Summary
Overview
Work History
Education
Skills
2011-Present Interim Leadership, Consulting, Projects--Kirby Bates & Associates, B.E.Smith/AMN Healthcare
Timeline
Generic

Mary Hidalgo

Cape Coral,FL

Summary

Proven 20+ years broad experience in healthcare with operational and clinical leadership management: Service lines, Perioperative Services, ambulatory surgery centers, construction initiatives and projects, emergency departments with Trauma Programs, inpatient departments (ICU, PCU, Telemetry, MS). Leader and collaborator with infection prevention and control, regulatory affairs and compliance, quality and safety/risk management, rehabilitative care, community health, and population health. Strong financial/operational accomplishments to include increasing net profit margin to 19%, expense cost savings greater than 25% (10 million plus). Successful organizational development, strategic planning, financial and quality initiatives. improvement, lean six sigma and project management.

Overview

34
34
years of professional experience

Work History

Interim Administrator and Director of Surgical Services

Barton Health System
South Lake Tahoe, CA
05.2023 - 09.2023
  • Ambulatory Surgical Center, Perioperative Surgical Home, Hospital Perioperative Services including: Sterile Processing, Endoscopy, Pre-Op, PACU, OR
  • 70 FTE's, 500-550 cases a month (surgery and GI)
  • Program director for the Orthopedic Center of Excellence for Total Joint and Spine. Certification renewed
  • Improved efficiency turnover, cancellations and FCOTS
  • Improved culture, teamwork, and collaboration with staff, surgeons, administrative leadership
  • Led value analysis committee
  • Reduced total operational expenses by 5% with 5 million in savings
  • Agency staff positions reduced to zero resulting in 1 million in savings
  • Hours per UOS reduced per regulatory staffing requirements
  • Additionally, reduced 2 million in supply costs
  • Average 25% contract/service reductions saving 5 million plus
  • Provided support to leadership on various projects.
  • State survey for ambulatory surgery center- no deficiencies
  • Implemented Survey readiness for TJC, CMS and state.

Interim Director of Perioperative Services

CHI Health Lakeside-Common Spirit Healthcare System
Omaha, NE
10.2022 - 01.2023
  • ASC, OR, PACU, Pre/Post, Pre-Admit, GI, SPD, Scheduling,
  • Successful Joint Commission survey-no deficiencies
  • Increased Revenue to a net profit margin 19% Increased volumes in outpatient surgery, IR/CV Project leader—opened additional Pre/Post unit for additional beds for surgery/IR/Cardiology patients
  • Improved FCOT starts by 10%, Turnover time less than 30 minutes, day of surgery cancellations less than 1%
  • SSI 0%, surgical complications less than 4%
  • Assessed and evaluated all departments for standards, compliance, and conditions of participation
  • Improvement activities in progress for tissue tracking (scanning), and instrument tracking/inventory
  • Improved many workflows, processes, and updated policies
  • Created position control and new staffing matrix (approved FTE increase) to meet staffing requirements
  • Hired several travelers to open OR room
  • Perm positions posted
  • Orientating new grads/fellows and on-the-job training for surgical techs and sterile processing techs
  • Partnered with colleges for student nurses, surgical techs, and sterile processing techs
  • Improved culture, teamwork and morale in all departments
  • Developed and maintained surgeon good surgeon relationships (partnered with Chief of surgery, Chief of anesthesia)
  • Implemented tools of high reliability organization
  • All staff and providers held accountable for patient care, quality and safety
  • Held the line with providers not adhering to compliance and patient safety (H&P, universal protocol etc)
  • Provided infrastructure and structure: implemented huddles, surgery readiness daily, staff meetings, communications, and more.

Consultant—Regulatory/Compliance/Clinical Services-Rapid Response

DIGNITY (COMMON SPIRIT)
Sacramento, CA
02.2022 - 03.2022
  • Assessment and evaluation of current state of clinical service, compliance, and regulations
  • Created strategic plan with leader collaboration
  • Action plan created for deficiencies and gaps from assessment and evaluation
  • Supported facility with many CDPH citations to avoid immediate jeopardy
  • State/CDPH/CMS informed of consulting services to assist facility.

