Peter Kim
Director Quality & Patient Safety at San Gorgonio Memorial Hospital- Claim this Profile
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Bio
Credentials
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Certified Professional in Healthcare Quality (CPHQ)
Healthcare Quality Certification BoardJan, 2011- Nov, 2024
Experience
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San Gorgonio Memorial Hospital
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United States
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Hospitals and Health Care
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100 - 200 Employee
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Director Quality & Patient Safety
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Dec 2020 - Present
Responsible for leading the Quality Department in daily operations. Led the hospital through the Triennial CIHQ (Center for Improvement in Healthcare Quality) Survey, Biennial Joint Commission Lab Survey, Event Review Investigations, as well as numerous CDPH visits. • Led the hospital through the 2021 Triennial CIHQ Survey preparing all aspects of preparation, document review, notification protocol, environment of care rounding, as well as submission of corrective action plans. Successfully… Show more Responsible for leading the Quality Department in daily operations. Led the hospital through the Triennial CIHQ (Center for Improvement in Healthcare Quality) Survey, Biennial Joint Commission Lab Survey, Event Review Investigations, as well as numerous CDPH visits. • Led the hospital through the 2021 Triennial CIHQ Survey preparing all aspects of preparation, document review, notification protocol, environment of care rounding, as well as submission of corrective action plans. Successfully accrediting the hospital for an additional 3 years. • Coordinated over 20+ CDPH Investigations including 2567 corrective action plan response and submissions. • Coordinated the hospital through the Biennial Joint Commission ABG Lab Survey successfully accrediting the hospital. • Led the hospital’s engagement in the Inland Empire Health Plan (IEHP) Pay for Performance Program resulting in increased performance for multiple measures in the program and increased reimbursements for the hospital. • Engaged and trained in the Beta Heart Patient Safety Initiative, a multi-hospital program promoting staff support, event reviews, and increased communication, earning the hospital additional funds for participation. • Led the coordination and submission of data for the Quality Incentive Program, a California state quality pay for performance program, earning the hospital significant funding for reporting and performance. • Successfully trained staff to complete the annual Leapfrog Hospital Survey, and increased the Hospital Safety Grade a full letter grade from D to C. • Trained staff on leading a team of physicians, nurses and pharmacists participating in the Leapfrog CPOE (Computerized Physician Order Entry) online test, resulting in the best score possible for the first time. • Developed multiple PDSA tools for department specific Performance Improvement projects. • Updated hospital wide Survey Readiness Handbook in preparation for upcoming Triennial CIHQ Survey Show less Responsible for leading the Quality Department in daily operations. Led the hospital through the Triennial CIHQ (Center for Improvement in Healthcare Quality) Survey, Biennial Joint Commission Lab Survey, Event Review Investigations, as well as numerous CDPH visits. • Led the hospital through the 2021 Triennial CIHQ Survey preparing all aspects of preparation, document review, notification protocol, environment of care rounding, as well as submission of corrective action plans. Successfully… Show more Responsible for leading the Quality Department in daily operations. Led the hospital through the Triennial CIHQ (Center for Improvement in Healthcare Quality) Survey, Biennial Joint Commission Lab Survey, Event Review Investigations, as well as numerous CDPH visits. • Led the hospital through the 2021 Triennial CIHQ Survey preparing all aspects of preparation, document review, notification protocol, environment of care rounding, as well as submission of corrective action plans. Successfully accrediting the hospital for an additional 3 years. • Coordinated over 20+ CDPH Investigations including 2567 corrective action plan response and submissions. • Coordinated the hospital through the Biennial Joint Commission ABG Lab Survey successfully accrediting the hospital. • Led the hospital’s engagement in the Inland Empire Health Plan (IEHP) Pay for Performance Program resulting in increased performance for multiple measures in the program and increased reimbursements for the hospital. • Engaged and trained in the Beta Heart Patient Safety Initiative, a multi-hospital program promoting staff support, event reviews, and increased communication, earning the hospital additional funds for participation. • Led the coordination and submission of data for the Quality Incentive Program, a California state quality pay for performance program, earning the hospital significant funding for reporting and performance. • Successfully trained staff to complete the annual Leapfrog Hospital Survey, and increased the Hospital Safety Grade a full letter grade from D to C. • Trained staff on leading a team of physicians, nurses and pharmacists participating in the Leapfrog CPOE (Computerized Physician Order Entry) online test, resulting in the best score possible for the first time. • Developed multiple PDSA tools for department specific Performance Improvement projects. • Updated hospital wide Survey Readiness Handbook in preparation for upcoming Triennial CIHQ Survey Show less
