Director of Performance Improvement/Risk Management
Behavioral Hospital of Bellaire
Houston, TX
06.2022 - Current
Compile and present detailed reports on risk management activities and performance improvement metrics to stakeholders.
Provide direction and oversight to staff involved in safety and risk mitigation efforts, fostering a culture of continuous improvement.
Formulate and enforce risk management policies and procedures to ensure consistent and effective practices.
Manage regulatory site visits and develop comprehensive corrective action plans to address any deficiencies.
Lead performance improvement task forces, teams, and committees to drive collaborative efforts towards quality enhancement.
Advise hospital administration on potential risks and recommend strategic solutions to minimize exposure and enhance operational efficiency.
Advanced Quality Specialist
Texas Children’s Hospital
Houston, TX
05.2021 - 05.2022
Provides intradepartmental nursing leadership with consulting and analysis services to support behavioral health and patient flow initiatives intended to achieve breakthrough or incremental process improvement in patient care.
Ensures assigned system-wide accreditation, certifications, and designations are complete. – Successful completion of TCH Pediatric Physician Assistant Surgical Fellowship, TCH Orthopedic Physician Assistant Fellowship, and TCH Community Surgical Physician Assistant Fellowship application, which resulted in full accreditation with the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).
Partner with operational leadership to oversee contractual services, to ensure that the services are provided safely and effectively to achieve optimal patient care. – quality metrics are tracked monthly and presented quarterly to the Regulatory Readiness committee and QSS Governing Board.
Director of Performance Improvement
Behavioral Hospital of Bellaire
Houston, TX
07.2018 - 05.2021
Reviewed and updated hospital policies and procedures to ensure compliance with The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and Texas Department of Health Services regulatory standards, Conditions of Participation, and administrative codes.
Established and measured performance metrics against organizational goals and objectives, ensuring progress in achieving programmatic growth and improving patient outcomes for both inpatient and outpatient populations.
Streamlined systematic process changes using Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FMEA) to identify adverse or high-risk events and implement sustainable corrective actions, including process redesign.
Collected, analyzed, and managed quantitative data monthly, creating meaningful reports to drive business improvement for Solis Medical Laboratory, resulting in a 33.2% cost reduction ($13,399.96 to $8,952.57) within a three-month period, which is continuously maintained.
Created new service lines (Adolescent Partial Hospitalization Program/IOP) to guide the organization in maintaining and improving its competitive position and profitability.
Supervised the Medical Staff Credentialing Officer to ensure regulatory compliance regarding provider delineation of privileges and the Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) processes.
Implemented a daily Environmental Hazard Round mechanism, leading to an 83% decrease in patient contraband from 2018 to 2019.
Senior Marketing Manager
Concern for Independent Living, Inc.
Medford, NY
09.2015 - 02.2018
Defined and identified market opportunities, implemented marketing strategies and developed sales plan to effectively penetrate the physician practices, hospitals, long-term care clinics, medical centers, surgical centers.
Demonstrated proficiency in the development and implementation of large group and individual presentations to identified customers and physicians on all aspects of the pharmaceutical services.
Promoted positive team relationships and maintained open lines of communication among sales, operations, clinical, and administrative personnel to achieve common goals and objectives.
Facilitated reporting and tracking on sales activities and developed forecasts on territory sales potential.
Assistant Director of Quality Assurance
St. Vincent’s Hospital Westchester
Westchester, NY
08.2013 - 08.2015
Implemented evidence-based interventions to reduce and prevent transmissions of infections in the hospital through a hand hygiene initiative and developed and maintained educational programs regarding infection control for a continuous 96-98% compliance in hand hygiene from all hospital employees, and contractors.
Facilitated team compliance of OMH, DOHMH, CMS, OSHA, and The Joint Commission compliance through documentation reviews, staff education and training, policy implementation, and tracking activities.
Responsible for ensuring quality standards for patient care is expanded to other clinical entities thus assuring efficient and effective coordination and delivery of all patient care services.
Provided in-depth analysis of all Medicaid Redesign Program metrics, patient satisfaction surveys, written and verbal compliments and complaints, and qualitative data from multiple sources.
Facilitated timely and accurate data collection, aggregation, and interpretation for submission to both internal and external regulatory and quality performance measurement entities.
Lead and managed projects using project plans; tracking key milestones using various project management tools to meet key deadlines and ensure team progress as we worked towards various departmental goals.
Administrative Coordinator of Psychiatry (CPEP)
Kings County Hospital
Brooklyn, NY
08.2009 - 08.2013
Launched and successfully managed 4 parts, 24 bed Comprehensive Psychiatric Emergency Program, with a budget of $4.5 million, interdisciplinary staff of 60, and commitment to clinical excellence and positive financial performance.
Managed and administered fiscal operations for total department, including accounting, planning budgets, authorizing expenditures, establishing rates for services and coordinating financial reports.
Conducted daily comprehensive assessments for individuals admitted with HIV/AIDS, substance abuse; suicidal ideations, sexual trauma, domestic violence, and other issues associated with their mental and physical health.
Collaborated with Psychiatrists to plan, monitor, review, and evaluate the efficiency of medication reconciliations and provided direct insight on drug applications and characteristics.
Education
Bachelor’s Degree - NursinG
University of Tulsa
01.2025
Master’s Of PubLic administration - health care management
Long Island University- Brooklyn Campus
01.2017
Bachelor’s Degree - criminology
John Jay College of Criminal Justice
01.2013
Skills
Expertise
Regulatory Compliance
TJC Standards/ CMS’ CoP’s
Data Analysis
Business Expansion
Process Improvement
Leadership/Management
Financial Operations
Provider Relations
Timeline
Director of Performance Improvement/Risk Management
Behavioral Hospital of Bellaire
06.2022 - Current
Advanced Quality Specialist
Texas Children’s Hospital
05.2021 - 05.2022
Director of Performance Improvement
Behavioral Hospital of Bellaire
07.2018 - 05.2021
Senior Marketing Manager
Concern for Independent Living, Inc.
09.2015 - 02.2018
Assistant Director of Quality Assurance
St. Vincent’s Hospital Westchester
08.2013 - 08.2015
Administrative Coordinator of Psychiatry (CPEP)
Kings County Hospital
08.2009 - 08.2013
Bachelor’s Degree - NursinG
University of Tulsa
Master’s Of PubLic administration - health care management