Lisa Hayes
West Jefferson
Summary
Results-oriented expert in regulatory compliance and patient safety, with a proven track record in conducting comprehensive consultations and leading educational workshops. Focused on promoting a culture of continuous improvement and ensuring adherence to regulatory standards in healthcare environments.
Overview
19
19
years of professional experience
3
3
Certifications
Work History
JCR CSR Consultant
Joint Commission Resources
West Jefferson
11.2018 - Current
- Conducted on-site consultations for Critical Access Hospitals to enhance regulatory readiness.
- Guided clients in navigating CMS and Joint Commission standards for compliance clarity.
- Delivered educational presentations at bi-annual Ohio CSR workshops on regulatory updates.
- Shared best practices among hospitals to bolster quality and patient safety protocols.
- Provided customized on-site support during CSR visits, addressing unique organizational needs.
- Prioritized patient safety during CSR visits, identifying opportunities for improvement.
- Discussed potential areas of opportunity if patient safety issues arose during consultations.
Accreditation - Associate Director
Ohio State Wexner Medical Center
Columbus
11.2012 - 11.2018
- Conducted on-site clinical tracers across all patient care departments to identify compliance trends and improvement opportunities.
- Facilitated Hospital and Ambulatory Accreditation committees in establishing new standards based on tracer results.
- Performed chart audits using EPIC to assess documentation compliance, collaborating with unit managers to develop solutions.
- Collaborated with cross-functional teams to implement effective healthcare policies and procedures.
- Led initiatives ensuring safe patient care and adherence to ODH, CMS, and Joint Commission standards.
- Assisted with on-site ODH, CMS, and Joint Commission surveys, reviewing results and developing action plans for identified deficiencies.
Accreditation Specialist
Grant Medical Center, OhioHealth
Columbus
10.2006 - 11.2012
- Reviewed and analyzed patient care documentation to ensure adherence to regulatory standards.
- Co-led efforts to review and upload hospital policies into Compliance 360.
- Developed training materials on accreditation requirements for staff education.
- Facilitated Joint Commission Accreditation and Disease-Specific Certification, including on-site surveys and action plan completion.
- Guided Hospital and Ambulatory Accreditation committees in implementing new standards.
- Shared insights from clinical tracers with stakeholders to promote best practices.
- Educated all new staff on Patient Safety Error Prevention program protocols.
Education
Master of Science - Nursing Education
Wright State University
Dayton, OH06-1994
Bachelor of Science - Nursing
Ohio University
Athens, Ohio, OH06-1989
Associate of Science - Nursing
Ohio University
Zanesville, OH06-1986
Skills
- EPIC charting
- Regulatory compliance
- Policy development
- Patient safety protocols
- Problem solving
- Educational presentation
- Clinical documentation review
Certification
Certified Professional Healthcare Quality - 2006
Timeline
JCR CSR Consultant
Joint Commission Resources
11.2018 - Current
Accreditation - Associate Director
Ohio State Wexner Medical Center
11.2012 - 11.2018
Accreditation Specialist
Grant Medical Center, OhioHealth
10.2006 - 11.2012
Master of Science - Nursing Education
Wright State University
Bachelor of Science - Nursing
Ohio University
Associate of Science - Nursing
Ohio University