Kathi Bietz

• Lead enterprise quality improvement initiatives across three acute care hospitals supporting CMS Star Rating, Leapfrog, physician quality metrics, and regulatory performance.
• Achieve improved performance metrics for CMS inpatient and outpatient systems through effective validation processes for eCQM and hybrid measures. Facilitate successful outcomes in pay-for-performance programs, including VBP, HRRP, and HACRP.
• Coordinate regulatory survey readiness through tracers, monitoring, and corrective action planning.
• Monitor and evaluate code blue and rapid response activation data to identify trends and improve patient outcomes.
• Manage multi-disciplinary teams to enhance outcomes related to readmissions, patient safety indicators, venous thromboembolism, and blood therapeutics.
• Develop and deliver presentations of quality and board goal performance data at physician section meetings to foster discussions.
• Analyze and report on quality metrics for physician contracts, ensuring compliance and performance enhancement across six medical groups and multiple state and insurance coalitions.

Accomplishments:

• Assisted in enhancing Siena's CMS star rating from 2 to 3 and San Martin's from 3 to 4 during employment tenure. Supported efforts that improved both Siena and San Martin's Leapfrog grades from C to B and C to A.
• Siena achieved recognition as recipient of the 2026 Patient Safety Excellence Award, placing them among the top 5% of hospitals nationwide.
• San Martin achieved recognition as the #1 hospital in Nevada on Newsweek's 2025 and 2026 list of America's Best-In-State Hospitals.

• Independently covered all departments of a very busy 485-bed hospital, including Chemistry, Hematology, Coag, UA, Serology, Virology, Immunology, and Blood Bank.

• Directed hospital quality reporting and performance improvement programs for CMS inpatient and outpatient quality initiatives.
• Led multidisciplinary teams to improve quality outcomes, patient safety, and regulatory compliance.
• Served as subject matter expert for Value-Based Purchasing, HACRP, HRRP, eCQM validation, and Meaningful Use.
• Partnered with physicians, nursing leaders, and executives to implement evidence-based quality initiatives.
• Supported successful Joint Commission surveys through regulatory readiness, tracers, and performance monitoring.
• Spearheaded development of processes for early sepsis recognition and management through implementation of standardized protocols and order sets across the hospital.
• Compiled and submitted federally mandated COVID-19 data to HHS on a daily basis.
• Supported provider credentialing and reappointment processes by gathering National Provider Data Bank (NPDB) information and OPPE data for department chair and MEC review.
• Facilitated infection control initiatives through comprehensive surveillance monitoring and data collection from CDC/NHSN.

Accomplishments:

• Led initiatives that garnered the Avera Quality Congress Award for impactful contributions to VTE reduction through strategic implementation and surgical excellence. Presented the project at the Premier National Convention in San Antonio, TX.
• Achieved CMS 5-star rating and recognition as a top 20 rural and community hospital for 2020 and 2022, demonstrating excellence in quality measures.

• Achieved smooth lab operations by effectively managing daily tasks. Executed specimen collection and conducted thorough testing to ensure quality results.
• Established a fully functional lab for new family practice office, enhancing patient care. Streamlined procurement process for testing equipment and kits to improve operational efficiency. Facilitated nursing staff training, resulting in proficient execution of lab tests.
• Assisted in performing routine x-ray procedures and operated CT scanner during surgeries (earned Limited Radiography Certification). Supported surgical teams during cataract surgeries and maintained sterilization of instruments.

• Initially employed as the Laboratory Manager; appointed to Laboratory Director in June 2006
• Created a Joint Commission accredited moderate complex lab: purchased instruments, developed procedures, conducted cost analysis, managed budget, monitored QC & QA processes, and ensured compliance with tracers and PDCA
• Assumed role of interim infection control officer, establishing comprehensive policies, procedures and monitoring processes.