FAHQ Annual Conference
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Go to Conference Overview/Hotel for more information on the hotel and CE. Book your hotel before March 1, 2026 to get the FAHQ conference rate. IF YOU HURRY YOU MAY GET THE FAHQ RATE – the hotel will honor the rate as long as we have rooms left in our block.
Quick check daily information on the Conference Schedule.
Go to Conference Registration for more information on fees and to register. EARLY BIRD REGISTRATION EXTENDED TO MARCH 15 – all fees increase after that date.
Healthcare-associated infections (HAIs) are a persistent patient safety concern despite the availability of evidence-based prevention bundles. Literature underscores that leadership engagement and structured reliability processes are essential to sustain adherence and reduce infection risk. This project aimed to decrease HAIs by implementing structured daily practices that strengthened accountability, promoted bundle compliance, and improved patient safety outcomes. The integration of daily multidisciplinary huddles and standardized leadership rounding established a consistent framework for infection prevention and process reliability. These changes reduced HAIs, strengthened documentation practices, and promoted a culture of accountability and collaboration. Challenges included workflow disruption and variability in compliance. If repeated, earlier staff education and broader stakeholder engagement would be prioritized.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Quality Review and Accountability; Performance and Process Improvement; Health Data Analytics; Patient Safety
Kimberly Neumann, MSN, RN, CEN, CPHQ, Program Manager of Nursing and Special Projects, Orlando Health 
Kimberly Neumann holds a Master of Science in Nursing with an emphasis in Healthcare Quality and Patient Safety from Grand Canyon University and is a Certified Professional in Healthcare Quality. She works closely with nursing leadership to drive meaningful, system-level improvements across the hospital setting. Kimberly has dedicated 15 years to Orlando Health, serving in a variety of roles including Emergency Nurse, Stroke Program Coordinator, Clinical Quality Specialist, and currently, Program Manager of Nursing and Special Projects at Dr. P. Phillips Hospital. Passionate about advancing high-quality patient care, she collaborates with quality teams, nursing leaders, and professional governance councils to identify opportunities and lead initiatives that strengthen care delivery and improve patient outcomes.
Nicole Arroyo, BSN, RN, CPN, Clinical Quality Specialist, Orlando Health 
Nicole Arroyo, is a registered nurse with a background in both adult and pediatric care. She earned her Bachelor of Science in Nursing from the University of Central Florida in 2017 and also holds a Bachelor’s degree in Psychology from Florida State University. Since graduating, she has worked at Orlando Health, gaining clinical and leadership experience in an adult cardiac progressive care unit and a pediatric cardiac intensive care unit. For the past two years, she has served as a Clinical Quality Specialist at Dr. P. Phillips Hospital, where she is actively involved in hospital and system-wide initiatives, including efforts to reduce healthcare-associated infections. She is currently pursuing a Master’s degree at the University of Central Florida, with a continued focus on improving healthcare quality and patient outcomes.
The PSI-90 composite and other combinations of Patient Safety Indicators (PSIs) and Hospital-Acquired Conditions (HACs) are used by third-party agencies like Leapfrog and U.S. News & World Report to assess hospital safety. In 2023, Tampa General Hospital identified its PSI-90 score as a key opportunity to avoid CMS penalties and improve rankings. This was addressed using the IHI Model for Improvement and several PDSA cycles. Most improvements were technical, involving accurate admission typing, coding selection, and capturing conditions present on admission. Many PSIs and HACs were inaccurately captured and did not reflect actual patient harm. Once this “noise” was removed, true clinical opportunities became visible and actionable.
NAHQ Competency Framework Domain(s): Quality Review and Accountability; Patient Safety
Danielle Stephen, MSN, CPHQ, Performance Improvement Supervisor, Tampa General Hospital
Danielle Stephen is a Performance Improvement Supervisor at Tampa General Hospital and oversees the Quality Clinical Review and Quality Regulatory Programs. Her background includes 5 years of bedside nursing on an acute cardiac care unit where she led quality and patient safety initiatives on the floor. This evolved into a career shift into full-time nursing quality roles for the last 10 years. Danielle acquired her Master’s Degree in Nursing with a focus in Patient Safety and Quality in 2017 from Southern NH University and became a Certified Professional in Healthcare Quality in 2018.