Interim Senior Director of Perioperative Services

PROVIDENCE ST. JOSEPH
Providence, Eureka, CA
11.2021 - 02.2022
  • Oversight of operations for 2 hospitals. Optimized efficiency reducing elective surgery cancellations resulting in increased volumes with increased revenue greater than 25 million
  • Collaborated with executive leaders in all departments and led emergency management for the hospitals bed capacity, surgeries, ED holds or transfers
  • Improved patient, surgeon/physician and staff satisfaction
  • Completed alternative work schedule, market analysis for retention plan
  • Implemented High Reliability Organization
  • Improved Surgery Readiness to decrease day of surgery cancellations
  • New EMR—revenue loss—CAPTURED revenue > $10 million
  • Assessed business operations waste, inefficiency and gaps: Noted need for oversight, need for inventory control
  • Started employee Caregiver COVID testing due to increase in positivity/many caregivers not working due to COVID.

Interim Consultant/educator for Regulatory Affairs/compliance/survey Readiness

El Camino Hospital
Mountain View and Los Gatos, CA
07.2021 - 10.2021
  • Assessed and evaluated clinical practice and policies for compliance with standards of care, regulations and survey standards (assessment for gaps, deficiencies)
  • Shared with leaders and collaborated to develop action items for deficiencies/gaps
  • Assessed education program for ambulatory surgery, outpatient and inpatient perioperative services, endoscopy, interventional radiology, cath lab
  • Etc
  • Collaborated with all leaders/managers of departments to create yearly education program to meet compliance and identified staff development needs within each department
  • Created training/education lessons with competencies for each department with skills fair days
  • Use of online programs such as HealthStream utilized as well.

Interim Manager Perioperative Services

UNIVERSITY OF MARYLAND SYSTEM-PRINCE GEORGE HOSPITAL CENTER
Baltimore, MD
03.2021 - 06.2021
  • Served in a leader role for moving into a new facility that included 10 OR’s, Hybrid and Procedure Rooms
  • Provided infrastructure, new processes, workflows, policies, and more to improve standards of care
  • Leader participation: emergency management (HICS) for moving to new building
  • Implemented Perioperative Services Guidelines for scheduling OR cases with all stakeholders
  • Previously, no written guidance in place
  • Addressed need for Periop and Central Supply Inventory/Bin/Par with business integration with new EPIC EMR
  • Team building with staff, surgeons, anesthesiologist, and all Periop departments
  • Created core staffing matrix for OR Block Time/Scheduling OR Rooms
  • Created 2022 Periop Budget Labor
  • Implemented High Reliability-Just Culture Tools-Safety & Quality
  • Started daily huddles and improved communication
  • Engaged staff to improve customer service.

Project Management Consultant-First State Vaccination Sites

GEMA-FEMA-Governor Brian Kemp-GDPH
GEORGIA
03.2021 - 03.2021
  • Planned, trained and implemented roles, workflow, and throughput for drive up vaccination site (flag ship) to be mirrored at other sites in GA
  • Successful
  • First day 1000 vaccinations (one site)
  • Second day met goal of 2000 vaccinations at one site.

Interim Director of Nursing

GRAND RIVER HEALTH DISTRICT
Rifle, CO
11.2020 - 02.2021
  • Upon arrival, the facility had new outbreak of COVID with regional and state positivity
  • No infection preventionist on site
  • Immediately implemented all IPC measures for COVID per CDC, state public/community health departments, etc
  • Oversight of education, contact tracing, cohorting, isolation/quarantine, line listing, testing, PPE and more
  • Implemented processes and infrastructure per Pandemic Emergency Plan and Infection Prevention and Control Plan
  • At present, facility is COVID free with first round of vaccine to residents and staff
  • Project management leader for all logistics concerning move into new building
  • Maintained 5-star rating, improved many systems, processes, workflows and more.

Interim Nurse Executive Consultant

STATE OF GEORGIA – GEMA-FEMA-PHD-VARIOUS HEALTHCARE FACILITIES
Atlanta, GA
04.2020 - 10.2020
  • Special task force for the State of Georgia to address COVID-19 clusters in care facilities
  • Member of the COVID-19 Rapid Response team for the State of Georgia
  • Traveled to various facilities conducting assessments and providing comprehensive infection control training on policies and procedures
  • Designed caregiver training manual for frontline workers, which addressed protocol for infectious disease mitigation and resolution
  • Designed train-the-trainer manual for leadership at LTC facilities to address issues in caregivers’ manual as well as CDC facility requirements related to COVID-19 protocols
  • Provided training to frontline caregivers and leadership on proper methodologies and processes to ensure sterile environment as recommended by CDC.

