Mandy Ashworth
Bridge City,TX
Summary
Experienced healthcare quality and risk management professional with over 5 years of leadership in Quality Assurance and Risk Management, including current corporate-level oversight across multiple service lines. Demonstrates expertise in Root Cause Analyses (RCA), process improvement, HEDIS measure optimization, and regulatory compliance with CMS, Joint Commission, and state standards. Skilled in leading quality initiatives, developing and evaluating QAPI plans, and driving patient safety and performance improvement across clinical environments. Brings over 20 years of progressive experience in Perioperative Services, offering a strong clinical foundation to support enterprise-wide quality outcomes. Adept at fostering cross-functional collaboration to promote regulatory readiness and continuous improvement.
Overview
22
22
years of professional experience
Work History
Director of Quality Assurance
Riceland Healthcare
Beaumont, Texas
01.2019 - Current
- Leads system-wide quality improvement efforts by reporting program updates and key quality metrics to the Corporate Quality Improvement Committee, and the Governing Board.
- Collaborates with executive leadership and facility administrators to elevate organizational performance and compliance across all locations.
- Oversees and executes a comprehensive Quality Management Plan (QMP) at the corporate level, ensuring alignment with regulatory standards and performance benchmarks. Identifies enterprise-wide opportunities for improvement through in-depth data analysis, trend monitoring, and risk assessments.
- Directs the collection, aggregation, and interpretation of quality and safety data from Ambulatory Surgery Centers (ASCs), clinics, and other care settings.
- Leads Root Cause Analyses (RCAs) following adverse events, and provides actionable recommendations to leadership for systemic process improvements.
- Serves as the internal expert on federal and state regulatory compliance (CMS, Joint Commission, DSHS, NHSN), providing guidance and policy updates to ensure enterprise adherence.
- Conducts quarterly evaluations of QAPI plans across all organizational sites—including Ambulatory Surgery Centers, clinics, and hospital departments—and assesses outcomes to refine quality initiatives and ensure system-wide alignment with performance goals."
- Maintains consistent communication with site administrators, clinical teams, and frontline staff to gather feedback on quality initiatives, resolve barriers, and foster a culture of safety and accountability.
- Champions the implementation of organization-wide policies and procedures based on performance data, research, and regulatory changes.
- Reviews patient satisfaction feedback and clinical outcomes to identify gaps and develop targeted action plans.
- Maintains corporate quality reporting infrastructure, including documentation of audits, inspections, statistical reviews, and compliance records. Guides and mentors quality and risk personnel across multiple facilities to ensure standardized practices and continuous improvement.
- Coordinates and oversees internal audits, performance evaluations, and mandatory quality measure submissions to entities such as DSHS and NHSN, ensuring timely and accurate reporting.
- Monitors and analyzes HEDIS measure performance across all sites to identify gaps in care, drive quality improvement initiatives, and support compliance with payer and regulatory expectations.
Registered Nurse, Surgery
Christus Southeast Texas Jasper Memorial
Jasper, Texas
02.2017 - 01.2019
- Pre-assessment of surgical patients prior to surgical and endoscopic procedures including: collection of current health history, completion of home medication list and insuring that patients completed any pre-procedural testing ordered by physician.
- Pre-operative preparation of patient prior to surgical and endoscopic procedures including: gathering current health history of patients, current home medication list, insuring patients followed all pre-procedural orders prepared by physician, and insertion of intravenous catheter.
- Circulate all surgery and endoscopic procedures, as well as first scrub some general surgery cases.
- Recovery of all surgery and endoscopic patients until discharge from the facility or admission to the floor post-procedure.
Registered Nurse, Surgical Services Educator
Baptist Hospitals Of Southeast Texas
Beaumont, TX
11.2014 - 02.2017
- Provided up to date surgical education to operating room staff, assisted with in-services on new operating room equipment, or new products introduced to the surgery unit, training of new operating room staff upon hire date, and assisted with new employee interviews.
- Insured that the surgical staff maintained current license and certifications according to state and facility guidelines.
- Assisted the director of surgical services in preparation for CMS inspection, as well as review and update of surgical policy and procedures in accordance with most recent surgical guidelines.
Assistant Director of Nursing, Surgical Services
Victory Hospital
Beaumont, TX
09.2012 - 11.2015
Perioperative Registered Nurse
Baptist Hospital of Southeast Texas
Beaumont, TX
05.2005 - 01.2008
Operating Room Nurse Intern
Baptist Hospital of Southeast Texas
Beaumont, TX
01.2003 - 05.2005
Education
Associate of Applied Science - Nursing
Lamar University
Beaumont, TX05.2005
Skills
- Quality assurance and regulatory compliance
- Data analysis and critical thinking
- Emergency response and infection control
- Team collaboration and conflict resolution
- Process improvement and root cause analysis
- Policy development and procedural assessment
- Patient assessment
- Surgical procedures
- Surgical patient care
- Pain management
- Medication administration
- Medical histories
- Preoperative assessment
- Sterile technique
- Vital signs
- Anesthesia monitoring
- Postoperative care
- IV administration
- Patient safety
- Scrub nurse skills
- EMR software
Timeline
Director of Quality Assurance
Riceland Healthcare
01.2019 - Current
Registered Nurse, Surgery
Christus Southeast Texas Jasper Memorial
02.2017 - 01.2019
Registered Nurse, Surgical Services Educator
Baptist Hospitals Of Southeast Texas
11.2014 - 02.2017
Assistant Director of Nursing, Surgical Services
Victory Hospital
09.2012 - 11.2015
Perioperative Registered Nurse
Baptist Hospital of Southeast Texas
05.2005 - 01.2008
Operating Room Nurse Intern
Baptist Hospital of Southeast Texas
01.2003 - 05.2005
Associate of Applied Science - Nursing
Lamar University
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