Healthcare organizations face challenges in embedding a strong culture of safety due to underreporting, limited engagement, and communication gaps. The VISN 8 Patient Safety Champion (PSC) Program aims to standardize patient safety by appointing trained frontline staff as PSCs to encourage reporting, educate on safety tools, and provide feedback. The program seeks to enhance safety culture, improve communication, and drive continuous process improvement through structured roles and peer support. The PSC program enhanced reporting, psychological safety, and transparency by embedding trained frontline staff in structured safety roles. It promoted proactive safety management and improved communication between leadership and frontline staff. Challenges included balancing responsibilities, variable engagement, and difficulty attributing results solely to the program. Future improvements will focus on stronger leadership support, baseline data, phased rollouts, enhanced recognition, and ongoing feedback.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Kristie L Power, DNP, MS, RN, VA-CM, Patient Safety Officer, Department of Veteran Affairs. VISN 8 Sunshine Healthcare Network, Orlando
Kristie Power, DNP, serves as the Patient Safety Officer for the Department of Veterans Affairs VISN 8, where she provides oversight and support to seven healthcare systems. She previously served as Chief Nurse of Patient Safety at the Orlando VA Healthcare System, overseeing Patient Safety, High Reliability, Protected Peer Review, and Risk Management. Dr. Power earned her Doctor of Nursing Practice in Executive Leadership from the University of Central Florida, and also holds a Master of Science in Health Informatics and Management, a Master’s Certificate in Health Management, and a Bachelor of Science in Nursing. She is a certified Lean Black Belt, advanced facilitator, Baldrige coach, and VHA coach and mentor at the fellow level, with more than a decade of experience advancing patient safety and quality within the VA.
Learn strategies to practice generational humility in leading and participating on teams comprised of multigenerational team members. A generation is a creation of shared experiences and culture. Birth year divides the generation of the last two centuries. This historical context provides definition and context to our interaction within and between generations.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Professional Engagement
Cassandra Vonnes, DNP, GNP-BC, APRN, AOCNP, EBP-CH, GS-C, CPHQ, AGSF, FAHA, FAAN, Geriatric Clinical Consultant, Change AGEnt LLC 
Cassandra Vonnes is a certified Gerontological and Advanced Oncology Nurse Practitioner and a Fellow of the American Heart Association, the American Geriatrics Society, and the American Academy of Nursing. She is the President-Elect of the Florida Association for Healthcare Quality and has been recognized as a Hartford Distinguished Educator in Geriatric Nursing. The Gerontological Advanced Practice Nurses Association awarded her the 2022 Excellence in Leadership Award, and she received the ONS Excellence in Care for the Older Adult with Cancer Award in 2019. Under her leadership, Moffitt Cancer Center was the first hospital in Florida and the first cancer center recognized by IHI as an Age-Friendly Health System Committed to Care Excellence.
Healthcare organizations face challenges in embedding a strong culture of safety due to underreporting, limited engagement, and communication gaps. The VISN 8 Patient Safety Champion (PSC) Program aims to standardize patient safety by appointing trained frontline staff as PSCs to encourage reporting, educate on safety tools, and provide feedback. The program seeks to enhance safety culture, improve communication, and drive continuous process improvement through structured roles and peer support. The PSC program enhanced reporting, psychological safety, and transparency by embedding trained frontline staff in structured safety roles. It promoted proactive safety management and improved communication between leadership and frontline staff. Challenges included balancing responsibilities, variable engagement, and difficulty attributing results solely to the program. Future improvements will focus on stronger leadership support, baseline data, phased rollouts, enhanced recognition, and ongoing feedback.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration
Megan Flynn, NP, RN, CNL, CPHQ, NE-BC, RNC-NIC, C-ELBW, Harm Prevention Program Manager, Nemours Children’s Hospital 
Megan Flynn is a dedicated leader, educator and speaker who is passionate about creating an environment where interdisciplinary teams are able to provide outstanding care. She holds a doctorate in nursing practice from the University of Connecticut and is a certified Clinical Nurse Leader. Megan is also a Certified Professional in Health Care (CPHQ), Certified Nurse Executive (NE-BC) and holds two certifications for both high risk and extremely low birth weight neonatal patients (RNC-NIC, C-ELBW). Megan joined the Quality and Safety Team at Nemours Florida in early 2025 where she serves as the Harm Prevention Program Manager for the state of Florida. Megan is committed to enhancing patient safety, standardizing best practices and fostering a culture of professional growth.
