RAFAEL COTA
Chandler,AZ
Summary
Registered nurse and healthcare quality executive with over 16 years of leadership experience in acute care and military settings. Demonstrated success in developing quality infrastructures and compliance programs that significantly improve patient safety outcomes across multiple facilities. Expertise in infection prevention and regulatory management, with a strong focus on interdisciplinary collaboration. Committed to fostering a culture of quality that prioritizes safety and reliability in healthcare delivery.
Overview
17
17
years of professional experience
2
2
Certifications
Work History
Clinic Quality RN
Dignity Health
06.2025 - Current
- Maintained zero healthcare-associated infections across 61 ambulatory clinics since program inception.
- Conducted monthly quality assessments and rounding at seven dedicated clinic sites, translating findings into targeted education.
- Led infection prevention priorities with quality metrics to align operations and promote best practices.
- Collaborated with multidisciplinary teams to enhance quality of care initiatives.
- Contributed to market-wide benchmarks for hypertension control, diabetes management, and depression screening.
- Provided oversight and compliance monitoring for infection prevention across all clinics.
- Implemented targeted education based on assessment findings to improve clinical outcomes.
Director of Quality, Compliance, and Risk
Dignity Health
Chandler, AZ
10.2024 - 06.2025
- Facility Compliance Officer and senior quality executive for a 50-bed inpatient rehabilitation facility (IRF), managing quality improvement, patient safety, and infection prevention.
- Maintained continuous accreditation compliance and survey readiness across CIHQ, CMS, and CARF regulatory frameworks through proactive readiness programs.
- Sustained zero HAI events throughout tenure including zero CLABSI, CAUTI, and MRSA transmission events.
- Supervised multidisciplinary quality team including case management, outcomes manager, and clinical educator.
- Led root cause analysis (RCA) and failure mode and effects analysis (FMEA) for high-risk safety events, driving systemic process improvement.
Quality & Patient Safety Program Manager
Arizona Hospital and Healthcare Association (AzHHA)
Phoenix, AZ
04.2022 - 09.2024
- Served as statewide quality and patient safety technical advisor for 17 Arizona hospitals.
- Delivered tailored technical assistance and regulatory guidance to quality and clinical leaders.
- Supported CMS and NHSN data reporting, ensuring accuracy and compliance with metrics.
- Facilitated statewide quality improvement collaboratives, promoting peer learning and evidence-based strategies.
- Guided hospitals in HQIC priorities like HAI reduction, sepsis management, and readmission reduction.
- Coached leadership on MBQIP measure performance to sustain quality benchmarks in clinical outcomes.
Director of Emergency Services
Mountain Vista Medical Center – Steward Health
Mesa, AZ
01.2022 - 04.2022
- Directed clinical operations in emergency department, emphasizing throughput and quality metrics.
- Identified and remedied DNV survey readiness gaps in safety documentation and compliance.
- Led initiatives to improve door-to-provider time and reduce left-without-being-seen rates.
- Enhanced patient experience outcomes through targeted performance improvements.
Patient Safety & Quality Program Manager
Dignity Health St. Joseph's Hospital & Medical Center
Phoenix, AZ
07.2021 - 01.2022
- Oversaw data collection validation and CMS submission for hiqrp, hoqrp, and leapfrog, ensuring data integrity across performance dashboards and public reporting platforms.
- Directed root cause analysis for high-risk patient safety events such as falls and documentation deficiencies, facilitating interdisciplinary corrective action planning.
- Supported continuous accreditation readiness and compliance with Joint Commission standards across clinical departments and service lines.
Associate Director, ED & Observation
Banner Gateway Medical Center
Gilbert, AZ
05.2019 - 06.2021
- Directed observation operations during COVID-19 pandemic surge, ensuring clinical quality and staff safety.
- Managed staff schedules to optimize resource allocation and coverage efficiency.
- Collaborated with medical personnel to develop and implement effective departmental protocols.
- Coordinated interdisciplinary meetings to enhance communication and collaboration among teams.
Logistics RN Manager
Chandler Regional Medical Center
Chandler, AZ
01.2019 - 04.2019
- Facilitated logistics operations, boosting patient flow capacity management, and strengthening interdepartmental cooperation across the acute care facility.
