 Consulting and oversight for 10 Long Term Acute Care (LTAC) hospitals in multiple states. Orientation, coaching and mentoring of 10 Director of Quality Management Mock regulatory surveys and involvement with accreditation/licensure action plans  Policy development and execution for quality, risk management and infection control  Development and implementation of evidence base practice bundles for Catheter Associated Urinary Tract Infection, Sepsis, and Central Line Associated Blood Stream Infection A member of the Cornerstone Corporate clinical, quality team in strategy development and implementation across 18 LTAC facilities Involvement in Inpatient Psychiatric facility operations and quality program

SHENANDOAH MEDICAL CENTER SHENANDOAH, IA 2015–PRESENTPrivately owned southwest Iowa rural medical center | 25-bed hospital | 50-bed skilled nursing facility | Home health/hospice services.Director, Quality, Risk Management, Infection Control (08/2015–Present)Director, Quality, Risk, Information Control | Administrator, Home Health/Hospice (08/15–03/17)Supervisor, Cardiac/Pulmonary Rehabilitation, Dieticians, Social Work (08/15–03/17)Scope: Direct report to CNO. 12 direct reports.• Subject matter expert in implementing new EHR for hospital, home health, and hospice.• Upgraded facility quality improvement and risk management programs, including policies/process updates.• Taught data definitions and inter-rater reliability in abstraction of CMS core measures• Implemented Clarity incident report system and campus-wide reporting of patient, employee, visitor incidents/complaints for timely resolution.• Increased patient influenza immunization from 33% to 86%.Successfully directed CMS home health/hospice regulatory recertification

SIERRA VISTA REGIONAL MEDICAL CENTER, SAN LUIS OBISPO, CA Tenet facility | Level 3 trauma center | Level 3 NICU | 164 bedsDirector, Quality & Risk ManagementScope: Reported to CNO. 9 direct reports.• Facilitated successful TJC triennial recertification survey, heart failure recertification survey, and stroke recertification survey.• Directed infection control program, developed Ebola program for CDPH.• Developed medical staff peer review processes for OPPE and FPPE, emphasis on neurospine case review.• Utilized Crimson data to formulate physician scorecards.• Co-led Lean Daily Management (LDI) methods for operational departments, including daily huddles.

TRACY COMMUNITY HOSPITAL, TRACY, CA | MEMORIAL HOSPITAL, LOS BANOS, CA Two Sutter Health acute care hospitals | Tracy (82 beds) | Los Banos (45 beds)Director, Quality and Risk ManagementScope: Reported to CNO, 8 direct reports• Collaborated with Sepsis Committee to reduce sepsis mortality from 35% to 19% in 19 months.• Team Leader, Lean Committee for 5S and value stream mapping Lean projects.• Implemented High Reliability Organization (HRO) principles at both hospitals.• Successfully completed two Mediation Error Reduction Program (MERP) surveys.

• CATHOLIC HEALTHCARE INITIATIVES (CHI) NEBRASKA 2008–2013ST. MARY’S COMMUNITY HOSPITAL, NEBRASKA CITY, NE (6/08–7/13) | 25 beds | Level 4 trauma centerChief Quality OfficerScope: Quality, Risk Management, Infection Control, Medical Staff, Pharmacy, Surgery, Laboratory, Cardiac/ Pulmonary Rehabilitation, Radiology, Rehabilitation Services. 9 Directors. Reported to CEO.• Co-led Just Culture Initiative for Catholic Healthcare Initiatives’ 5 Nebraska hospitals.• Implemented TeamSTEPPS program house-wide and improved hand-offs and transitions from 21% to 38%.• Launched High Reliability Organization (HRO) strategic initiative, achieved a reduction to zero serious safety events after 9 months.• Oversaw successful CMS hospital licensure surveyCHI RURAL HEALTH OFFICE, LINCOLN, NE (11/08–08/10)Rural Performance Improvement CoordinatorScope: Credentialing/Quality oversight of 12 critical access hospitals.• Developed CMS Critical Access Hospital (CAH) mock survey tool.• Directed/performed over 35 CAH mock surveys in Nebraska.• Provided statewide quality improvement education to rural hospitals via telehealth system.• Developed protocols and guidelines for rural hospital recovery audit contractor audits.SAINT FRANCIS MEDICAL CENTER, GRAND ISLAND, NE (06/08–11/08) | 110 beds | Level 3 NICUManager, Nursing Quality• Coordinated Alaris Smart Pump data for drug library decisions/edits.• Developed NDNQI Nursing measures for 6 clinical units.• Directed IHI sepsis quality improvement efforts.• Chair, TJC Regulatory Committee.