Nicholas J. Senuta
Wake Forest,NC
Summary
Accomplished Executive Leader equipped with natural leadership talents and proven business acumen. Specializes in effectively running and continuously optimizing Quality and Performance Improvement operations. Proven talents in building strategic partnerships with stakeholders and driving necessary change.
Overview
16
16
years of professional experience
Work History
Chief Officer, Organizational Excellence
SouthLight HealthCare
08.2021 - Current
- Executive position providing direct supervision and day-to-day oversight to 9 team members
- Quality and Performance Improvement- Responsible for the overall direction, leadership and operational management of the quality and performance programs
- Direct and implement evidence-based practices focused on increasing efficiency, effectiveness, and outcomes while improving patient safety
- Decrease claims denials from $180K to < $20K per year in 2024
- Achieved the first Certified Community Behavioral Health Clinic accreditation in North Carolina
- Medical Records and Privacy Oversee the establishment, implementation, maintenance of, and adherence to privacy policies and procedures including HIPAA Part II where applicable
- Perform periodic privacy risk analyses, internal audits, and assessment of policies and procedures, staff activities, and training programs; determines remediation priorities and resources necessary to address existing or potential privacy issues and problems
- Serve as principal point of contact for receipt and disposition of medical records, subpoenas, complaints and grievances, and the provision of information regarding privacy practices
- Facilitate Clinical Educational and staff development process through assessment, development, planning, implementation and evaluation of competency assessment, continuing education and leadership development
- Develop Policy and Procedure using CoP Interpretive Guidelines, Accreditation Standards, and relevant state licensing requirements
- Risk Assessment- proactively lead the ongoing evaluation, planning and support of the continuing readiness infrastructure and processes, ensuring accreditation by accrediting organizations, state and federal licensing agencies
- Identified and managed adherence to federal and state laws, regulatory guidelines, and Centers for Medicare and Medicaid Services requirements
- Managed partnerships and strategic business relationships by negotiating contract terms and handling conflicts.
- Built productive relationships with industry partners and competitors to support strategic business objectives.
- Devised new promotional approaches to boost customer numbers and market penetration while enhancing engagement and driving growth.
- Implemented several new technologies including the migration to the EchoVantage EMR, migration to NinjaOne, FirstNet, PowerBI, PowerDMS, NC Health Information Exchange connection, Eleos Augmented Intelligence, and the MyCare Crisis Platform
- Cultivated forward-thinking, inclusive, and performance-oriented business culture to lead industry in innovation and push progress.
- Budgeting Responsible for the administration and accounting of $1.5 million budget
- Organization had sustained growth from $9M in 2021 to $22M in 2024
Director, Accreditation (Interim)
Atlanta Medical Center (B.E. Smith)
02.2022 - 08.2022
- Permitted by CEO of SouthLight for temporary contract position
- 6-month interim leader assuming the responsibility to steer the two hospital 1400 bed organization through both the State of Georgia licensure survey and the triennial Joint Commission Survey
- Developed and implemented organizational initiatives to support accreditation and regulatory continuous readiness including program scope, standard interpretation, standard compliance, education and communication, and survey operations
- Promoted a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance
Accreditation Manager
University of North Carolina (UNC) Health
05.2020 - 06.2021
- Accreditation and Regulatory compliance preparation activities for UNC Medical Center in Chapel Hill and Hillsborough Hospital encompassing 1,100 beds, 7 sterile compounding pharmacies, and 35 outpatient settings
- Performed regular compliance reviews and audits, identifying non-compliance issues, effectively managed Joint Commission, CMS and Division of Health Services Regulation (DHSR) surveys
- Prepare and coordinate written responses and follow-up
- Provide technical assistance to stakeholders on matters pertaining to the application of Joint Commission standards, CMS regulations and North Carolina Division of Health Service Regulation requirements
- Provide guidance on the interpretation and application of Joint Commission standards, state and federal regulations for the organization's stakeholders
- Prepares policies and educational materials required for accreditation and regulatory compliance
- Coordinates investigations and responses to complaints received from The Joint Commission and North Carolina Division of Health Service Regulation; participates in root cause analysis review of sentinel events; assists with development and monitoring of corrective action plans
- Ensures organizational readiness and ongoing compliance with standards and regulations across UNC Medical Center
- Leads activities designed to monitor and improve compliance with standards, including focused tracers, mock surveys and educational sessions
- Successfully developed, built, and launched Tracers with AMP
Corporate Quality, Compliance, & Risk Management Officer
Veritas Collaborative
07.2016 - 01.2020
- Developed and executed organization's first Corporate Compliance Program
- Applied subject matter expertise and industry knowledge to provide independent oversight to operational risk management activities.
