Wayne M Sullivan
North Plainfield
Summary
Director, Accreditation and Regulatory Affairs
Certified Joint Commission Professional (CJCP) with over 20 years of experience in the Healthcare industry in both clinical and management positions. Lead, manage, and facilitate survey preparation to achieve successful accreditations, licensures, certifications, and re-certifications from The Joint Commission (TJC), the New Jersey Department of Health (DOH), Center for Medicaid and Medicare Services (CMS) and other regulatory agencies. Lead, manage, and facilitate survey inspections for the State and Accreditation agencies in opening of a new $290 million patient tower and $300 million Proton Treatment Center. Organize, lead, manage, and facilitate mock surveys and staff education in survey preparation. Experience in healthcare analysis, project management, and process improvement. Lead and manage root cause analysis (RCA), apparent cause analysis (ACA), failure mode and effects analysis (FMEA), and Proactive Risk Assessments (PRA) to implement sustainable changes and improve safety. Review, plan, and make recommendations to improve healthcare systems, processes, and quality of care delivered to patients. Experience in auditing and analysis of hospital operations to identify trends, make strategic plans, and implement sustainable processes based on data analysis. Experience in team training, hands on coaching, and facilitation to optimize regulatory compliance and service delivery. Experience in managing diverse employees, equipment and materials. Forged strong business relationships focused on teamwork, client retention, and cost containment. Experience in crisis management. Excellent communication skills. Collaborate with multi-disciplinary teams focusing on improving safety, effectiveness, efficiency, and quality of care. Trained member of the Hospital Emergency Management Team.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Director, Accreditation and Regulatory Affairs
University Hospital Newark
Newark, New Jersey
01.2020 - Current
- Lead, manage, and facilitate survey preparation and continuous readiness.
- Develop and implement electronic survey tracer tools.
- Chairs the Survey Readiness Committee for both the hospital and skilled nursing facility.
- Collaborate with Johns Hopkins Health System (JHHS) to standardize survey preparation processes across the health system.
Director, Regulatory Compliance & Assistant Administrator
Sibley Memorial Hospital
Washington DC
01.2019 - Current
- Serve as the point of contact for regulatory agencies and accredited organizations.
- Initiate and facilitate the survey process for multiple regulatory bodies including DC DOH, TJC, CMS, FDA, NRC, CAP, and other regulatory agencies.
- Oversee and facilitate the successful initial certification and/or re-certification of LVAD, Transplant, Organ Donation, Stroke and the annual licensure and accreditation surveys.
- Provide prompt submission of corrective action plans and response to inquiries from DC DOH/TJC.
- Teach Culture of Safety, HRO Error Prevention, and New Associates Orientation.
- Lead multiple RCAs, ACAs, FMEAs, and Proactive Risk Assessments, and implementation, and auditing of corrective action plans.
- Serve as Administrator for TJC Extranet, Accreditation Management Plus (AMP), Verge Solutions, and other regulatory readiness software.
- Provide frequent updates to both hospital and health system leadership on regulatory and survey activities.
- Manage the day-to-day operations of the Quality Department from June to Oct. 2018.
- Mentor direct reports to set professional and personal goals for the coming year.
- Facilitate the hospital Quality Safety & Service (QSS) Committee on a monthly basis.
- Serve as the regulatory expert on multiple committees including Environment of Care, Infection Prevention, Adverse Event, Pharmacy & Therapeutics, Proactive Drug Diversion, Sepsis, and Stroke.
- Collaborate with the Administrator and Director of Nursing in the day-to-day operation of the SNF.
- Co-chair the Quality Assurance & Performance Improvement (QAPI) Committee of the SNF.
- Participate in the weekly care planning of residents of the SNF.
- When necessary, remove barriers to appropriate and safe discharges.
- Participate in the SNF collaborative of Washington, DC.
Respiratory Care Practitioner/Assistant Department Manager/Respiratory Therapy Supervisor
Mercy Medical Center
Baltimore, MD
01.2013 - Current
- Supervised 45 Respiratory Care Practitioners and support staff.
- Contribute improved leadership skills in managing all aspects of daily operations.
- Conducted process improvement projects both individually and with team members.
- Developed and make presentations to senior executives on a consistent basis.
- Conducted audit and analysis of departmental and hospital operations to identify trends and make strategic plans based on data analysis.
