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Work Background
Park Royal HospitalDirector of Operations
May. 2023Fort Myers, Florida AreaFacilitate, direct and coordinate operational activities and programs relative to the day to day operations for a 126 bed free-standing acute care psychiatric hospital with intensive outpatient service. Serves as Executive Leadership in the absence of the CEO and provides guidance, facilitation of processes and interpretation of hospital policy. Working with the Chief Executive Officer to ensure the hospital meets necessary regulatory and compliance approvals and quality accreditations (AHCA, DCF, Joint Commission and CMS) in conjunction with the hospital's Chief Nursing Officer. Evaluate operational processes by analyzing business objectives and patient needs. Provide staff management to include hiring, development, training, performance management and communication to ensure effective and efficient department operations for Risk Management, PHP-IOP, ECT, Food Services and Medical Records. Assist Director of Plant Operations to maintain a safe and operational facility; ensuring Life-Safety, Proactive Risk Assessment, and Scheduled Maintenance is completed in conjunction with stated and federal requirements. Serve as facility Privacy Officer and ensure proper management of PHI and management of Ethics Complaints in conjunction with Director of Risk Management.
Park Royal HospitalDirector of Risk Management
Mar. 2019 - May. 2023Fort Myers, Florida AreaDirected all aspects of the hospital's Risk Management Program, supporting nearly 200 hundred employees. Spearheaded and Implemented ObservSmart Patient Safety Observation platform; working proactively with CNO/ADON to ensure all aspects of Patient Safety, Patient Satisfaction and Patient Advocacy programs. Conduct investigations and report results to senior leadership and corporate. Complete Root Cause Analysis and FMEA processes in Advancing High Reliability. Led facility Risk Loss Prevention Committee – identifying and implementing proactive strategies, developing and/or building out corresponding policies and infrastructure for proactive risk management and regulatory functions. Served as facility liaison on Joint Commission Accreditation preparations and program evaluation. Partner with facility department leadership to Integrate policy and practices to ensure patient safety and quality of care in regulatory compliance and standards. Advisory member for Board of Governors, providing guidance for operational risk and regulatory compliance for AHCA, The Joint Commission, and CMS. Appointed by the Board of Governors to serve as facility HIPAA and Privacy Officer. Investigate complaints. Conduct annual audit. Develop and deliver Orientation and Annual Privacy Training programs in Risk Management and Zero Tolerance programs
Tampa Family Health CentersDirector of Continuing Quality Improvement and Risk Management
Sep. 2017 - Jun. 2018Tampa/St. Petersburg, Florida AreaDirected Continuing Quality Improvement and Quality Assurance (CQI/QA), Risk Management program. Responsible for Culture of Patient Safety and Satisfaction for a $60MM, FQHC with 525 staff, 14 full-service medical centers with 9 dental clinics. Serving 103,000 patients annually. Oversight of AAAHC, PCMH and NCQA accreditation preparation; conducted program evaluation, mock survey and site inspections. Integrated best practices, regulatory compliance requirements to policy/practice. Increased CQI/QA Performance Improvement and Infection Prevention and Control programs by 25% through weekly performance data acquisition/analysis of 1500+ patient satisfaction surveys/250+ comment cards. Developed/Implemented Patient Fall and Needle Stick Reduction Programs. Reduced future patient harm by 25% through routine Life-Safety audits; conducted/reported Incident Investigations. Utilized Lean Six Sigma/Root Cause/Failure Mode analysis to effect clinical and operation efficiencies. Collaborated with Chief Medical, Dental and Pharmacy Officers to improve Peer Review/Charting Compliance by 50% Ownership of HEDIS/MACRA/MIPS and Meaningful Use goals and expectations; yielding a significant 50% improvement in patient identification, care and quality outcomes for A1C, Colorectal, Breast Cancer screening rates. Realized a 30% decrease in breaches, serving as HIPAA Privacy Officer. Developed, coached, and trained 14 Center Managers and 500+ staff on regulatory compliance to include AHCA, AAAHC, CMS, HIPAA, and OSHA.