This session explores how purpose-anchored resilience sustains healthcare quality and patient safety professionals working in complex, high-risk environments. Grounded in high-reliability principles, participants examine links between resilience, safety culture, workforce stability, and continuous improvement. Using mission-vision-values and the Ikigai framework, attendees reflect on their professional purpose and identify practical strategies to strengthen resilience in themselves and their teams to support safe, reliable, high-performing, and patient-centered care.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Sandy Weiss, DBA, MBA-HCM, RN, CPHQ, CPPS, CSM, PMP, Prosci Certified Change Practitioner, Assistant Professor of Instruction, Muma College of Business, University of South Florida
Dr. Weiss is an Assistant Professor of Instruction at the University of South Florida’s Muma College of Business, primarily teaching Strategic Management and Decision Making, an undergraduate capstone course, as well as Healthcare Management at the undergraduate and graduate levels. She is currently developing High Reliability Healthcare and Process Improvement for USFs Executive MBA in Healthcare Leadership. Beyond her teaching responsibilities, Dr. Weiss is also involved in management consulting within the healthcare sector and offers career coaching to professionals and healthcare practitioners through her company, Elevate My Career. She is an instructor for the Tampa General Hospital – University of South Florida’s People Development Institute and USF’s Corporate Training and Professional Education program. Her research focuses on the intersection of healthcare worker emotional intelligence, turnover intention, resilience, burnout, grit, and job performance. She has held significant leadership roles in the healthcare industry. She served as the Division Director of Quality for a large for-profit healthcare system, where she spearheaded clinical quality and regulatory compliance initiatives in the ambulatory care setting. She later became the Vice President of Education for a medical device startup, successfully guiding the company through an acquisition. Her broad experience spans the healthcare continuum, including co-founding a companion care company, managing CMS contracts, and leading in acute care and inpatient rehabilitation settings. Dr. Weiss is active in various professional organizations, serving as Immediate Past President for the Florida Association for Healthcare Quality. Additionally, she serves as the Co-Chair of the Junior Achievement of Tampa Bay Connections Board. Dr. Weiss is a Certified Professional in Healthcare Quality (CPHQ), a Certified Professional in Patient Safety (CPPS), a Certified Scrum Master (CSM), a Project Management Professional (PMP), a Prosci Certified Change Practitioner, and a Registered Nurse (RN). She also holds a graduate certificate in Innovation and Human-Centered Design from the Johns Hopkins Carey Business School.
When patients are admitted to health facilities, their medication lists are entered into the EMR. This process is vulnerable to multiple errors due to unreliable medication sources, poor communication, limited staff knowledge, and time constraints. According to the WHO (2023), over 50% of patient harm is preventable, with half attributed to medication errors. Using Lean Six Sigma and the Model for improvement, this initiative significantly reduced medication-related harm and improved patient safety. Challenges included inconsistent event reporting (85% of RL entries were incomplete). Future improvements will focus on enhancing reporting compliance and sustaining checklist use.
NAHQ Competency Framework Domain(s): Patient Safety; Performance and Process Improvement
Brittney Costello, M
BA, CPHQ, Director of Quality and Risk, Encompass Health Rehabilitation Hospitals, St. Augustine and Jacksonville, Florida
Brittney Costello serves as the Director of Quality and Risk at Encompass Health Rehabilitation Hospital since 2022. She brings extensive experience in healthcare, having served in diverse roles spanning performance improvement, risk management, and accreditation. Brittney is a Six Sigma Master Black Belt and holds a Master of Business Administration degree. She is also a Certified Professional in Healthcare Quality (CPHQ) through the National Association for Healthcare Quality, reflecting her commitment to excellence and continuous improvement in patient safety and quality care.
Fajr S. Hassan, PharmD, BC-ADM, Director of Pharmacy Services , Encompass Health, McDonough, Georgia 
Fajr Hassan received her Doctorate of Pharmacy from Florida A&M University’s College of Pharmacy and Pharmaceutical Sciences in Tallahassee, FL. She went on to serve as a Pharmacy Practice and Research Fellow specializing in Diabetes Management in Primary Care. She subsequently obtained board certification in Advanced Diabetes Management, serving community members with diabetes and chronic comorbidities. Dr. Hassan joined Encompass Health Rehabilitation Hospital in Tallahassee in 2015 where she created and cultivated the weekly Diabetes Self-management Education curriculum for inpatients and their families. As Director of Pharmacy Services since 2017, her passion is helping to redefine the roles and contributions of pharmacists in inpatient settings. She served as a member of FAMU College of Pharmacy’s Clinical Faculty for over 10 years where she educated Doctor of Pharmacy Candidates in chronic disease management both in the classroom and on clinical rotations.
