STEPHANIE MARTINEZ, MBA, CPHQ
Lincoln,CA
Summary
Motivating leader and analytical problem-solver with focus on compliance regulation, risk management, and talent for team building. Excellent interpersonal, communication, and relationship-building skills with knowledge in establishing and implementing annual performance improvement goals as well as High Reliability Organization (HRO) principles. Dedicated to improving patient care and clinical outcomes, reducing adverse events, and enhancing value.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Quality and Patient Safety Program Manager
Woodland Memorial Hospital
01.2022 - Current
- Coordinate, prepare, and surveillance accreditation and regulatory compliance of the facility by monitoring tracer activities, conducting gap analysis', sharing updates to standards, leading accreditation surveys as well as the Continuous Readiness Committee (CRC)
- Design and deploy the biweekly 'Quality Corner Newsletter' using Patient Safety Objectives such as the National Patient Safety Goals (NPSGs), TJC Perspectives, and current topics in Regulatory Compliance to over 700 hospital employees
- Attend, accurately prepare meeting agendas, committee data packet, and communicate with those content experts who are scheduled to submit data reports and/or presentations to the monthly Quality Management Committee (QMC)
- Manage the Quality and Regulatory Performance Improvement Metrics (PIMs) by communicating with over 30 hospital leaders to accurately submit, track, and collect relevant data on a quarterly basis
- Manage and update the annual Quality and Performance Improvement Plan (QAPI) and Evaluation to maintain an effective, data driven quality assessment and performance improvement program and to establish an interdisciplinary approach to improving the services provided
- Manage the Complaints and Grievances Process through the IRIS Event Reporting System as well as work with the appropriate leaders to efficiently develop a response to the patient within 30 days of receipt
- Systematically perform investigations and facilitate meetings for any Cause Analysis (RCA)
- Participate in the Daily Leadership Huddle by appropriately identifying Safety Stories using IRIS and communicate with leaders who are assigned a story to share, update the monthly HRO safety topic, and manage the Action Item Log
- Manage, update, and communicate the following areas of the Quality and Patient Safety Dashboard to nursing leadership and the CMO daily: 7-Day Readmissions and the Current Foleys, C-diff Tests Needed, and Patient Risk Scores on Med/Surg Units & ICU
- Facilitate survey submission to the annual Leapfrog Survey Group by collecting and analyzing various hospital data
- Manage the Language Services Program as the facility Language Lead by serving as a point of contact, coordinating communications, training events, audits of local Language Services usage, and monthly documentation
- Responsible for tracking and reporting deaths associated with the use of restraint or seclusion as well as the 2567 form to CMS
- Responsible for tracking and submitting waivers and flexes to CDPH
- Responsible for reporting Workplace Violence (WPV) events to OSHA when applicable
Supervisor of Nutrition Services
Mercy General Hospital
03.2021 - 01.2022
- Discipline and motivate staff to achieve challenging objectives in the nutrition services department.
- Control food costs, manage inventory, and effectively increase sales in the hospital cafe.
- Evaluate employee performance and coach to improve weaknesses and support key initiatives.
- Perform annual evaluations and reviews for over 50 employees.
- Assist quality management with regulatory compliance.
- Work alongside director to design and implement various clinical and nonclinical projects as well as data collection tools and processes in order to meet department productivity goals and ensure compliance with CDPH and The Joint Commission.
- Train new employees on administrative procedures, company policies, and performance standards to promote safety and activities focused on clinical quality improvement and the patient experience.
- Educate employees on proper food safety and sanitation procedures.
- Balancing cash drawers, reconciling retail transactions, and depositing cash revenue.
- Input financial data daily to track interdepartmental transfers.
- Perform daily audits of temperature, sanitation, and floor stock logs.
Senior Program Assistant
Mercy General Hospital
12.2017 - 03.2021
- Trained employees on administrative procedures, company policies, and performance standards to promote safety and activities focused on clinical quality improvement.
- Educated employees on proper food safety and sanitation procedures.
- Balanced cash drawers, reconciled retail transactions, and deposited cash revenue.
- Recorded financial data daily to track interdepartmental transfers.