- Created executive leadership oversight committee and training programs for Board of Directors, leadership, and staff
- Created and enforced the organization's Code of Conduct and policies & procedures related to care quality, compliance, and internal audit
- Created and executed the duties of the organization's Privacy Officer
- Monitored healthcare trends, assessed potential impact, and made recommendations while staying true to the mission, vision and values of the organization
- Streamlined policy development & management, increasing efficiency and effectiveness; ensured adherence to rigorous policies and templates
- Investigated adverse patient events, utilizing principles of high reliability reformed risk management
- Refined Quality and Performance Improvement program into a proactive, real-time, evidence-based organizational strength by implementing a patient safety reporting database
Regional Manager, Regulatory Compliance
Hartford HealthCare East
10.2014 - 07.2015
- Promoted to oversee two 200-plus bed acute care hospitals, a stand-a-lone 24/7 emergency department and surgical center, and 11 outpatient care sites
- Ensured continuous survey readiness by directing mitigation, preparation, and response/recovery activities
- Led team in Connecticut renewal licensure and Joint Commission accreditation for acute care hospitals, as well as initial licensure and accreditation for multiple outpatient facilities
- Led multidisciplinary team through successful completion of the 56 finding corrective action plan process related to a Center for Medicare and Medicaid Services consent agreement
Director, Quality and Regulatory Compliance
William W. Backus Hospital (Acquired by Hartford HealthCare)
12.2008 - 10.2014
- Quality, infection control, patient safety, clinical documentation, licensure and accreditation, policy development & management, and physician peer review for a multi-site acute care hospital network
- Served as subject matter expert on accreditation and regulation within Healthcare System
- Developed new program capturing $3.5M in additional revenue (2010-2014) in area of clinical documentation improvement and evaluating medical records usage and management
- Awarded the organization's first Blue Center of Distinction (2012) for delivering quality healthcare
- Increased Quality Insights Hospital Incentive Program (QHIP) scores from 34 in 2010 to 93 in 2013
- Improved ORYX score from 92% to 99% by implementing concurrent core measure review process; CMS validation rate of 97%
- Managed the review, tracking, and classifying of safety events across Health System, maintaining the serious safety event dashboard, and developing & monitoring corrective action plans
- Implemented multi-faceted plan for continuous survey readiness; successfully navigated 12+ surveys and obtained first ever Joint Commission accreditation for Behavioral Health Services
- Facilitated activities related to attaining high reliability organization (HRO) status, as instructor for the Safety Starts with Me program
Education
Bachelors' - General Studies with minor in Science
Eastern Connecticut State University
Willimantic, CT01.2012
Associates of Science - Paramedicine
New Hampshire Technical Institute
Concord, NH01.1993
Skills
- Executive Leadership
- Healthcare Administration
- Accreditation
- Risk Assessment
- HIPAA
- Root Cause Analysis
- Patient Safety
- Performance Improvement
- Training
- Education
- EpicR Super User
- MeditechR
- EchoVantageR User
- PowerBi
- Eleos Augmented Intelligence
- Microsoft Office
- PowerDMS
- Accreditation Manager Plus (AMP) software program
- E-dition standards
- CMS CoPs Interpretive Guidelines
- Organizational turnaround
- Policy development and optimization
Community Service
- Saving Grace Animal Rescue, Wake Forest, NC, 11/2016, Present
- Preston City Congregational Church, Board of Directors, Preston, CT, 01/2011, 06/2016
Certificationsandlectures
- ASQ, Lean Six Sigma Green Belt, exam scheduled March 2025
- NCQA, Certified Professional Healthcare Quality, exam scheduled April 2025
- Role of Leadership in the use of Augmented Intelligence, i2i Conference, Winston-Salem, NC, 12/2024
Timeline
Director, Accreditation (Interim)
Atlanta Medical Center (B.E. Smith)
02.2022 - 08.2022
Chief Officer, Organizational Excellence
SouthLight HealthCare
08.2021 - Current
Accreditation Manager
University of North Carolina (UNC) Health
05.2020 - 06.2021
Corporate Quality, Compliance, & Risk Management Officer
Veritas Collaborative
07.2016 - 01.2020
Regional Manager, Regulatory Compliance
Hartford HealthCare East
10.2014 - 07.2015
Director, Quality and Regulatory Compliance
William W. Backus Hospital (Acquired by Hartford HealthCare)
12.2008 - 10.2014
Associates of Science - Paramedicine
New Hampshire Technical Institute
Bachelors' - General Studies with minor in Science
Eastern Connecticut State University
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