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Quality & Patient Safety Program Manager
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Jun 2016 - Dec 2020
Responsible for the coordination of regulatory, accreditation and performance improvement activities in the hospital, as well as developing data tools for ongoing quality metric monitoring, and identification of issues. • Led the hospital through the 2016 and 2019 Triennial Joint Commission Survey preparing all documents, tracer activities, Mock Survey Preparations for all departments in the hospital, resulting in a successful accreditation of the hospital both surveys. • Coordinated… Show more Responsible for the coordination of regulatory, accreditation and performance improvement activities in the hospital, as well as developing data tools for ongoing quality metric monitoring, and identification of issues. • Led the hospital through the 2016 and 2019 Triennial Joint Commission Survey preparing all documents, tracer activities, Mock Survey Preparations for all departments in the hospital, resulting in a successful accreditation of the hospital both surveys. • Coordinated over 150+ CDPH Investigations including patient complaints, pressure ulcers, etc. • Coordinated the hospital through the Biennial Joint Commission ABG Lab Survey successfully accrediting the hospital. • Collaborated with the NICU/Pediatrics Director during the California Children’s Services Inspection Survey. • Coordinated the annual Leapfrog Hospital Survey and Hospital Safety Grade increasing the letter grade from a letter grade of C to a B. • Coordinated and led a team of physicians, nurses and pharmacists participating in the Leapfrog CPOE (Computerized Physician Order Entry) online test, resulting in the best score possible four consecutive times. • Coordinated the corrective actions and Plan of Correction submission to CDPH for the Annual TCU Inspection Survey. • Coordinated the corrective actions and Plan of Correction submission to CDPH for the Laboratory. • Collaborated with the Environment of Care Director during the CDPH inspection for the Annual Waste Management Inspection • Coordinated the submission of the Intra Cycle Monitoring submission to the Joint Commission for the Blood Gas Laboratory. • Updated the Annual Quality Department Plan for 2017. • Collaborated with the Laboratory Director during the Biennial CAP Inspection Survey for the Laboratory. • Developed multiple PDSA tools for department specific Performance Improvement projects. • Updated hospital wide Survey Readiness Handbook in preparation for upcoming Triennial Joint Commission Survey
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Interim Director Quality & Risk/Patient Safety Officer
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Nov 2016 - Nov 2017
Responsible for leading the Quality & Risk Department in daily operations. Led the hospital through the Triennial Joint Commission Survey, Event Review Investigations, Patient Experience, Complaints & Grievance Process, as well as numerous CDPH visits. • Led the hospital through the Triennial Joint Commission Survey, preparing all documents, tracer activities, Mock Survey Preparations for all departments in the hospital, successfully accrediting the hospital. • Led the hospital through… Show more Responsible for leading the Quality & Risk Department in daily operations. Led the hospital through the Triennial Joint Commission Survey, Event Review Investigations, Patient Experience, Complaints & Grievance Process, as well as numerous CDPH visits. • Led the hospital through the Triennial Joint Commission Survey, preparing all documents, tracer activities, Mock Survey Preparations for all departments in the hospital, successfully accrediting the hospital. • Led the hospital through the Biennial CAP Laboratory Survey, successfully accrediting the lab. • Led the hospital through the Biennial Stroke Certification Survey, successfully certifying the hospital. • Led the hospital through 60+ CDPH investigations successfully. • Led the Event Review (RCA) process for numerous investigations to mitigate potential harm for patients. • Responsible for the transition to Press Ganey for the organization, focusing on patient satisfaction improvement efforts. • Responsible for Patient Complaints and Grievance process, emphasizing service recovery and health insurance grievance reconciliation. • Presented status reports to both the Community Board as well as the Quality Subcommittee of the Board.
