Mary Windham

Healthcare accreditation and quality manager and speech-language pathologist with approximately 20 years of clinical experience across acute care, inpatient rehabilitation, and outpatient care.

Background includes rehabilitation leadership, regulatory readiness, performance improvement, clinical documentation, and interdisciplinary collaboration. Interested in remote, part-time or PRN clinical review, medical record review, quality, and accreditation opportunities.

Manager, Accreditation and ISO at Piedmont Healthcare (2025-10 – Present)

• Manage continuous survey readiness for assigned DNV-accredited hospital entities and support compliance with accreditation and ISO standards.
• Lead clinical and operational improvement work related to internal audit findings, accreditation survey results, DNV nonconformities, and corrective action plans.
• Monitor and analyze performance data to identify trends and risks, communicate findings, and recommend improvements.
• Coordinate education for staff and physicians on regulatory requirements, accreditation processes, and survey readiness.
• Partner with clinical and operational teams to standardize improvements and sustain readiness across departments.

Director of Rehabilitation Services at Piedmont Macon (2022-07 – 2025-09)

• Directed daily operations and strategic planning for rehabilitation services, including departmental goals, staffing, and service delivery.
• Monitored quality and outcome measures, advanced improvement initiatives, and maintained regulatory and accreditation standards for inpatient rehabilitation.
• Managed staff and collaborated with hospital leaders to support safe, effective patient care and department performance.

Rehab Therapy Manager at Piedmont Macon / Coliseum Medical Center (2018-08 – 2022-06)

• Managed rehabilitation care delivery and therapist staffing across acute care and inpatient rehabilitation settings.
• Established and monitored department measures and quality improvement initiatives; supported operational and strategic planning.
• Supported maintenance of Joint Commission Stroke Rehabilitation Certification through quality initiatives focused on patient outcomes.

Speech-Language Pathologist at Piedmont Macon / Coliseum Medical Center (2007-12 – 2022)

• Evaluated and treated adult and pediatric patients in acute care, inpatient rehabilitation, and outpatient settings for speech, language, cognition, swallowing, and related disorders.
• Performed modified barium swallow studies, developed swallowing protocols and care plans, and communicated findings and recommendations to interdisciplinary teams.
• Completed evaluations, plans of care, progress notes, and certification documentation; participated in data collection and process improvement.

Master of Education in Communication Disorders – Valdosta State University (2006)

Bachelor of Science in Speech-Language Pathology – Mississippi University for Women (2004)

Associate of Arts and Sciences – Itawamba Community College (2001)