Accreditation Coordinator with a focus on developing high standards of practice, compliance, and evaluating patient care for effectiveness and implementing necessary changes to programs and policies.
Education and Training
Associate of Science : NursingEl Centro College － Dallas, TXNursing
Bachelor of Arts : Business, 1995Loyola Marymount University － Westchester, CABusiness
Personal and professional integrity
Relationship and team building
Sound decision making
Cultural awareness and sensitivity
Critical thinking proficiency
Proven patience and self-discipline
Well versed in Centers for Medicare and Medicaid Services (CMS)
Comfortable with all levels of staff (executive, clinical, administrative)
Accreditation Coordinator March 2013 to June 2015Texas Health Resources, Texas Health Presbyterian Hospital Dallas － Dallas, TX
Coordinated and lead a successful hospital-wide Joint Commission accreditation surveys.
Initiated hospital-wide Failure Mode Effects Analysis (FMEA) tubing misconnections study to identify areas for process improvement Implemented and maintained a continuous readiness program Provided education/reports/updates regarding accreditation activities, results and action plans Negotiated pricing, application overhaul, and implementation of hospital's regulatory depository Coordinated with Chapter Champions with data display and metrics Coordinated survey activities, both announced and unannounced Provided follow up to accrediting and regulatory bodies as indicated Facilitated action plans and other follow up/ documentation / improvements occur Provided education and training regarding standards and initiatives for respective work groups and leaders Participated with other certification and accreditation activities Led The Joint Commission Task Force Committee Skillfully participated in Policy & Procedure committee when appropriate Oversees access to TJC web site and manages other accreditation/certification resources (Readypoint Health) Coordinated scheduled tracer activities, which includes updating tracers to ensure ongoing education.
Scheduled, planned, and facilitated annual mock survey Updated TJC applications for Accreditation and Certification as needed Identified areas of vulnerability and worked with medical, nursing, and ancillary staff to resolve issues Monitored regulatory publications for updates and communicated changes with Chapter Champions and The Joint Commission Taskforce Maintained and updated the required documents for announced and unannounced surveys Attended Joint Commission Resources biannual conferences Trained all pertinent clinical and non-clinical staff on the use of hospital\'s regulatory repository, which included super-user training and basic data entry Led planning and achievement of goals and objectives consistent with the agency mission and philosophy Communicated ongoing regulatory and accreditation compliance to entity leadership to ensure continued readiness Routinely collaborated with department managers to correct problems and improve services.
Investigated, provided and submitted information to Quality Department about special incidents, events and complaints (TJC, Department of State Health Services, CMS, etc.) Contributed to entity's weekly Environment of Care rounds with Infection Prevention, Life Safety, Environmental Services, Security, and Compliance Contributed to Root Cause Analysis (RCA) events as needed.
Sr. Administrative Assistant Health Resources November 2011 to March 2013Texas Heath Presbyterian Hospital Dallas － Dallas, TX
Performed daily administrative duties for entity staff patient advocate, quality manager, and quality director
Performed duties to maintain entity accreditation from The Joint Commission
Extracted and formalized monthly and quarterly quality reports
Interacted with physicians, nurses, patients, family members, and other entity staff to ensure patient safety and advocacy was carried out in a timely manner
Acted as a liaison between entity administration and patient/family members to document complaints and concerns, and then followed up with the appropriate individuals for resolution
Served as back up patient advocate which included meeting with patients and family members during hospital stays and after discharge
Performed purchasing duties office equipment and supplies for quality improvement which also included Oncology Data and Infection Control.
Business Process Specialist February 2006 to September 2011Health Care Service Corporation Blue Cross and Blue Shield of Texas － Richardson, TX
Managed system development and integration projects through all phases of project life cycle - analysis, development, testing, implementation, and post-production support
Coordinated the Richardson headquarters move which included business customers, technical leads, and management to move over 2,700 employees from various locations in the Dallas/Fort Worth area to the new headquarters building
Coordinated efforts for several IT projects which included participation of IT leads, business management, executives, and vendors.
Accountable for writing new processes for hardware and infrastructure of new and existing buildings
Lead a team of technical and business resources to perform Voice Over IP refreshes for facilities throughout Texas, Illinois, Michigan, and Oklahoma
Scheduled installation and training for essential computer and phone equipment for all entity new hires by working with management, human resources, and information technology
Coordinated new employee on boarding project which included project management, test plans, acquiring technical resources.