Responsible for managing in collaboration with administrative team and physicians, all functions related to compliance including risk, quality of patient care, safety, regulatory compliance including infection control and some employee health functions. Reports to the CEO. Supports or performs duties including accreditor, state and federal applications, submissions, and responses, development and maintenance of policies and procedures, especially in response to regulatory changes, including conducting employee training when applicable, all compliance-related information (state, federal, accreditor, programmatic, agency, etc.), for revisions, including analysis and summary for distribution, the development of and reviewing/editing for accuracy and compliance, publications and documents (including public-facing materials such as website and marketing), Participates in/coordinates/manages the execution of internal audit programs and processes.  Correctly identifies compliance-related issues to determine whether to escalate, forward to others, or resolve, when appropriate.  Maintains mandatory compliance trainings for all employees.  Initiates investigations and/or routine monitoring for program compliance and/or in response to reports of non-compliance or concerns.  Reviews new regulations to determine impact on the institution and applicable faculty, staff, or students.  Develops and provides technical and administrative guidance on safety and health policies and programs.  Represents the Institution and all affiliate brands professionally and positively.

The position is responsible for leading, improving, monitoring and sustaining adherence with the Tenet operating system Patient Safety Program.  The position Reduces clinical risks at the point of care and mitigate those risks once occurred in collaboration with the tenet Quality and Patient Safety Department.  Implements and evaluates the effectiveness of the Patient Safety Plan through tracking multiple facilities acquired conditions and through the developing and reporting of other key performance indicators. Collaborates with hospital leaders, Reports to the CEO directly as well as system home office Patient Safety Officer, as well as local CNE, COO, CME, Compliance Officer, and DCQI in the application of Federal, State and local Regulations

Administrative Team- Licensed Nurse/CPHQ/CPHRM. Responsible for managing the operations of the Quality Services department for Sutter Health South Valley Area Director in activities of planning, coordinating and guiding for the integrated functions of quality but distracted by the COVID19 activities.  Works collaboratively with other administrative team members, physicians and staff to reduce risk and promote quality patient care and safety. This is accomplished through various assessment activities and corrective actions through Medical Staff Leadership, Quality/Patient Safety Committee of the whole or ad hoc meetings. Manages and coordinates efforts to ensure that quality management programs are developed and managed using a data driven focus and sets priorities for improvements aligned with ongoing strategic imperatives.

Local Risk Management Leader and expert for the local Sutter affiliate. Relocated due to husband's ministry. In collaboration with the service area risk officer, leads the affiliate risk and risk mitigation operations function including the risk management program development, claims management, risk mitigation, risk assessment and guidance, and education in assigned affiliate. As a member of the Healthcare Risk team and the Office of General Counsel (OGC) the affiliate Risk Officer collaborates with the affiliate leadership to improve the patient experience and patient safety by identifying and controlling risk reducing and eliminating the possibility of loss associated with Healthcare delivery and related Core Business activities collaborates with affiliate and system leadership in developing and executing proactive patient safety focused risk management, risk mitigation, and loss prevention programs. Develop a collaborative relationship with other members of the OGC in order to ensure risk legal and Regulatory concerns are addressed properly. The affiliate Risk Officer reports directly to the Service Area Risk officer with a dotted functional line relationship to the affiliate.

Prospect Medical Holdings- Alta Hospitals System, Los Angeles, CA, 1/2017 to August 2018The Corporate Director of Patient Safety/Risk Management, offered VP prior to leaving, manages a comprehensive program to include the coordination and development of hospital-wide patient safety initiatives and risk mitigation strategies designed to reduce medical error and improve patient safety for a 7 facility Hospital system. Reports and supports the Senior VP of Risk Management, Insurance and Claims on other company projects.• Primary oversight of hospital-wide patient safety programs and will provide leadership in the development of cultures of safety and in identifying opportunities and strategies for ongoing initiatives to improve upon patient safety.• Coordinates and develops hospital-wide risk assessments to reduce medical errors, investigates all matters relating to loss prevention/risk reduction and on behalf of the hospitals.• Assists in legal defense activities as requested by the corporate leadership and general counsel; investigates, reviews, and maintains all files related to claims and litigation to include high risk events.• Monitors the hospitals compliance with laws and regulations and provides recommendations for remediation.• Facilitates and/or assists in handling all medical legal and regulatory/accreditation issues to include the reporting of mandatory adverse and/or sentinel events.• Facilitates educational programs to meet the Patient Safety/Risk Management educational needs of staff. Facilitates an annual Culture of Safety Survey at assigned hospital campuses; participates in hospital based Patient Safety Committee meetings; provides risk management consultations to hospital administration and medical staff leadership regarding patient related issues and works with hospital administration to administer the patient complaint/grievance management programs.

Start up. Hospital /1st CA Licensed & TJC accredited during this period.

Promoted with increasing responsibilities

When CHW

Promoted several times.