OVERVIEW:Direct all performance improvement, risk management, and infection control functions for a 163-bed acute psychiatric hospital with ECT and IOP clinics, reporting to the CEO. Oversee multiple programs that include Risk Management, Performance Improvement, Patient Advocacy, Infection Control Prevention, and Employee Health Programs. Provide evidence-based data to multiple Committees.Maintain regulatory readiness, quality improvement measures, public reporting, and pay-for-performance programs and initiatives by CMS and insurance companies. Manage multiple analytic tasks, including metrics collection and analysis, presentations, reporting, and others. Guide hospital leaders in identifying potential risks; provide recommendations to mitigate and avoid risk.Oversee all facets of the Infection Control Prevention Program as the Infection Control Officer. Work with physicians, nursing staff, senior leaders, and the Infection Control Committee to ensure compliance with federal, state, and local requirements. Manage the Employee Health Program, coordinating with HR.Serve as the hospital’s primary liaison for federal and state health and accreditation surveys.HIGHLIGHTS:☑ Established a Quality program that enabled an increase in Patient Satisfaction scores significantly from 3.5 to 4.5. Led the transition from a multi-use to a single-use glucometer, increased hospital leadership involvement in patient safety initiatives, and instituted departmental Quality Reporting.☑ Decreased laboratory costs by a 6-figure annual total through implementing clinical guidelines for a 3rd-party lab that cut inpatient lab turnaround times from 8 to 4 hours, as well as negotiating a lab formulary that reduced lab costs to CMS standards.☑ Reduced seclusions and restraints 50% by creating and implementing a Patient Safety Initiative data tracking and analysis system that enabled proactive staff education and interventions.

OVERVIEW:Planned and implemented all activities for Performance Improvement, Risk Management, and Regulatory Compliance programs within a 72-bed acute behavioral hospital with an outpatient satellite clinic. Conducted assessments of clinical quality, efficiency, and patient safety to support the hospital’s mission of clinical and operational excellence. Oversaw daily implementation of the medical staff peer review process, as well as developing and implementing the ongoing physician performance evaluation and focus review process. Held concurrent management duties for infection control, medical staff credentialing, and patient advocacy programs.HIGHLIGHTS:☑ Created and coordinated a Master Treatment Plan, an interactive, interdisciplinary process among physicians, nurses, therapists, and mental technicians that include the patient to provide exceptional service.☑ Reduced the time to discharge from 5 to 2 hours (representing a substantial decrease) through leading and orchestrating a multidisciplinary Discharge Plan Task Force. Additionally, drove a significant reduction in the admission process from an average of 5-8 hours to an average of 2 hours.☑ Facilitated successful Joint Commission accreditation surveys as well as CMS and Texas Department of Health regulatory surveys. Achieved zero findings in Quality – Data Collection and Performance Improvement, Infection on an 11/2017 Full Unannounced Joint Commission Survey.

OVERVIEW:As Director of Risk Management and Quality Management Services within a 100-bed acute behavioral health hospital (with an outpatient satellite clinic), led the development and administration of the Risk Management program. Ensured compliance with requirements and policies/changes related to risk quality improvement. Created and oversaw quality management activities, including audits, corrective actions, FMEAs, RCAs, and data analyses. As Director of Infection Control and Employee Health Services, led all regulatory monitoring for infection control practices, OSHA compliance, and employee health. Created and revised infection control policies and procedures, conducted outbreak investigations, and managed all regulatory reporting. Conducted infection control orientations; served as the infection control consultant for all hospital team members.HIGHLIGHTS:☑ Facilitated a successful DNV accreditation survey process by applying ISO-9001 and NAIHO within 1 year (vs. the standard 3 years). Revised all policy and procedure manuals, instituted QA system controls, and transitioned the hospital from paper-based to electronic systems.☑ Developed and implemented patient safety initiatives that enabled the hospital’s DNV certification, facilitated state compliance within 1 year, and achieved ISO 9001 compliance.☑ Increased staff health compliance and eliminated needlestick-related injuries, among others, through revising existing Infection Control policies and procedures to reflect current state regulations.☑ Prevented negative outcomes for the hospital by implementing a self-reporting process, correcting abuse and neglect immediately, taking corrective actions, and training staff on compliance matters.☑ Reduced lab costs by a 6-figure total annually through closing the on-site lab and utilize a 3rd-party lab to provide the same level of patient care.

OVERVIEW:As Infection Control Officer within a 100-bed acute behavioral health hospital with 3 outpatient satellite clinics, conducted surveillance and data collection, investigated incidents of infection, and implemented remedial actions. Educated medical and hospital teams on infection prevention and provided infection control oversight for the entire hospital system. As Director of Purchasing Services, planned and managed the Central Supply budget to achieve profit goals. Developed and implemented multiple continuous performance improvement processes.HIGHLIGHTS:☑ Achieved “No Findings” status on the Triannual Joint Commission Survey related to infection control, with an accommodation for best infection control practices announced by the lead surveyor. Reduced hospital-acquired infections, increased staff compliance in disinfecting multi-use equipment, and maintained hospital sanitation.☑ Paved the way for 99% hospital-wide employee TB compliance (inherited a 38% rate) by creating and implementing an Employee Health Program to track annual TB compliance and immunization.☑ Played instrumental role in creating the Staff Annual competency skills, leading to increased staff engagement and compliance.☑ Improved patient safety and led the development of cost reduction systems that saved $1,000s per month in medical supplies, biomedical equipment, and general hospital equipment.☑ Co-chaired the Infection Control Committee to establish infection control standards and procedures.Additional Positions:The Menninger Clinic: Lab Services Coordinator, Central Supply/Purchasing Coordinator, Staff NurseEast Texas Medical Center: Staff NurseUnited States Army: Military Police Corps