Medication errors are among the most common safety incidents in primary care, with error rates ranging from 1 to 90 per 100 prescriptions. These include prescribing errors, contraindications, overprescribing, under prescribing, and adherence issues. This project aimed to partner with patients to improve medication history accuracy and reconciliation in cancer care. The initiative fostered a culture of shared decision-making and improved patient safety awareness. Patients and families were elevated as partners in care, enhancing the accuracy of medication histories and reducing potential harm.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Cassandra Vonnes, DNP, GNP-BC, APRN, AOCNP, EBP-CH, GS-C, CPHQ, AGSF, FAHA, FAAN, Geriatric Clinical Consultant, Change AGEnt LLC
Cassandra Vonnes is a certified Gerontological and Advanced Oncology Nurse Practitioner and a Fellow of the American Heart Association, the American Geriatrics Society, and the American Academy of Nursing. She is the President-Elect of the Florida Association for Healthcare Quality and has been recognized as a Hartford Distinguished Educator in Geriatric Nursing. The Gerontological Advanced Practice Nurses Association awarded her the 2022 Excellence in Leadership Award, and she received the ONS Excellence in Care for the Older Adult with Cancer Award in 2019. Under her leadership, Moffitt Cancer Center was the first hospital in Florida and the first cancer center recognized by IHI as an Age-Friendly Health System Committed to Care Excellence.
During a Gemba walk in a new service line, a recurring theme emerged from staff feedback: the current HIPEC (Hyperthermic Intraperitoneal Chemotherapy) process was no longer sustainable. Using a combination of IHI and Lean tools, key lessons were learned included the importance of involving IT partners earlier in the process redesign. The tabletop pilot should have been conducted in a test environment rather than as a verbal walkthrough. These adjustments would have improved the implementation and staff engagement.
NAHQ Competency Framework Domain(s): Performance and Process Improvement
Deborah Raposo, BSN, CIDI, BC-NI, LNC, CPHIMS, CPPS, IN
Supervisor, Performance Improvement, Tampa General Hospital 
Deborah Raposo holds a Bachelor of Science in Nursing from the Salve Regina University and is a Desert Storm and Persian Gulf War Army Nurse Veteran entering her 42nd year in the profession of healing bodies and minds. Her passion for lifelong learning has allowed her to continue a journey through the 31 flavors of nursing. From the bedside (BC-NICU), to leadership, to informatics (BC-NI) and analytics, to legal nurse consulting (LNC), to information systems(CPHIMS) to patient safety (CPPS), and to performance Improvement (LSSGB). Throughout her career, she has always focused on the outcomes and experience of her patients and their families. Continually striving to meet their needs, and expectations, heal their bodies and minds, and do no harm in the process. She has been practicing performance improvement well before there was a name for it. She can remember working in the kitchen of a nursing home as a young high school student trying to think of ways to entice her patients to want to eat their meals (even the pureed bowls of “brown mush” as she called it) but how they were presented, how they smelled and how they tasted. And now in her current position in the Oncology Service Line and system wide initiatives, – her motto “We are human, to Err is Human but we must strive to create Zero Harm”.
DNV accreditation preparation at AdventHealth was historically reactive, resource-heavy, and stressful, leading to inconsistent compliance. Challenges included fragmented communication, variable staff engagement, and limited real-time resources. This project aimed to shift to a proactive, system-wide model emphasizing daily readiness, education, and accountability. Embedding accreditation into daily practice improved compliance, accountability, and sustainability. The initiative reduced stress and strengthened collaboration. Lessons learned included the importance of early engagement, tailored resources, and feedback. With the right framework and culture, continual readiness becomes everyday excellence.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration
Kimberly Klein, MSN, RN, PCCN, NPD-BC, Nursing Outcomes Program Manager, Advent Health Orlando 
Kimberly Klein is an experienced nursing professional and healthcare leader with a strong background in accreditation readiness, education management, and regulatory compliance. She holds a Master of Science in Nursing in Nursing Education from the University of Central Florida and is board certified in Nursing Professional Development (NPD-BC). For eight years, Kimberly has served as a primary liaison to DNV surveyors, supporting organizational readiness, survey coordination, and post-survey improvement efforts. Her expertise includes translating DNV and ISO-based standards into operational practice, guiding leaders and frontline staff through continuous readiness strategies, and fostering sustainable compliance. Kimberly has managed annual education programs for all employees and nursing staff, ensuring alignment with regulatory requirements, competency standards, and organizational priorities. During the COVID-19 pandemic, she also managed a COVID infusion clinic, overseeing education, workflow development, and operational coordination to support safe and effective patient care during a rapidly evolving public health crisis.
