Kelly Welch

Accomplished Director of Quality with a proven track record of developing and implementing quality initiatives. Skilled in driving continuous improvement and ensuring regulatory compliance for optimal organizational performance. Strategic, organized Director of Quality Management with 29 years of experience achieving organizational excellence in the healthcare industry. Excellent leadership and communication skills integrated with analytical abilities to determine areas for potential improvement. Continuously evaluated and improved quality of care and patient satisfaction and experience.

Led the facility to a CMS 5-star rating for five consecutive years.

• Healthcare Accreditation Certification Professional (HACP)
• Ambulatory Clinic Nursing (AMB-BC)
• Team STEPPS Master Trainer
• Lean Six Sigma

• Policy and Procedure Committee
• Clinical Compliance Accreditation Committee
• Co-Chair of system falls committee
• Regional patient experience service advisor
• COVID-19 initiatives for the regional center
• Pathway to Excellence and Magnet Certification

• Lead regulatory activities and survey accreditation processes
• Educate staff on regulatory compliance requirements, TJC, CMS standards
• Provide clinical support, quality, and patient safety initiatives to hospital staff
• Lead process improvement initiatives (PDCA, FMEA)
• Report data analytics and deliver presentations to senior leadership
• Multidisciplinary collaboration on patient experience metrics, HCAHPS
• Provide leadership, supervision, and new staff orientation preceptorship
• Provide direct patient care
• Perform pre-and post-operative x-rays, wound care
• Provide patient education on disease process’ and surgical procedures
• Manage physician’s clinic and hospital rotation schedule
• Coordinate interdisciplinary care between home health, specialists, DME, and therapy