- Performed daily audits of temperature, sanitation, and floor stock logs.
- Coordinated and directed all hospital catered events.
- Reviewed and strengthened program operations with continuous assessment of operational plans and strategies.
Lead Dietetic Assistant
Mercy General Hospital
08.2016 - 12.2017
- Acted as department lead in absence of management.
- Entered patients' meal selections.
- Audited tray tickets to ensure diet compliance while honoring patients' food preferences.
- Effectively communicated with patients and nursing staff to resolve tray service issues.
- Prepared tallies for production staff.
- Explained nutrient parameters and goals to patients on therapeutic diets.
Education
MBA - Business Administration
Western Governors University
Salt Lake City, UT09-2021
Bachelor of Science - Family Consumer Sciences, Food and Nutrition
California State University
Sacramento, CA05-2016
Skills
- Organization/ Performance Improvement (PI)
- Evidence-Based Practice (EBP)
- Patient Safety/ Experience
- Regulatory Compliance
- Risk Assessment/ Management
- Event Reporting/ Management
- Data Analysis/ Management
- Process Improvement
- Strategic Planning
- Quality Management/ Improvement
- Project Management
- Leadership/ Communication
Accomplishments
- Worked alongside the VP of Quality and Patient Safety to lead Woodland Memorial Hospital to a successful Joint Commission Survey in July 2022 by effectively communicating with over 40 members of the leadership team and conducting extensive survey preparation activities
- Worked alongside the Stroke Coordinator to lead Woodland Memorial Hospital to a successful Joint Commission Primary Stroke Recertification Survey in November 2022 by effectively communicating with over 15 members of the stroke care team
- Worked alongside the Chest Pain Coordinator to lead Woodland Memorial Hospital to a successful Joint Commission Chest Pain Recertification survey in March 2023 by effectively communicating with over 15 members of the chest pain care team
- Worked alongside the Director of Quality to collect, analyze, and submit the necessary data to The Leapfrog Survey Group to achieve an "A" grade in the Spring 2023 Leapfrog Hospital Safety Grade for Woodland Memorial Hospital
- Worked alongside the Director of Pharmacy as the facilitator of the 'Clean Room Project' by organizing meetings and managing action items to successfully obtain CMS licensure in May 2023 for the new pharmacy and sterile compounding room
Affiliations
- Member, Emerging Leader Academy, Sutter Health University, 2026
- Member, National Association for Healthcare Quality, 2022 - Present
- Host, Continuous Readiness Committee (CRC), Woodland Memorial Hospital, 2022 - 2024
- Member, Quality Management Committee (QMC), Woodland Memorial Hospital, 2022 - 2024
- Member, Patient Safety Committee (PSC), Woodland Memorial Hospital, 2022 - 2024
- Member, Environment of Care Safety Committee (EOC), Woodland Memorial Hospital, 2022 - 2024
- Member, Policy and Procedure Committee (P&P), Woodland Memorial Hospital, 2022 - 2024
- Member, Mission Services Committee, Mercy General Hospital, 2018 - 2022
- Member, Employee Engagement Council, Mercy General Hospital, 2019 - 2022
- Member, Environmental Actions Committee, Mercy General Hospital, 2019 - 2022
- Chairman, Food & Nutrition Services Department Advisory Council, Mercy General Hospital, 2016 - 2022
University, 2010 - 2016
Certification
NAHQ Micro-Credential in Performance and Process Improvement, 08/2025
Certified Professional in Healthcare Quality (CPHQ), 02/2024
Certified Emergency Manager (CEM), 11/2022
Certified Dietary Manager (CDM), 07/2020-07/2022
Certified Food Protection Professional (CFPP), 07/2020-07/2022
Timeline
Quality and Patient Safety Program Manager
Woodland Memorial Hospital
01.2022 - Current
Supervisor of Nutrition Services
Mercy General Hospital
03.2021 - 01.2022
Senior Program Assistant
Mercy General Hospital
12.2017 - 03.2021
Lead Dietetic Assistant
Mercy General Hospital
08.2016 - 12.2017
MBA - Business Administration
Western Governors University
Bachelor of Science - Family Consumer Sciences, Food and Nutrition
California State University