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Los Robles Hospital and Medical Center
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United States
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Hospitals and Health Care
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500 - 600 Employee
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Quality Improvement Coordinator III
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Jun 2010 - Jun 2012
Responsible for oversight and coordination of regulatory, accreditation and performance improvement activities in the hospital. Developing data tools for ongoing quality metric monitoring, and identification of issues. •Coordination of annual Leapfrog Patient Safety Survey data for public reporting, including a gap analysis to identify potential opportunities for improvement resulting in an increase of patient safety standards ratings from "Some Progress" to "Fully Meets… Show more Responsible for oversight and coordination of regulatory, accreditation and performance improvement activities in the hospital. Developing data tools for ongoing quality metric monitoring, and identification of issues. •Coordination of annual Leapfrog Patient Safety Survey data for public reporting, including a gap analysis to identify potential opportunities for improvement resulting in an increase of patient safety standards ratings from "Some Progress" to "Fully Meets Standards". •Coordinated the annual AHRQ Culture of Safety Survey to assess the organizational culture of safety, and identify areas for improvement increasing employee participation rates from 40% to 80%. •Responsible for Core Measure Performance Improvement functions including Pneumonia Case Identification, Pneumonia Concurrent Review, Chart Abstractions for Pneumonia, AMI, Heart Failure, Outpatient Surgery, Outpatient AMI resulting in the increased Overall Core Measure Compliance from 80% to 100% for all measures. •Provided guidance with various Joint Commission standards compliance including triennial survey readiness, annual Periodic Performance Reviews, and Tracer Activities. •Project leader for the SBARQ communication hand off safety initiative for house wide rollout. •Coordinating the annual National Quality Week to promote organization awareness regarding the importance of quality of care and patient safety. •Coordinated the Quality Subcommittee of the Board of Trustees meeting. •Collaborated with various physicians regarding HSAG (Health Services Advisory Group) performance improvement plans and data collection and submission. •Responsible for developing multiple Quality Improvement Dashboards for the following areas or issues: Overall Organizational Quality, Cardiovascular, Radiology, Code Blue, Rapid Response Teams, and Restraints. •Responsible for coordinating the submission of CDAC (Clinical Data Abstraction Center) Core Measure abstraction verification for the federal government. Show less Responsible for oversight and coordination of regulatory, accreditation and performance improvement activities in the hospital. Developing data tools for ongoing quality metric monitoring, and identification of issues. •Coordination of annual Leapfrog Patient Safety Survey data for public reporting, including a gap analysis to identify potential opportunities for improvement resulting in an increase of patient safety standards ratings from "Some Progress" to "Fully Meets… Show more Responsible for oversight and coordination of regulatory, accreditation and performance improvement activities in the hospital. Developing data tools for ongoing quality metric monitoring, and identification of issues. •Coordination of annual Leapfrog Patient Safety Survey data for public reporting, including a gap analysis to identify potential opportunities for improvement resulting in an increase of patient safety standards ratings from "Some Progress" to "Fully Meets Standards". •Coordinated the annual AHRQ Culture of Safety Survey to assess the organizational culture of safety, and identify areas for improvement increasing employee participation rates from 40% to 80%. •Responsible for Core Measure Performance Improvement functions including Pneumonia Case Identification, Pneumonia Concurrent Review, Chart Abstractions for Pneumonia, AMI, Heart Failure, Outpatient Surgery, Outpatient AMI resulting in the increased Overall Core Measure Compliance from 80% to 100% for all measures. •Provided guidance with various Joint Commission standards compliance including triennial survey readiness, annual Periodic Performance Reviews, and Tracer Activities. •Project leader for the SBARQ communication hand off safety initiative for house wide rollout. •Coordinating the annual National Quality Week to promote organization awareness regarding the importance of quality of care and patient safety. •Coordinated the Quality Subcommittee of the Board of Trustees meeting. •Collaborated with various physicians regarding HSAG (Health Services Advisory Group) performance improvement plans and data collection and submission. •Responsible for developing multiple Quality Improvement Dashboards for the following areas or issues: Overall Organizational Quality, Cardiovascular, Radiology, Code Blue, Rapid Response Teams, and Restraints. •Responsible for coordinating the submission of CDAC (Clinical Data Abstraction Center) Core Measure abstraction verification for the federal government. Show less
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Children's Hospital Los Angeles (CHLA)
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United States
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Hospitals and Health Care
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700 & Above Employee
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Quality Improvement Coordinator II