Florida Gulf Coast UniversityAssistant Director: Healthcare Administrator – Student Health Services
Jan. 2012 - May. 2016Fort Myers, Florida AreaOversight of day-to-day healthcare operations; ensured continuous quality improvement, maintained accreditation readiness, and patient satisfaction. Led 32 Providers, 6 Administrative staff; serving 13,000 patients. $4MM budget. Directed 3-Year AAAHC accreditation; maintained continuous readiness for survey through awareness and education programs, mock survey(s), and alignment of JCAHO, AHCA, NCQA, PCMH accreditation/state/federal regulatory standards. Realized a 20% reduction of HIPAA breaches; serving as HIPAA Privacy Officer. Investigated incidents, assured effective Business Partner Agreements. Completed orientation and annual employee training for HIPAA and OSHA. Oversight of Clinical Quality Improvement, Credentialing, Medical Records Release, EMR Vendor relations and Health Insurance Programs. Collected, analyzed and reported Patient Satisfaction and Assessment Surveys to improve patient safety, satisfaction and engagement by 25% in comparison to national benchmarks. Resolved 100% of patient complaints in timely manner. Co-led $1.6MM clinical expansion; doubling exam room space from 9 -18. Improving scope and service lines adding vision and dental services. Developed and led Infection Prevention and Control program. Implemented POS and pharmacy scanners to aid in $500K cost recovery initiative. Utilized Lean Six Sigma to reduce medication errors 15% and inventory completion time by 40% and improve clinical flow by 35%.
Lee Health SystemOrganizational Development Intern
Mar. 2009 - Aug. 2009Fort Myers, Florida AreaPartnered with senior Human Resources, Organizational Effectiveness and Clinical Leadership to serve as a change agent on co-development and coordination of a system-wide improvement initiative for a five-hospital, 17,000 employee health system. Reviewed HCAHPS Scores, identified opportunities for change; improved patient safety by 20%; reduced medical and patient hand-off errors. Facilitated development of customized S-BAR and I-Pass patient handoff training for all nursing staff. Delivered training modules for flagship program “Introduction to Leadership; achieved 95% satisfaction ratings. HR Project Manager for 3rd party development of effective hiring solutions and competency assessment tools. Served as subject matter expert for instructional design and development of competency assessments. Developed mid to long range training strategies; wrote key proposals to establish clinical residency program and ancillary health professions pipeline.
The University of Mississippi - School of MedicineClinical Education Administrator | Business Manager
Dec. 2006 - Aug. 2008Jackson, Mississippi AreaResponsible for day-to-day business operations, curricular, and accreditation functions of The Office Of The Associate Dean for Academic Affairs. Coordinated an 8-year reaccreditation term for LCME with Commendation. Managed clinical curriculum. Integrated AHCA, AAAHC, ACGME, CMS, NCQA, TJC (JCAHO) and SACS-SOC quality and accreditation standards into practice. Significantly improved patient safety and physician engagement by 20%, developed/implemented patient-centered rounding process and peer review tools; Co-chair for the “Professionalism in Medicine” committee. Supervised 25 PTE and 1 FTE positions; scheduled clerkships with department heads. Coordinated payroll, time-keeping and performance evaluations. Project Manager for $75K Digital Signage/Patient Safety and Awareness Messaging; led a team of 12. Coordinated institutional e-learning platform. Prepared and developed $350K operations and capital budget for Clinical Skills Lab.
The University of Georgia - College of EducationProgram Administrator
Jan. 2004 - Dec. 2006Athens, Georgia AreaServed as Program Administrator for The Associate Dean for Academic Programs; Key Member of Accreditation and Curriculum Leadership and Safety Committees. •Coordinated successful 7-Year NCATE, SACS-SOC, and ancillary program re-accreditation. Served as Safety Committee Co-Chair, and as FERPA coordinator for student data privacy. Assisted Grant Development Officer in $30MM expansion of college; increased COE Alumni magazine subscriptions by 30% and Donor contributions by 25% Led research, data collection, preparation, and dissemination of program and departmental data and quality programs for U.S. News World and Report, Board of Regents, Curriculum Committee and Accreditation reports. Conducted statewide needs assessment of 159 counties and 200 clerks and judges; developed 1st Probate Court Continuing Education Certificate program for State of Georgia.
MacMillan Bloedel Ltd. - Alberni Pacific DivisionHealth, Safety, Hygiene and Training Specialist
Oct. 1990 - Dec. 1997Port Alberni, B.C. CanadaRendered care and treatment for illness and injury for 300+ employee in a forest industry products manufacturing division. Partnered with Human Resources to develop, deliver and ensure a strong safety culture. Facilitated knowledge transfer of 50+ safety training programs dedicated to identifying and mitigating safety risks.
Hospitality and Human Capital Consulting Executive Chef/Consultant
Jan. 1985 - Jan. 1996British Columbia, CanadaFormally trained Executive Chef, experienced in Regionally-Based Nouvelle Cuisine encompassing indigenous foods from the West Coast of British Columbia. Capturing fresh flavors, and completing the journey from ocean & farm to table. Enhancing the dining experience with the customer service needs in mind. Developed working partnerships for a variety of fine dining establishments, inns and hotels - responsible for back of the house operations, profitability and inventory controls. Experienced in food service training, customer service, consulting to Corporate and Institutional food and beverage operations and catering events to 1500 people
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