Interim Manager Operating Room

UNIVERSITY OF MARYLAND MEDICAL CENTER MIDTOWN CAMPUS
Baltimore, MD
11.2019 - 04.2020
  • Responsible for 7 ORs, GI, Endoscopy, Central Sterile Processing areas
  • Completed an assessment of OR, GI, ENDO and implemented recommendations
  • GI/ENDO - Educated staff to comply with current evidence-based best practices, standards, compliance
  • Implemented Transformational Culture Change
  • Improved First Case on Time Starts to less than 1 percent late starts
  • Improved Block Utilization to greater than 90 percent.

Interim CNE/COO

Chinese Hospital
San Francisco, CA
07.2019 - 10.2019
  • Created business plan and increased revenue/surgeries
  • Project Chair Leader with State DHHS/CMS and managed care network –including SF General to provide outpatient surgical services to Medicare/Medicaid recipients on waiting list for months at area hospitals
  • 300 recipients received surgery within 3 months at Chinese Hospital.

Interim Director, Perioperative Services

EL CENTRO REGIONAL MEDICAL CENTER
El Centro, CA
11.2018 - 07.2019
  • Directed five OR’s, Robotic surgery, endoscopy, procedure rooms, SPD, PACU, Preop, PAT, scheduling, business operations
  • Additionally, Consultant (Director) for Regulatory Affairs (compliance)
  • Project development and grant writer for community partnership for homelessness (police department, fire department, social services, county behavioral services, non-profit org.)
  • Improvement initiatives for clinical practice standards, compliance, and regulations
  • Six Sigma Lean business operations, standardization, cost savings greater than 750,000, contracts
  • Created Nurse Residency Program (AORN Periop 101), didactic, simulation, clinical lab, mentoring and more.

Interim Director Perioperative Services

KAISER PERMANENTE
Richmond and Oakland, CA
10.2017 - 02.2018
  • Managed Perioperative Services, 24 OR’s (Richmond/Oakland)
  • Addressed workplace violence issues resulting in improved safety, teamwork, and respect
  • Implemented Early Recovery After Surgery program (ERAS)
  • Decreased day of surgery cancellations to 2 percent from 8 percent
  • Improved PAT/Pre-op operations/practice which decreased cancellations and improved patient satisfaction
  • Developed Pre-op teaching with clear instructions and a reminder call, which improved post-operative outcomes (SSI, readmissions) and day of surgery cancellations
  • Changed discharge teaching process resulting in pre- and post-op day of surgery improved outcomes
  • Improved First Case on Time Starts to less than 1 percent late starts
  • Improved Block Utilization to greater than 90 percent.

Interim Leader, (Director, Manager) Emergency Department

PROVIDENCE ALASKA MEDICAL CENTER
Anchorage, AK
06.2017 - 09.2017
  • Managed 400-bed trauma level II 60-bed ER (pediatric and psychiatric) 90,000 visits/year, 148 FTEs
  • Initiated consortium with other hospitals for pediatric trauma care
  • Leader for new addition of pediatric unit
  • Improved ED Throughput metrics
  • Door to admit time decreased by 50%
  • Exceeded quality initiatives – STEMI, Stroke, Trauma, Sepsis, LWBS, Member of Interdisciplinary Hospital Throughput Council
  • Organized and facilitated ED Shared Governance
  • Sustained and improved productivity to 95%-103%.

Interim Leader, (Director, Manager) Critical Care

PROVIDENCE TARZANA MEDICAL CENTER
Los Angeles, CA
07.2016 - 06.2017
  • Managed ICU, CVICU, CVU, PCU; 200+ FTEs
  • Achieved the Joint Commission accreditation successfully
  • Achieved Primary Stroke Center Certification
  • Chaired nurse clinical ladder and residency programs
  • Reduced contract labor expenses – $200,000 monthly savings
  • Attained retention metrics with vacancy rate <1% and turnover rate <4%
  • Engaged staff in unit strategic planning aligning with facility/organizational plan, research projects, evidence-based improvement initiatives
  • Achieved top regional staff engagement scores (staff satisfaction)
  • Improved patient satisfaction (HCAPS) by 20%
  • Spearheaded project work (facilitated/empowered staff participation)
  • Improved patient outcomes: Reduction in mortality, falls, hospital acquired infections, readmissions
  • Decreased average length of stay less than 3 days
  • Provided structure, infrastructure: standardization for clinical process and policy development
  • Organized multi-disciplinary teams for patient centered care delivery
  • Improved physician engagement and team cohesiveness by developing multi-disciplinary peer review committee
  • Implemented safety and quality model, High Reliability Organization, Science of Caring, Patient-centered Care, Outcomes, Interdisciplinary, Continuum of Care models
  • Sponsored/Initiated Shared Governance and Leader for Magnet Journey (service excellence)/Application.