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Jun 2008 - Apr 2010
Managed and facilitated multiple projects involving the Joint Commission, Leapfrog Patient Safety, U.S. News and World Report as well as multiple Internal Performance Improvement Projects. •Coordinated and facilitated the Joint Commission Core Measure for Children’s Asthma Care. Assessed Home Management Plan of Care measure performance through chart review and identified intervention strategies designed to increase compliance. Increased compliance rates from 0% to 83%. •Facilitated the… Show more Managed and facilitated multiple projects involving the Joint Commission, Leapfrog Patient Safety, U.S. News and World Report as well as multiple Internal Performance Improvement Projects. •Coordinated and facilitated the Joint Commission Core Measure for Children’s Asthma Care. Assessed Home Management Plan of Care measure performance through chart review and identified intervention strategies designed to increase compliance. Increased compliance rates from 0% to 83%. •Facilitated the data collection and submission of data for Leapfrog Patient Safety Group resulting in the Hospital receiving the Leapfrog Top Hospital Award. oCoordinated and led a team of physicians, nurses and pharmacists participating in the Leapfrog CPOE (Computerized Physician Order Entry) online test receiving the highest possible score. •Facilitated data collection and submission of data for the US News & World Report for Best Children’s Hospitals publication resulting in the hospital being ranked in the Honor Roll for Top 10 Children's Hospital in the country. •Involved in multiple Joint Commission Activities including: oCommand Center operations during a Joint Commission full survey. oCoordinated submission of Evidence of Standards compliance for the Joint Commission. oCoordinated submission of Measures of Success to the Joint Commission. Worked with focus groups to monitor and ensure 90% goals were met for all Indirect Impacts. oCoordinated various departments for Joint Commission Periodic Performance Review (PPR) compliance. •Coordinated and presented the Hospital Quality Dashboard. Presented results to the Quality Improvement Committee and the Board of Trustees. •Coordinated data collection and input of dashboard report for Rapid Response Team monitoring. Presented dashboard report to Critical Response Systems Committee. •Coordinated annual AHRQ Culture of Safety survey for the hospital. Presented results of safety survey to QIC and Board of Trustees. Show less Managed and facilitated multiple projects involving the Joint Commission, Leapfrog Patient Safety, U.S. News and World Report as well as multiple Internal Performance Improvement Projects. •Coordinated and facilitated the Joint Commission Core Measure for Children’s Asthma Care. Assessed Home Management Plan of Care measure performance through chart review and identified intervention strategies designed to increase compliance. Increased compliance rates from 0% to 83%. •Facilitated the… Show more Managed and facilitated multiple projects involving the Joint Commission, Leapfrog Patient Safety, U.S. News and World Report as well as multiple Internal Performance Improvement Projects. •Coordinated and facilitated the Joint Commission Core Measure for Children’s Asthma Care. Assessed Home Management Plan of Care measure performance through chart review and identified intervention strategies designed to increase compliance. Increased compliance rates from 0% to 83%. •Facilitated the data collection and submission of data for Leapfrog Patient Safety Group resulting in the Hospital receiving the Leapfrog Top Hospital Award. oCoordinated and led a team of physicians, nurses and pharmacists participating in the Leapfrog CPOE (Computerized Physician Order Entry) online test receiving the highest possible score. •Facilitated data collection and submission of data for the US News & World Report for Best Children’s Hospitals publication resulting in the hospital being ranked in the Honor Roll for Top 10 Children's Hospital in the country. •Involved in multiple Joint Commission Activities including: oCommand Center operations during a Joint Commission full survey. oCoordinated submission of Evidence of Standards compliance for the Joint Commission. oCoordinated submission of Measures of Success to the Joint Commission. Worked with focus groups to monitor and ensure 90% goals were met for all Indirect Impacts. oCoordinated various departments for Joint Commission Periodic Performance Review (PPR) compliance. •Coordinated and presented the Hospital Quality Dashboard. Presented results to the Quality Improvement Committee and the Board of Trustees. •Coordinated data collection and input of dashboard report for Rapid Response Team monitoring. Presented dashboard report to Critical Response Systems Committee. •Coordinated annual AHRQ Culture of Safety survey for the hospital. Presented results of safety survey to QIC and Board of Trustees. Show less
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Cedars-Sinai
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United States
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Hospitals and Health Care
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700 & Above Employee
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Performance Improvement Committee Coordinator
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Aug 2005 - Apr 2007
