Kimberly Titzer Msn Cphrm Cphq Email & Phone Number

North Carolina, United States

Advanced to Director of Risk and Quality Services in November 2022. Serve as the Patient Safety and Corporate Compliance Officer. Facilitated accreditation process during change to DNV from Joint Commission. Prepare leadership for survey readiness, lead the survey process, and guide regulatory improvements. Work with legal and malpractice carrier to mitigate risk and improve patient safety. Advocate for patient safety at the committee level and promote best practices through policy and education. Report to the CEO/CMO.

North Carolina

Provide oversight and guidance in the development and continuous improvement of processes and systems to ensure the highest standards of quality and safety for patients. Ensure best practices and regulatory standards are in place to promote patient safety and mitigate patient risk. Collaborate with physician, nursing, and other committees to provide efficient and effective change. Lead multidisciplinary committees to guide data analysis and performance improvement projects. Demonstrate effectiveness by measurable improvement of key patient safety indicators.

Ensured regulatory compliance with DNV and TJC standards. Conducted interdisciplinary QAPI Team meetings. Analyzed data and led process improvement initiatives. Facilitated OPPE/FPPE with CMO. Led teams for RCAs. Provided employee training and education related to process improvement. Managed patient satisfaction and grievances. Mitigated risks and ensured patient safety. Worked with leadership team to meet reporting requirements. Served as Director for Infection Prevention.

Derry, Nh

Managed stroke and sepsis programs, improving stroke process “door to needle” time by 20% from the previous year. Prepared for TJC regulatory reviews. Assessed risks and mitigated with concurrent process review and retrospective case analysis. Collected, analyzed, and presented data. Optimized clinical processes through collaborative practice. Facilitated committees with administration and front-line clinical staff. Coached clinicians and provided education. Optimized policy, process, and order sets.

Peterborough, Nh

Led Lean and Six Sigma projects. Reduced ED length of stay by 29% through process improvement. Reduced “decision to incision” time for emergent cesarean sections to less than 30 minutes. Managed interim infection prevention, including NHSN database maintenance. Prepared for CMS regulatory reviews. Conducted RCAs for state reporting. Collected, analyzed, and presented data.

Peterborough, Nh

Successful team leader for EMR build and implementation from paper to electronic record in the OR. Optimized clinical application build for nursing and providers. Clinical staff education ORM and Clinical Care station

Peterborough, Nh

Circulator, scrub, Successful completion and team leader of electronic record implementation utilizing ARON standards of care. Streamlined OR supplies and optimized process for retrieval with electronic data base and standardization of picking cards. Streamlined and updated malignant hyperthermia supply cart and policy. Delivered education using simulation. CNOR certification.

Peterborough, New Hampshire

• Team leader: education and process change for sepsis identification, order set, and bundle implementation• Team leader for pediatric patient preparedness. • Provided ICU education and utilized simulation for process improvement. • Hospital committees: Nursing Peer Review, Nursing Education committee, and Nursing Practice committee• Certified AHA ACLS instructor and CCRN

Master’S Degree, Nursing- Patient Safety And Quality, 3.97

Associate’S Degree, Nursing Science

Education record