Responsibilities included standardizing policies/procedures for two hospitals in Washington, DC, ensuring compliance with Joint Commission standards, and DC standards and DOH regulations.

Coordinates Joint Commission and all Regulatory functIons. Responsible for Quality Council, Patient Safety and Infection Control activities. Serves as the Safety Officer and Risk Manager

Responsible for planning and implementing hospital performance improvement activities; provide education on quality to medical staff, employees and governing board;acts as a resource for the implementation of continuous quality improvement;functions as risk manager and safety officer;oversight responsibility for all regulatory bodies: Joint Commission, Dept. of Health, CMS,etc.

Directed a dept of 5 ;outcomes staff; responsible for PI activities, patient safety, CORE MEASURES, risk related to pt. Complaints; conducted RCA's

Managed the PI dept. with 4 PI Outcomes managers. Provided oversight for CORE Measures data collection and reporting to CMS. Was responsible for all PI initiatives, clinical and medical staff. Was responsible for the Patient Safety functions, collaborating with clinical depts. and medical staff in conducting RCA's when appropriate. Was a member of the Cooper Rowan Medical School Curriculum committee.

Accountable for ensuring adherence to all external regulatory requirements related to JCAHO, NJDHSS and CMS. Carried out functions of Risk Manager role by conducting investigations related to sentinel events, deviations in compliance to standards of care / practice; worked closely with hospital designated insurance brokers and claims representatives to address and resolve claims issues. Developed Physician Report Card with performance indicators. Coordinated the Nursing and Medical Staff Peer Review activities. Collaborated with Medical staff in the development of departmental clinical indicators. Coordinated the JCAHO continuous readiness process. Coordinated Hospital Wide, Laboratory and Behavioral Health triennial and extension surveys. Conducted educational sessions on performance improvement methodology for the executive team, Board of Trustees, medical staff leadership, nursing leadership and nursing staff.