Affiliated with the Medical Staff Office, coordinated Performance Improvement Committees for the following departments: Surgery, OBGYN, Psychiatry, Pediatrics, Physical Medicine & Rehabilitation, Anesthesia, Emergency, Imaging, Pathology, and Radiation Oncology. •Close interaction with Department Chairs, Vice Presidents, Physicians and Nursing staff in order to facilitate improvement activities. •Thorough minutes taken of all issues and resolutions noted during Performance Improvement… Show more Affiliated with the Medical Staff Office, coordinated Performance Improvement Committees for the following departments: Surgery, OBGYN, Psychiatry, Pediatrics, Physical Medicine & Rehabilitation, Anesthesia, Emergency, Imaging, Pathology, and Radiation Oncology. •Close interaction with Department Chairs, Vice Presidents, Physicians and Nursing staff in order to facilitate improvement activities. •Thorough minutes taken of all issues and resolutions noted during Performance Improvement Committees. •Compiled reports, presentations, agenda packets, and actionable items within 1157 protected documents in public folders. Show less Affiliated with the Medical Staff Office, coordinated Performance Improvement Committees for the following departments: Surgery, OBGYN, Psychiatry, Pediatrics, Physical Medicine & Rehabilitation, Anesthesia, Emergency, Imaging, Pathology, and Radiation Oncology. •Close interaction with Department Chairs, Vice Presidents, Physicians and Nursing staff in order to facilitate improvement activities. •Thorough minutes taken of all issues and resolutions noted during Performance Improvement… Show more Affiliated with the Medical Staff Office, coordinated Performance Improvement Committees for the following departments: Surgery, OBGYN, Psychiatry, Pediatrics, Physical Medicine & Rehabilitation, Anesthesia, Emergency, Imaging, Pathology, and Radiation Oncology. •Close interaction with Department Chairs, Vice Presidents, Physicians and Nursing staff in order to facilitate improvement activities. •Thorough minutes taken of all issues and resolutions noted during Performance Improvement Committees. •Compiled reports, presentations, agenda packets, and actionable items within 1157 protected documents in public folders. Show less
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UCLA Health
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United States
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Hospitals and Health Care
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700 & Above Employee
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Quality Improvement Coordinator
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Jan 2003 - Dec 2005
Assigned broad responsibilities for various performance improvement projects in numerous areas of the hospital and directed the ongoing coordination of hospital-wide special interests. •Appointed to lead the re-implementation of Joint Commission Safety Compliance Regulations project, including interviewing, training, administrative and operational duties. •Implemented Joint Commission safety contest at both the Westwood and Santa Monica hospitals, improving participation and safety… Show more Assigned broad responsibilities for various performance improvement projects in numerous areas of the hospital and directed the ongoing coordination of hospital-wide special interests. •Appointed to lead the re-implementation of Joint Commission Safety Compliance Regulations project, including interviewing, training, administrative and operational duties. •Implemented Joint Commission safety contest at both the Westwood and Santa Monica hospitals, improving participation and safety awareness rates by 50% Project Leader (2003 – 2004) Chosen to lead a multi-departmental performance improvement project consisting of 15 volunteers, with the goal of assessing the level of patient satisfaction involving staff communication effectiveness to patients. •Established, and implemented the HOPE (Help Optimize the Patient Experience) Project. Surveyors would gain patient feedback about the communication effectiveness of physicians, nurses and care partners •Implemented a patient satisfaction survey tool •Conducted presentations to a committee of hospital executives, to identify key areas for improvement Show less Assigned broad responsibilities for various performance improvement projects in numerous areas of the hospital and directed the ongoing coordination of hospital-wide special interests. •Appointed to lead the re-implementation of Joint Commission Safety Compliance Regulations project, including interviewing, training, administrative and operational duties. •Implemented Joint Commission safety contest at both the Westwood and Santa Monica hospitals, improving participation and safety… Show more Assigned broad responsibilities for various performance improvement projects in numerous areas of the hospital and directed the ongoing coordination of hospital-wide special interests. •Appointed to lead the re-implementation of Joint Commission Safety Compliance Regulations project, including interviewing, training, administrative and operational duties. •Implemented Joint Commission safety contest at both the Westwood and Santa Monica hospitals, improving participation and safety awareness rates by 50% Project Leader (2003 – 2004) Chosen to lead a multi-departmental performance improvement project consisting of 15 volunteers, with the goal of assessing the level of patient satisfaction involving staff communication effectiveness to patients. •Established, and implemented the HOPE (Help Optimize the Patient Experience) Project. Surveyors would gain patient feedback about the communication effectiveness of physicians, nurses and care partners •Implemented a patient satisfaction survey tool •Conducted presentations to a committee of hospital executives, to identify key areas for improvement Show less
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Education
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2020 - 2023
Western Governors University
Bachelor's degree, Registered Nursing/Registered Nurse -
2007 - 2009
UCLA
Masters, Public Health -
UC Irvine
Bachelors, Social Science
Community