Performance Improvement RN – Trauma Services
Chandler Regional Medical Center
Chandler, AZ
01.2017 - 12.2018
- Directed multidisciplinary case reviews and compliance initiatives for trauma performance improvement.
- Recognized as a key strength in performance improvement during successful ACS survey.
- Facilitated accreditation efforts for trauma center through rigorous performance evaluations.
Emergency & Trauma RN | Captain
United States Air Force
Joint Base San Antonio, TX
02.2012 - 12.2016
- Led emergency and trauma nursing teams in military settings, including overseas deployments.
- Developed crisis management skills and high-stakes decision-making through formal USAF leadership training.
- Enhanced mission-driven team performance during overseas service by fostering effective leadership competencies.
Emergency Department & Neuro Med-Surg RN
St. Joseph's Hospital & Medical Center
Phoenix, AZ
09.2009 - 02.2012
- Provided direct patient care across emergency and neurological medical-surgical settings, building foundational expertise in high-acuity, acute care nursing.
Education
Master of Business Administration -
Grand Canyon University
Phoenix, AZ01.2016
Master of Science in Nursing - Leadership in Health Care Systems
Grand Canyon University
Phoenix, AZ01.2016
Bachelor of Science in Nursing -
Grand Canyon University
Phoenix, AZ01.2009
Skills
Quality & Patient Safety, Infection Prevention & HAI Reduction, Regulatory Compliance & Accreditation, QAPI & Performance Improvement, Risk Management (RCA/FMEA), High Reliability Organizations (HRO), Healthcare Data Analytics & Reporting, Multi-Site Program Leadership, Population Health & Value-Based Care, Survey Readiness & Mock Surveys, Staff Development & Clinical Education, Interdisciplinary Leadership, Process Optimization (Lean/PDSA), Case Management Oversight, Patient Safety & Just Culture, Regulatory Reporting (CMS, NHSN, QualityNet)
Affiliations
- National Association for Healthcare Quality (NAHQ)
- Association for Professionals in Infection Control (APIC)
- American Nurses Association (ANA)
- Arizona Nurses Association (AzNA)
Websites
Technical Skills And Systems
Cerner, Midas, Tableau, Business Warehouse, UDS ProCentral, QualityNet, NHSN, CMS, The Joint Commission (TJC), CARF, CIHQ, DNV, CDC, QAPI, HQIC, MBQIP, CQPI, HIQRP, HOQRP, Leapfrog, VBP, HRRP, Core Measures, HCAHPS, HAI Surveillance, PSI/HAC, IRF-PAI, FIM, RCA, FMEA, PDSA, Lean, HRO, Just Culture, Tracer Methodology, Mock Surveys, Gap Analysis
Certifications And Licensure
- Registered Nurse, Arizona, Active
- CPHQ, Certified Professional in Healthcare Quality
- CPPS, Certified Professional in Patient Safety
- BLS, American Heart Association, Active
Certification
Certified Professional in Healthcare Quality (CPHQ)
Timeline
Clinic Quality RN
Dignity Health
06.2025 - Current
Director of Quality, Compliance, and Risk
Dignity Health
10.2024 - 06.2025
Quality & Patient Safety Program Manager
Arizona Hospital and Healthcare Association (AzHHA)
04.2022 - 09.2024
Director of Emergency Services
Mountain Vista Medical Center – Steward Health
01.2022 - 04.2022
Patient Safety & Quality Program Manager
Dignity Health St. Joseph's Hospital & Medical Center
07.2021 - 01.2022
Associate Director, ED & Observation
Banner Gateway Medical Center
05.2019 - 06.2021
Logistics RN Manager
Chandler Regional Medical Center
01.2019 - 04.2019
Performance Improvement RN – Trauma Services
Chandler Regional Medical Center
01.2017 - 12.2018
Emergency & Trauma RN | Captain
United States Air Force
02.2012 - 12.2016
Emergency Department & Neuro Med-Surg RN
St. Joseph's Hospital & Medical Center
09.2009 - 02.2012
Master of Business Administration -
Grand Canyon University
Master of Science in Nursing - Leadership in Health Care Systems
Grand Canyon University
Bachelor of Science in Nursing -
Grand Canyon University