DEBRA S.

WILLIAMS, RN, MBA, CPHQ

Richardson, TX 75801
dwilliams634@gmail.com 214-454-6885 LinkedIn

DIRECTOR OF PERFORMANCE IMPROVEMENT & RISK MANAGEMENT

Seasoned professional with over 10 years of experience ensuring quality benchmarks are met or
exceeded. Focused on establishing performance improvement/quality metrics that identify the
needs of the organization and also meet the regulatory standards.
Solid history of success in implementing performance improvements, risk management programs
and organizational opportunities concentrated on increasing operational effectiveness.
Collaborative member of management team dedicated to providing recommendations and
opportunities for improvement.
Areas of Expertise/Experience:
Strategic Planning & Compliance & Regulatory
Implementation Authorities
Risk Management Productivity Enhancements
Executive Communications Improvement Methodologies
Process Improvements Quality Management

PROFESSIONAL WORK EXPERIENCE

October 2014-April 2016: Director of Performance Improvement/Risk Manager for Haven

Behavioral Hospital of Frisco-Haven Behavioral Hospital of Frisco is a new 36 bed inpatient
geriatric-psychiatric facility and opened in in November 2014.
Instrumental in establishing the Performance Improvement/Quality and Risk Management
program for this start up organization.
Attained Joint Commission Accreditation in December 2014.
Duties include but are not limited to:
o Provided the CEO with timely and accurate information related to Risk
Management, Regulatory Compliance, Performance Improvement and safety
issues.
o Maintained the Quality dashboard and presented results to the Quality Council
monthly, to the Medical Executive Committee and Governing Board on a
quarterly basis.
o Facilitated the monthly Quality Council and Patient Safety Committees.
o Facilitated Performance Improvement Teams and used the Plan-Do-Check-Act
performance improvement methodology.
o Facilitated, analyzed, reported identified causes in variation that resulted in
sentinel or critical events via Root Cause Analysis (RCA) teams. Reported RCA
findings and action plans to the Quality Council and Governing Board.
o Identified knowledge deficits through direct observation or medical record review
and communicated findings to the appropriate management team member.
o Assisted in the development and implementation of plans to improve staff
performance.
o Coordinated the agenda and reports for Medical Executive Committee (MEC).
o OPPE/FPPE credentialing oversight.
o Maintained the Incident Report database and reported incidents to Quality
Council, Safety Committee and Governing Board
o Followed up with the incidents and performed RCA on sentinel or critical
incidents.

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 o Reported hospital core measures to Quality Council, MEC and Governing Board.
o Responsible for reporting patient satisfaction data obtained through Press-Ganey
to Quality Council and Governing Board.
o Served as Safety Officer and EOC manager.

April 2014-August 2014: CONTRACT POSITION Director Quality Assurance-Behavioral

Health for Green Oaks Behavioral Hospital-Green Oaks is a Dallas-based hospital dedicated
to inpatient psychiatric care.
Contracted as part of Executive Management Team to oversee the Quality operations of
the Parkland Health & Hospital System Behavioral Health Services.
Duties include but are not limited to:
o Maintaining and distributing to Leadership the Quality Report Card.
o Daily review of patient safety and customer complaint posts
o Daily review of patient restraint videos to evaluate violations to regulation, policy,
procedure and technique
o Maintaining and distributing to Leadership and QRO the QRO report.
Contract ended August 2014

July 2013-April 2014 Home Health Nurse/Quality Assurance Nurse for Town & Country Home
Health Agency.
Perform skilled nurse visits-completed OASIS
Assure nursing documentation compliant with regulatory bodies

July 2011-June 2013 Self Employed-Home Based Business

Oct 2009- July 2011: Director of Quality Management for Global Rehabilitation Hospital
Dallas. Global Rehabilitation Hospital was a newly opened multi-specialty 42 bed acute care
rehabilitation hospital.
Directed the quality/risk management/regulatory processes
Assured all departments reported quality measures in a timely manner and if measures
were below threshold, held department accountable for implementing and submitting
action plans
Chaired the Quality Committee.
Investigated and followed-up on patient complaints/grievances
Performed Root Cause Analysis on adverse events, informing the corporate offices of
potentially compensable events
Trended and reported quality measures, complaints, grievances, adverse events and PI
team updates to the Quality Committee, Medical Executive Committee and the
Governing Board
Served as Director of Education and coordinated monthly new hire orientation
Responsible for the Employee Health program

March 2008-March 2009-Performance Improvement Manager/Risk Manager for North Central

Surgical Center, a United Surgical Partners International hospital; Dallas, TX (Average 700-
800 surgeries/month)
A newly opened surgery center (was formerly an Ambulatory Surgery Center, but was
converted to a hospital in December 2007 with 10 operating rooms, 3 pain and GI
procedure rooms and 17 inpatient beds) The hospital was on conditional Joint
Commission accreditation when I was hired in March.
By August 2008, with a tremendous amount of Performance Improvement activity, the
facility received full Joint Commission accreditation with no requirements for
improvement.
By September 2008, the facility was fully licensed with the State of Texas and received
their Medicare number.