- Conducted comprehensive review and analysis of departmental and hospital policies and develop protocols and programs.
- Exhibit consistent leadership qualities in teaching and communicating with others.
- Relied upon to lend expertise toward actively mentoring employees and play a solid role in supporting the development of top-performing team members.
- Demonstrate strong industry expertise and technical abilities to optimize performances and outcomes.
- Perform all respiratory care modalities in all clinical settings.
Respiratory Care Practitioner/Assistant Department Manager/Respiratory Therapy Supervisor
Prince George’s Hospital Center (PGHC)
Cheverly, MD
01.1998 - Current
- Supervised 45 Respiratory Care Practitioners and support staff.
- Contribute improved leadership skills in managing all aspects of daily operations.
- Conducted process improvement projects both individually and with team members.
- Developed and make presentations to senior executives on a consistent basis.
- Conducted audit and analysis of departmental and hospital operations to identify trends and make strategic plans based on data analysis.
- Conducted comprehensive review and analysis of departmental and hospital policies and develop protocols and programs.
- Exhibit consistent leadership qualities in teaching and communicating with others.
- Relied upon to lend expertise toward actively mentoring employees and play a solid role in supporting the development of top-performing team members.
- Demonstrate strong industry expertise and technical abilities to optimize performances and outcomes.
- Perform all respiratory care modalities in all clinical settings.
Manager, Regulatory Compliance
Sibley Memorial Hospital
Washington DC
01.2015 - 01.2019
- Lead, manage, and facilitate survey preparation and continuous readiness.
- Develop and implement electronic survey tracer tools.
- Chairs the Survey Readiness Committee for both the hospital and skilled nursing facility.
- Collaborate with Johns Hopkins Health System (JHHS) to standardize survey preparation processes across the health system.
Quality Manager
MedStar Washington Hospital Center
Washington DC
01.2012 - 01.2015
- Facilitate physician peer review practice committee meetings for several service lines including Oral Surgery, Ophthalmology, General Internal Medicine, Gastroenterology, OB/GYN, Neonatology, Nephrology, and Pathology.
- Work closely with department chairs to reduce length of stay (LOS) and mortality.
- Work closely with department chairs to prepare annual reports for the Performance and Clinical Improvement Committees.
- Collaborate with department chairs to identify and develop performance improvement projects, matrix, and benchmarks.
Education
M.B.A. -
University of Maryland University College
Adelphi, MD06.2011
B.S.B.A. - undefined
University of Maryland University College
Adelphi, MD05.2005
Associate Degree - Respiratory Therapy
Prince George’s Community College
Largo, MD01.1998
Skills
- Microsoft Office Suite and Microsoft Project, MIDAS, UHC, MEDITECH, MedConnect, Epic, HERO, and HPO
Accomplishments
- Achieved [Result] by completing [Task] with accuracy and efficiency.
- Achieved [Result] through effectively collaboration with[Task].
- Documented and resolved [Issue] which led to [Results].
- Supervised team of 28 staff members.
- Collaborated with multidisciplinary team of in the development of strategies to improve patient outcome.
Affiliations
LNHA – License Nursing Home Administrator – 2019
CJCP – Certified Joint Commission Professional – 2014
NBRC – National Board of Respiratory Care – 1998
AARC – American Association of Respiratory Care – 1998
Certification
- LNHA – License Nursing Home Administrator – 2019
- CJCP – Certified Joint Commission Professional – 2014
- NBRC – National Board of Respiratory Care – 1998
- AARC – American Association of Respiratory Care – 1998
Timeline
Director, Accreditation and Regulatory Affairs
University Hospital Newark
01.2020 - Current
Director, Regulatory Compliance & Assistant Administrator
Sibley Memorial Hospital
01.2019 - Current
Manager, Regulatory Compliance
Sibley Memorial Hospital
01.2015 - 01.2019
Respiratory Care Practitioner/Assistant Department Manager/Respiratory Therapy Supervisor
Mercy Medical Center
01.2013 - Current
Quality Manager
MedStar Washington Hospital Center
01.2012 - 01.2015
Respiratory Care Practitioner/Assistant Department Manager/Respiratory Therapy Supervisor
Prince George’s Hospital Center (PGHC)
01.1998 - Current
B.S.B.A. - undefined
University of Maryland University College
Associate Degree - Respiratory Therapy
Prince George’s Community College
M.B.A. -
University of Maryland University College