Interim Manager, Critical Care

KAISER PERMANENTE
Vacaville, CA
03.2016 - 06.2016
  • Managed ICU/PCU, 54 total beds
  • Productivity 95%-105%; met target Implemented Shift huddles, safety briefing.

Interim Director, Perioperative Services

SUTTER HEALTH – MEMORIAL HOSPITAL
Los Banos, CA
07.2015 - 03.2016
  • Surgical Services Director; responsible for inpatient and outpatient Prep OP, OR, SDS, PACU, Endoscopy, Sterile Processing/Decontamination; 3,800 surgical cases/yearly; 60 FTEs
  • Completed Lean Six Sigma Surgical Services project to improve surgical services customer experience, quality and decrease cost (waste)
  • Increased revenue 20%; over $1 Million in cost reduction/savings
  • Achieved improved efficiency with pre-operative patient readiness: Less than 1% surgery cancelations/monthly
  • OR on-time starts 98%
  • Decreased OR and PACU minutes
  • Turnover 14 minutes
  • Phase II to discharge 60 minutes
  • Sponsored/Chartered Surgical Services Shared Governance facilitating multidisciplinary collaboration, communication and leadership with shared vision aligned with organizational goals
  • Executed key preoperative safety and quality initiatives
  • Ensured AORN, AAMI, ASPAN, CDC, CDPH standards/regulatory/governing body compliance
  • Achieved Joint Commission Accreditation.

Interim Director, Patient Care Services

DIMENSIONS HEALTHCARE SYSTEM
Laurel, MD
04.2013 - 10.2013
  • Implemented and led Electronic Health Record (Cerner)
  • Sponsored/chartered unit-based council.

Interim Director of Nursing

COALINGA MEDICAL CENTER
Coalinga, CA
10.2012 - 03.2013
  • Supervised, planned, coordinated operations ,and personnel for patient care delivery based on nursing practice, regulatory, and accreditation standards with ongoing quality improvement initiatives
  • Communicated and collaborated well with all organizational healthcare professionals to provide quality, cost-effective, and efficient care to achieve the best patient outcome
  • Participated with California Department of Health and Human Services and Ombudsman in sharing best practice in implementing Title 22 Mandated Reporter for Adult/Child Abuse/Neglect
  • Implemented programs to decrease falls, infections, ER visits
  • Improved patient-centered care by involving patients in plan of care (prevention, chronic disease management).

Interim Director, Emergency Department

COMMUNITY HEALTH SYSTEMS
Roswell, NM
03.2012 - 08.2012
  • Directed 23-bed trauma Level III ER facility with over 65,000 visits per year, 95 FTEs
  • Achieved Throughput Benchmarks
  • Generated revenue over one million with development of tele-neurology in emergency department.

Interim Director, Emergency Department

PRESBYTERIAN ESPAÑOLA HOSPITAL
Española, NM
08.2011 - 02.2012
  • Developed and implemented (trained staff) Early Identification (screening), Protocol/Treatment of Sepsis Bundle evidence based in ER
  • Implemented 5 Level Triage in ER trained all staff (competency) with policy/guidelines and resource tools
  • Implemented successful ER Navigation Federal Grant Project with the Rio County Health Department
  • Black Belt Lean Six Sigma project
  • Navigated patients to the right care, place, and time
  • Decreased ED for clinic use; Sustained Productivity 100% to 103%
  • Program/Project manager for hospital participating in State of New Mexico Emergency Preparedness Program (Federal grant Homeland Security)
  • Implemented continuous readiness initiatives for accreditation, regulatory compliance, CMS.

