committees
- Directed quality assurance program, complaint & grievance resolution and contract oversight
- Led Physician Credentialing program. Reviewed all contracts for potential liability issues and ensured all contractors complied with contract and liability insurance requirements.
- Responsible for assisting with employee education on the new computer system.
MDS Coordinator
Wetumpka Health and Rehab
08.2011 - 05.2012
- Oversaw PPS/MDS reimbursement processes and documentation accuracy for sub-acute patients
Director of Nursing/ Infection Control Nurse/ Quality Assurance/ Employee Health
Elmore Community Hospital
09.2008 - 07.2011
- Directed all nursing services, infection control, quality assurance, and regulatory reporting
- Managed budgets
- Managed patient satisfaction program.
- Oversaw and approved recruitment, hiring, and orientation of new nursing staff.
- Monitored and evaluated nursing staff performance, providing feedback and guidance to support standards of care.
- Streamlined nursing operations by optimizing staffing schedules, resource allocation, and workflow processes.
- Established and monitored infection control program to provide a safe, sanitary environment to prevent transmission of disease and infection.
Director of Surgery
Elmore Community Hospital
04.2007 - 09.2008
- Led surgical services department operations to include budgeting, policy development, and successful ADPH state survey
- Navigated the company through periods of significant change, maintaining focus on long-term strategic goals.
- Trained and guided team members to maintain high productivity and performance metrics.
- Assisted in recruiting, hiring, and training of team members.
Education
MBA - Health Care Management
Columbia Southern University
Gulf Shores, AL12.2024
Bachelor of Science - Health Care Administration
Columbia Southern University
Gulf Shores, AL11.2023
Associate of Science - Nursing
Troy University
Montgomery, AL05.2002
Skills
- Microsoft Excel, Word, PowerPoint, Outlook
- Data Analytics & Dashboard Tools
- Detail-oriented
- Quality Improvement
- Problem-solving
- Organizational Skills
- Team Leadership
- Training and Development
- Strategic Planning
- Project & Program Management
- Risk Analysis
- Change Management
- Regulatory Compliance
- Litigation Support
- Business Acumen
Certification
- Registered Nurse License, State of Alabama (Multi-State)
- CIC – Certified in Infection Control (2021)
- FEMA ICS I-100, I-200 for Healthcare Organizations
Timeline
Accreditation Coordinator
Baptist Medical Center South
07.2023 - Current
Director of Nursing Quality
Jackson Hospital & Clinics
05.2022 - 05.2023
Director of Infection Control & Employee Health
Jackson Hospital & Clinics
05.2018 - 05.2022
Research & Development Director
The Compliance Store
09.2017 - 05.2018
Centers of Excellence Stroke & Trauma Coordinator
Jackson Hospital
05.2014 - 09.2017
Risk Manager / Director of Quality & Safety / Director of Medical Records
Capitol Hill Healthcare Facility
05.2012 - 05.2014
MDS Coordinator
Wetumpka Health and Rehab
08.2011 - 05.2012
Director of Nursing/ Infection Control Nurse/ Quality Assurance/ Employee Health
Elmore Community Hospital
09.2008 - 07.2011
Director of Surgery
Elmore Community Hospital
04.2007 - 09.2008
MBA - Health Care Management
Columbia Southern University
Bachelor of Science - Health Care Administration
Columbia Southern University
Associate of Science - Nursing
Troy University
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