Director of Risk Management, Performance Improvement and Quality Assurance - MILLWOOD HOSPITAL
(2025-12 - 2026-03)
Drive operational excellence by aligning risk, quality, and performance improvement initiatives to executive priorities, accreditation standards, and sustainable outcomes
- Lead strategic audits and initiatives focused on patient safety, regulatory compliance, accreditation readiness, and performance, continuous quality improvement
- Oversee risk management programs, incident investigations, performance metrics, policy governance, and regulatory reporting, ensuring adherence to CMS, state, and accrediting body standards
- Work with executives and clinical teams to use data for better patient outcomes, lower risk, and improved operations.
Term Lecturer – Quality Improvement in Healthcare - MASS GENERAL HOSPITAL – INSTITUTE OF HEALTH PROFESSIONS
(2023-11 - 2025-11)
- Designed and teach graduate-level courses on healthcare quality, safety, Lean Six Sigma, and change management tools
- Educate students on patient safety frameworks, including event reporting, RCA, FMEA, and High Reliability principles.
- Mentor students on quality projects addressing safety events, clinical inefficiencies, and risk mitigation.
- Promote sustainability of safety practices by embedding ADKAR tools into process redesign
- Teaching employees and students from several universities and organizations, including Harvard Medical School
Founder & CEO – Coach, Trainer, Mentor - LEANING TOWARDS CHANGE, LLC
(2020-11)
Teaching courses part time, only two Saturdays and two weeknights per month. Delivering operational excellence through Lean Six Sigma, change management, process improvement in healthcare systems
- Coached and certified over 1,000+ professionals in LSS and Change Management tools, methods, and techniques; many applied projects focused on reducing patient harm, improving compliance, and enhancing safety outcomes
- Consulted with large healthcare clinic system, achieving 60% reduction in denials and costs within 90 days while aligning improvements to quality and safety standards
- Developed 100% online Lean Six Sigma curriculum with Excel-based safety/quality tracking tools
- Delivered workshops on Just Culture, Risk & Quality Integration, Safety in Change, and Lean Daily Management
- Partnered with ACHE, NAHSE, NALHE and DFW Hospital Council to teach leaders safety-centered process improvement strategies and deliver LSS training nationwide
- Coached students on PDSA, A3, DMAIC, DMADV, Kaizen, 6S, and other Lean Six Sigma methods, tools, and techniques
Program Director, Compliance Operations & Project Management - TEXAS HEALTH RESOURCES - Arlington, TX
(2024-12 - 2025-06)
Directed Compliance & Privacy operations at 16 hospitals, supporting 30K+ employees in maintaining regulatory readiness. Worked at THR Corporate, led, organized and conducted system-wide compliance and privacy audits, performed root cause analysis, implemented process improvements and training to ensure we met Compliance and Privacy policies and guidelines
- Oversaw Ethics & Culture surveys, aligning findings to enterprise patient safety and compliance initiatives
- Advanced operational excellence across compliance operations by standardizing workflows, dashboards, and audit processes to improve efficiency, transparency, and readiness
- Designed dashboards to track compliance metrics, gaps, safety concerns, and corrective actions for executive review
- Partnered with leadership to embed compliance into daily operations, ensuring safe, ethical care delivery
- Improved Code of Business Ethics, made it shorter, streamlined over– 50% reduction in pages- also created a 1-page CODE
Supervisor, Data Governance - TEXAS HEALTH RESOURCES - Arlington, TX
(2021-03 - 2024-12)
Worked for THR Corporate, supported 16 wholly owned hospitals, and per Gartner review, built an award-winning Data Governance Program within 2 years – Other DFW hospitals were coming to us asking us for help
- Led Governance & Reclamation teams, strengthening data integrity for quality and safety dashboards.
- Built Systemwide Data Literacy Program, improving accuracy of reporting for CAUTI, CLABSI, Falls, and readmissions
- Standardized governance processes for metrics, reducing misinterpretation of patient safety indicators.
- Developed Governance Scorecards and policies to improve accountability for safety-related data ownership and accuracy.
- Supported integration of safety event reporting into enterprise dashboards for visibility and transparency.
- Helping employees to understand the data behind the dashboards, and how to use it to make improvements
- Improved dashboard adoption, security, and cross-functional communication
Performance Improvement Coach & Engineer / LSS Master Black Belt - TEXAS HEALTH RESOURCES - Arlington, TX
(2017-06 - 2021-03)
Worked for THR Corporate, served as a trusted advisor to executive leaders at 14 wholly owned hospitals, translating data-driven insights into strategic roadmaps, prioritization decisions, and resource allocation aligned with organizational goals and regulatory requirements – Traveled to THR hospitals all across the DFW Metroplex to help them solve problems
- Designed and implemented standardized performance improvement frameworks, dashboards, and governance structures to ensure sustainability, transparency, and enterprise-wide alignment of quality, safety, and operational KPIs.
- Established, monitored, and reported enterprise KPIs across quality, safety, patient experience, and operational efficiency, cross-functional accountability and measurable, sustained results
- Partnered with Patient Safety leaders to embed HRO principles and Just Culture into performance improvement.
- Reduced CLABSI's and CAUTI's by 75% through bundle compliance and frontline accountability.
- Reduced blood culture contamination from 5.6% → 0.7%, preventing harm and saving $500K annually for one hospital. Implemented at all 14 wholly owned hospitals across all of THR
- Streamlined ED throughput by creating a JET process, reducing ED Throughput by 2+hours per patient, reducing AMA and LWBS risks and enhanced patient safety.
- Reduced Blood/Specimen Wastage by 27% by eliminating needle sticks, implementing small refrigerators and timers in all surgery rooms
- Facilitated RCAs and FMEAs for high-risk events; designed corrective action plans to prevent recurrence
- Created PI dashboards for tracking safety metrics and reporting to executive teams
- Coached 200+ Yellow/Green Belts on projects that improved safety outcomes and delivered $12M+ in savings
- Created systemwide PI training and assessment tools using Kainexus and Lean Six Sigma principles
- Designed an online Lean Six Sigma White Belt Certification Program for 30,000+ employees
- Coach students on the PDSA, A3, DMAIC, DMADV, Kaizen, 6S, and other Lean Six Sigma methods, tools, and techniques
- Awarded for the work that was done, Magnet designations, Joint Commission Accreditation, and Quality/Safety Awards
Quality Assurance & Process Improvement Coordinator (Interim Director, QAPI) - CHRISTUS GOOD SHEPHERD MEDICAL CENTER - Longview, TX
(2016-07 - 2017-06)
Directed hospital-wide Quality and Patient Safety Program across two campuses
- Led a team of 5 department leads (L&D, H&V, Bariatric, ER, and Lab) in implementing systemwide improvement initiatives
- Chaired Patient Safety Committee; facilitated RCAs, FMEAs, and proactive risk assessments
- Implemented safety huddles across departments, improving communication of risks and near misses
- Reduced falls, CAUTI, CLABSI, and pressure injuries by aligning frontline practice with evidence-based bundles
- Achieved $3M in savings while improving patient outcomes (e.g., reducing ED delays, linen usage reduction, ED throughput, and revenue cycle inefficiencies)
- Led Joint Commission readiness activities, and implemented quality improvement initiatives achieving strong compliance scores with no major deficiencies across two hospitals – helped org to get reaccredited by Joint Commission
- Advanced NICU to Level 3 designation by aligning with safety and quality requirements
- Improved survey process, created playbooks, updated documentation, helped to improve Joint Commission