Nursing Educator

OKLAHOMA UNIVERSITY
Shawnee, OK
01.2010 - 01.2011

Multiple Positions

DCH REGIONAL MEDICAL CENTER (15 PLUS YEARS, KELL WEST and HealthSouth (TX)
Tuscaloosa, AL
05.1989 - 06.2009
  • Managed Critical Care PICU and adult TSICU, pediatric/adult burn,CVICU, MICU, Neuro-ICU, PCU, Telemetry, Interventional Radiology
  • Directed inpatient and outpatient surgical services with 1200 monthly cases and over 400 FTEs
  • Managed emergency department; 90,000 visits/yr

Education

Master of Science -

Oklahoma Baptist University
Shawnee, OK
05.2011

Bachelor of Science - Nursing

The University of Alabama
Tuscaloosa, AL
05.1989

Skills

  • business and clinical operations
  • performance improvement (systems, process improvement)
  • service development
  • employee/physician engagement
  • building accountable collaborative teams
  • patient experience
  • physician and staff satisfaction
  • financial performance
  • clinical practice standards
  • survey readiness
  • community relationships
  • projects, Lean Six Sigma certification

2011-Present Interim Leadership, Consulting, Projects--Kirby Bates & Associates, B.E.Smith/AMN Healthcare

First-hand experience in many areas optimizing organizational strategies and performance improvement initiatives. Ability to develop systems cross functional teams.  Experienced in a variety of environments: Up to 800-beds, up to 24 ORs and 60-Bed ERs, Level I trauma, academic, research, tertiary, multi-site hospital system, outpatient, ASC, FP/NFP, union and non-union, community hospitals, ANCC magnet designated facilities. Hits the ground running (assessing, evaluation, gap analysis, analytics) adapting quickly to meet objectives/goals.

Timeline

Interim Administrator and Director of Surgical Services

Barton Health System
05.2023 - 09.2023

Interim Director of Perioperative Services

CHI Health Lakeside-Common Spirit Healthcare System
10.2022 - 01.2023

Consultant—Regulatory/Compliance/Clinical Services-Rapid Response

DIGNITY (COMMON SPIRIT)
02.2022 - 03.2022

Interim Senior Director of Perioperative Services

PROVIDENCE ST. JOSEPH
11.2021 - 02.2022

Interim Consultant/educator for Regulatory Affairs/compliance/survey Readiness

El Camino Hospital
07.2021 - 10.2021

Interim Manager Perioperative Services

UNIVERSITY OF MARYLAND SYSTEM-PRINCE GEORGE HOSPITAL CENTER
03.2021 - 06.2021

Project Management Consultant-First State Vaccination Sites

GEMA-FEMA-Governor Brian Kemp-GDPH
03.2021 - 03.2021

Interim Director of Nursing

GRAND RIVER HEALTH DISTRICT
11.2020 - 02.2021

Interim Nurse Executive Consultant

STATE OF GEORGIA – GEMA-FEMA-PHD-VARIOUS HEALTHCARE FACILITIES
04.2020 - 10.2020

Interim Manager Operating Room

UNIVERSITY OF MARYLAND MEDICAL CENTER MIDTOWN CAMPUS
11.2019 - 04.2020

Interim CNE/COO

Chinese Hospital
07.2019 - 10.2019

Interim Director, Perioperative Services

EL CENTRO REGIONAL MEDICAL CENTER
11.2018 - 07.2019

Interim Director Perioperative Services

KAISER PERMANENTE
10.2017 - 02.2018

Interim Leader, (Director, Manager) Emergency Department

PROVIDENCE ALASKA MEDICAL CENTER
06.2017 - 09.2017

Interim Leader, (Director, Manager) Critical Care

PROVIDENCE TARZANA MEDICAL CENTER
07.2016 - 06.2017

Interim Manager, Critical Care

KAISER PERMANENTE
03.2016 - 06.2016

Interim Director, Perioperative Services

SUTTER HEALTH – MEMORIAL HOSPITAL
07.2015 - 03.2016

Interim Director, Patient Care Services

DIMENSIONS HEALTHCARE SYSTEM
04.2013 - 10.2013

Interim Director of Nursing

COALINGA MEDICAL CENTER
10.2012 - 03.2013

Interim Director, Emergency Department

COMMUNITY HEALTH SYSTEMS
03.2012 - 08.2012

Interim Director, Emergency Department

PRESBYTERIAN ESPAÑOLA HOSPITAL
08.2011 - 02.2012

Nursing Educator

OKLAHOMA UNIVERSITY
01.2010 - 01.2011

Multiple Positions

DCH REGIONAL MEDICAL CENTER (15 PLUS YEARS, KELL WEST and HealthSouth (TX)
05.1989 - 06.2009

Master of Science -

Oklahoma Baptist University

Bachelor of Science - Nursing

The University of Alabama

Similar Profiles

CREATE PROFILE
Mary Hidalgo