Director Quality Improvement

• Jan 2017 - Present

Regulatory Coordinator

• Jun 2014 - Dec 2016

Responsible for organizational compliance with Joint Commission standards, CMS Conditions of Participation, and NJDOH regulations. Establishes leadership structures and processes to facilitate ongoing survey readiness. Investigates and manages response to patient safety events. Responsible for all aspects of the process for management of patient safety adverse events including reporting, investigation, facilitating root cause analysis teams, and development and monitoring of action plans in collaboration with clinical leadership and staff to achieve improvements. Show less

Quality Improvement Director

• Oct 2009 - May 2014

Led quality program for 300 bed community hospital. Managed seven person Quality Services Department. Responsible for Joint Commission accreditation, compliance with CMS and NJDOH regulations, monitoring and reporting of quality indicators to CMS and Joint Commission, hospital performance improvement initiatives, medical peer review process, ongoing professional practice evaluation, patient safety initiatives, and reporting of serious adverse events and submission of root cause analyses to NJ Patient Safety Authority. Show less

Director of Standards

• Jun 2008 - Nov 2008

Responsible for accreditation, licensure and regulatory compliance for a 600 bed teaching hosptital in suburban New Jersey. Oversees Joint Commission, CMS, and NJ Department of Health and Senior Service survey readiness. Leads patient safety and performance improvement initiatives including root cause analysis. Develops action plans and monitors results to achieve process improvements. Responsible for accreditation, licensure and regulatory compliance for a 600 bed teaching hosptital in suburban New Jersey. Oversees Joint Commission, CMS, and NJ Department of Health and Senior Service survey readiness. Leads patient safety and performance improvement initiatives including root cause analysis. Develops action plans and monitors results to achieve process improvements.

Director, Accreditation and Standards Compliance

• 1999 - 2008

Developed and implemented policies and processes for achieving continuous survey readiness for a 700 bed academic medical center and 150 bed orthopedic specialty hospital. Successfully implemented policies and procedures to comply with federal HIPAA regulations.•Established process for Joint Commission survey preparation and continuous survey readiness.•Communicated clinical, administrative, and facility standards and expectations to leadership and staff.•Facilitated changes in operational processes to improve quality and compliance with Joint Commission standards. •Responsible for policy development and implementation of HIPAA privacy regulations to ensure compliance. •Developed monitoring reports and tools to track compliance and sustain organizational improvements.•Developed and delivered training programs to assure ongoing compliance with standards and policies. Show less

Director, Planning and Program Development

• May 1996 - Dec 1998

Defined program requirements and plans for proposed new initiatives. Managed the process from program development to Certificate of Need approval• Conducted feasibility analyses for new programs• Participated in program and facility planning for major capital projects• Managed process for preparation of Certificate of Need applications• Built relationships at governmental regulatory agencies to facilitate development, proposal submissions, and approval• Supervised planning staff• Responsible for budget preparation and all Planning Department activities Show less

Associate Director, Planning and Program Development

• Nov 1989 - May 1996

• Developed program requirements and business plans for new programs• Led multidisciplinary teams to establish program goals, utilization, facility and resource requirements• Participated in primary care strategy and planning for off-site locations• Managed consultants engaged to assist in determining program alternatives

Planning Analyst

• 1987 - 1989