Chief Compliance and Quality Officer

• Jan 2021 - Present

Director of Quality and Process Improvement

• May 2017 - Jan 2021

Oversee quality improvement initiatives to ensure high clinical outcomes, improved patient safety, regulatory compliance and enhanced patient experience. Develop long and short term business strategies and operational plans and oversees implementation. Responsible for quality, service and regulatory compliance for fifty primary- and specialty practices, approximately 100 physicians. Demonstrate the organization’s Mission, Vision, and Values in the achievement of excellent clinical quality… Show more Oversee quality improvement initiatives to ensure high clinical outcomes, improved patient safety, regulatory compliance and enhanced patient experience. Develop long and short term business strategies and operational plans and oversees implementation. Responsible for quality, service and regulatory compliance for fifty primary- and specialty practices, approximately 100 physicians. Demonstrate the organization’s Mission, Vision, and Values in the achievement of excellent clinical quality outcomes and improved results in the Triple Aim (improved individual quality, improved population health, and lower costs of care). Direct performance improvement activities to reach top decile performance and outcomes ensuring alignment with system goals. Coordinate and facilitate quality improvement teams with a focus on quality, safety, compliance and risk mitigation. Oversee case management, transitions of care, and Electronic Health Record training departments.

Director of Compliance and Risk Management, Privacy Officer

• Nov 2015 - May 2017

Directed day-to-day operation of the Compliance and Risk Management Programs for a 100-physician medical group. Redesigned the Code of Conduct to ensure continuing currency and relevance in providing guidance to the leadership team and employees. Responded to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Developed and implemented a system for uniform handling of violations.… Show more Directed day-to-day operation of the Compliance and Risk Management Programs for a 100-physician medical group. Redesigned the Code of Conduct to ensure continuing currency and relevance in providing guidance to the leadership team and employees. Responded to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Developed and implemented a system for uniform handling of violations. Identified potential areas of compliance vulnerability and risk; developed/implemented corrective action plans for resolution of problematic issues, and provided guidance on avoiding and managing similar situations in the future. Ensured proper reporting of violations or potential violations to enforcement agencies as appropriate. Established an anonymous compliance Hotline. Monitored the performance of the Compliance Program and related activities on a continuing basis, taking appropriate steps to improve its effectiveness.

Director of Accreditation and Emergency Management

• Apr 2013 - Nov 2015

Provided management and leadership in the development and implementation of regulatory strategies and processes for a 293-bed hospital, 48 primary and specialty care physician practices, two urgent care clinics and an ambulatory surgery center. Responsible for organization-wide compliance with all applicable regulatory standards. Responsible for keeping leadership team informed of the regulatory status of the hospital and physician practices. Represented the organization before regulatory… Show more Provided management and leadership in the development and implementation of regulatory strategies and processes for a 293-bed hospital, 48 primary and specialty care physician practices, two urgent care clinics and an ambulatory surgery center. Responsible for organization-wide compliance with all applicable regulatory standards. Responsible for keeping leadership team informed of the regulatory status of the hospital and physician practices. Represented the organization before regulatory authorities, including The Joint Commission, CMS, Department of Health and Human Services, and College of American Pathologists. Provided interpretation, consultation, and training of Joint Commission and other regulatory standards to Elliot Health System personnel. Represented the Organization during accreditation and regulatory surveys. Direct the organization’s Emergency Management Program. Conducted a system-wide disaster preparedness self-assessment. Implemented and all-hazards Emergency Operations Plan that aligns with the HICS (Hospital Incident Command Structure). Facilitated all system-wide command center activations. Show less Provided management and leadership in the development and implementation of regulatory strategies and processes for a 293-bed hospital, 48 primary and specialty care physician practices, two urgent care clinics and an ambulatory surgery center. Responsible for organization-wide compliance with all applicable regulatory standards. Responsible for keeping leadership team informed of the regulatory status of the hospital and physician practices. Represented the organization before regulatory… Show more Provided management and leadership in the development and implementation of regulatory strategies and processes for a 293-bed hospital, 48 primary and specialty care physician practices, two urgent care clinics and an ambulatory surgery center. Responsible for organization-wide compliance with all applicable regulatory standards. Responsible for keeping leadership team informed of the regulatory status of the hospital and physician practices. Represented the organization before regulatory authorities, including The Joint Commission, CMS, Department of Health and Human Services, and College of American Pathologists. Provided interpretation, consultation, and training of Joint Commission and other regulatory standards to Elliot Health System personnel. Represented the Organization during accreditation and regulatory surveys. Direct the organization’s Emergency Management Program. Conducted a system-wide disaster preparedness self-assessment. Implemented and all-hazards Emergency Operations Plan that aligns with the HICS (Hospital Incident Command Structure). Facilitated all system-wide command center activations. Show less

Director of Accreditation, Regulation and Licensing

• Oct 2010 - Dec 2012

Directed the Medical Center’s operations and activities to comply with all accreditation, regulation, and licensing requirements for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. Translated various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Implemented systems to… Show more Directed the Medical Center’s operations and activities to comply with all accreditation, regulation, and licensing requirements for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. Translated various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Implemented systems to effectively monitor compliance to standards. Oversaw the hospital’s Leapfrog patient safety program. Coordinated Periodic Performance Review process. Acted as liaison with State and Federal regulatory agencies. Oversaw the hospital’s Medical Staff Office functions, including Credentialing and Privileging, Continuing Medical Education, and Graduate Medical Education.

Project Manager III

• Aug 2005 - Oct 2010

Provided expert technical leadership to highly visible, sensitive and multi-faceted projects. Developed project plans, which identify key issues, barriers, approaches, performance metrics and resources required. Acted as liaison, problem solver and facilitator. Responsible for the strategic development, implementation and evaluation of compliance management systems at the Medical Center. Conducted compliance risk assessment and implemented corrective action plans. Implemented controls to… Show more Provided expert technical leadership to highly visible, sensitive and multi-faceted projects. Developed project plans, which identify key issues, barriers, approaches, performance metrics and resources required. Acted as liaison, problem solver and facilitator. Responsible for the strategic development, implementation and evaluation of compliance management systems at the Medical Center. Conducted compliance risk assessment and implemented corrective action plans. Implemented controls to guarantee privacy and security, identify fraud, waste, and abuse and ensure compliance to state and federal regulations. Conducted investigations arising from allegations of improper employee conduct. Collaborated with Medical Center leadership to ensure operating procedures, systems and standards align with compliance requirements and controls, and that staff is trained on these controls. Developed strong collaborative leadership relationships with the Medical Group, external regulatory agencies and accreditation bodies, and used these relationships to manage risks and establish priorities and plans to address risks.

Quality and Utilization Senior Analyst

• Jan 2003 - Aug 2005

Analysis and consultation to multiple high-level committees, including the Medial Executive Committee, Quality Management Committee, and Surgical Collaborative Practice Team. Performed data abstraction for Joint Commission Core Measures. Analyzed Core Measure results and other publicly reported measures. Coordinated the physician Peer Review process. Key contributor in two successful Joint Commission Surveys. Collaborated with the VP for Quality and Safety to complete the response, report… Show more Analysis and consultation to multiple high-level committees, including the Medial Executive Committee, Quality Management Committee, and Surgical Collaborative Practice Team. Performed data abstraction for Joint Commission Core Measures. Analyzed Core Measure results and other publicly reported measures. Coordinated the physician Peer Review process. Key contributor in two successful Joint Commission Surveys. Collaborated with the VP for Quality and Safety to complete the response, report and supporting documents to the Joint Commission Recommendations for Improvement.