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 Planned, coordinated and oversaw administration of Performance Improvement (PI) and
Risk Management (RM) processes within the Hospital.
Administered and disseminated information to staff concerning prevailing PI and RM
national and state standards of practice and policies of the Hospital.
Facilitated Performance Improvement Teams as well as Failure Modes and Effect
Analysis.
Communicated appropriate information to other team members.

October 2006-March 2008- R.N., Root Cause Analysis Program Coordinator and
Performance Improvement and Patient Safety Analyst for Parkland Health & Hospital
System; Dallas, TX (Parkland is a 900 bed, acute care hospital)
Instrumental in standardizing the root cause analysis process of the hospital
In conjunction with the Medical Director of Quality, conducted RCAs on adverse events
Coordinated the implementation of the Good Catch program. This program celebrated
the reporting of near miss events

March 2005-October 2006- R.N., Clinical Outcomes Coordinator for Dallas Methodist Medical
Center Quality Management Department (Methodist is a 400 bed hospital)

Assessed and analyzed current trends in the clinical practice as reported in current data
base, benchmarking, and clinical research information resources
Instrumental in developing a new mortality review process for quality coordinators and
physician peer reviewers
Facilitated and provided leadership role on physician led clinical improvement teams
Reported to administrative, staff, departmental, and physician leadership groups on
current clinical improvement efforts and clinical outcomes data
Work within the standards of care to assure patients are being provided the best possible
care from admission to discharge through quality data collection and reporting
Report problem areas to peers, director, or appropriate department for follow up or review
Medical Staff peer review coordinator for the departments of Medicine, Nephrology and
Urology
Abstracted charts and reported Core Measures

January 2001 to January 2005- Legal Nurse Consultant for a Dallas law firm-Kimberly Stovall
& Associates.

Assisted attorneys in evaluating standard of care for medical malpractice, personal injury,
and nursing home negligence cases

Reviewed medical records for standards of care issues

Provided medical summary and medical chronology on assigned cases

Located, interviewed, and recommended physician and nursing experts

Coordinated dialogue between expert physicians/nurses and attorneys

Assisted paralegals and attorneys during the discovery phase

Collaborated with attorneys during all phases of depositions, mediations, and trials

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August 1998-November 2000- R.N., Administrative Supervisor for San Angelo Community
Hospital, San Angelo, TX.

Engaged to ensure standard of care and adequate staffing for 160-bed hospital, including
emergency room, intensive care, pediatrics, geriatrics, and medical/surgical units.

Analyzed staff/patient ratio matrix and supervised and evaluated a staff of 35 licensed
and unlicensed personnel.

Evaluated all patients for unit and room assignment and accepted transfer patients in/out
hospital.

Located surgical crews, heart teams, and anesthesiologists after hours.

Assumed after hours responsibilities for pharmacist, dietician, medical records, and
material management for patient needs.

Additional work experience available upon request.

EDUCATION/TRAINING

Accelerating Best Care (ABC) program training- Rapid Cycle Change Methodology: Baylor,
Dallas

Six Sigma Green Belt training-Parkland Hospital

MBA-Health Care Administration-Columbia Southern University

Diploma in Legal Nurse Consulting from Kaplan College

Bachelor of Business Administration Marketing Concentration- from Angelo State University

R.N. - Diploma in Nursing from Texas Eastern School of Nursing

Associate of Science in Nursing from Tyler Junior College

CERTIFICATIONS/LICENSES

Basic Life Support (BLS) certified

Certified Professional in Healthcare Quality (CPHQ)

Licensed to Practice Professional Nursing in Texas

Professional Associations/Positions

National Association of Healthcare Quality

Texas Association for Healthcare Quality-Board Member- 2007

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 Presentations/Recognition

Improving Patient Safety Through Root Cause Analysis (RCA). Nursing Leadership Academy.
Parkland Health & Hospital System-Dallas, TX. 5/2007

Introduction to Legal Nurse Consulting. KDJ Consultants. Dallas, TX. 2/2006

Move Your Dot: The IHI Initiative What Mortality Review Can Mean for You. QTNT. Fort Worth,
TX. 3/2006

Mortality Review. Methodist Medical Center. Dallas, TX. 2005

Recognition:
Cambridge Whos Who Registry of Executives and Professionals-Honored Member 2007-2008