Alexis Marano, MSN, RN, CPHQ, PCCN, NPD-BC. Nursing Outcomes Program Manager, Advent Health Orlando 
Alexis Marano holds a Master of Science in Nursing Education from the University of Central Florida and is a second-year doctoral student in the DNP Nurse executive tract at UCF. She brings 13 years of nursing experience across multiple clinical, academic, and system l-level leadership roles withing the AdventHealth Central Florida Division. For the past four years, Alexis has served as Nursing Outcomes Program Manager, leading division-wide practice change initiatives focused on quality, outcomes, and professional practice advancement. She has also held dual academic appointments, most recently as a Clinical Adjunct at AdventHealth University. Her professional interests cent on bridging transition from academic preparation to clinical practice to strengthen nursing performance and patient outcomes.
Jodie Romero, BSN, RN, Executive Director, Nursing Operations Administration, Advent Health Orlandol 
Jodie Romero provides system-level leadership supporting inpatient nursing operations across nine hospitals in AdventHealth’s Central Florida Division. Jodie brings over 20 years of progressive nursing experience, serving in a variety of clinical and leadership roles including bedside nurse, assistant nurse manager, nurse manager, nursing operations manager, and director of nursing. In her current role, Jodie partners closely with nursing leaders, quality teams, and executive stakeholders to advance operational excellence, regulatory readiness, and sustainable performance improvement. Her work has focused on division-wide initiatives related to accreditation readiness, nursing documentation optimization, workflow standardization, patient experience, and leadership development. She is recognized for her collaborative leadership style and her ability to translate evidence-based practice into practical, frontline-ready solutions. Jodie is currently enrolled in the Master of Science in Nursing Informatics program at Western Governors University. Her professional interests include leveraging technology, and evidence-based practice to drive regulatory readiness, standardizing nursing workflow, and sustaining high quality, compliant care delivery across the healthcare system.
This presentation will seek to demystify the often-complex conditions of participation (CoPs) that are required by CMS. This introduction to the CMS process will include the different tiers of non-compliance and survey outcomes. There will be a discussion regarding The Joint Commission Standards that were rewritten (effective January 2026) to realign more closely with CMS requirements. A summary of frequent issues of non-compliance for the first quarter of 2026 will be presented along with strategies for a successful survey. A live question and answer time will be provided.
NAHQ Competency Framework Domain(s):
Marianne Sevcik, RN, MSN, Healthcare Advisor/Founder, Partnership Consulting International, LLC, St Petersburg
Marianne Sevcik’s clinical foundation began over 35 years ago as a labor and delivery RN gaining experience in diverse health care settings. She held leadership positions directing multiple Women’s and Children’s service lines in the US and was successful in improving quality outcomes for childbearing families and in streamlining clinical workflow to increase safety, efficiency, and value. Marianne led the team that was first in the state of Florida to receive TJC’s Perinatal Certification. She was appointed as a Florida Perinatal Regional Leader as well as a recipient of The Spirit of Planetree Award for contributions in patient experience, leadership and volunteerism. Prior to starting her own consulting business, Marianne worked for The Joint Commission (TJC) as a Surveyor in the Hospital Accreditation Program. She was a team leader for many survey types including Perinatal Certification, Intracycle Monitoring (ICM), Medicare Deficiency, Office of Quality and Patient Safety (OQPS) Surveys, Preliminary Denial of Accreditation (PDA) and Focused Surveys (FSA). She worked collaboratively to facilitate decrease of the national maternal mortality rate as a subject matter expert through authoring policy, conducting process improvements to standardize survey activity, national public speaking, and education in her role at TJC.
Improving septic shock documentation was key to increasing expected mortality and lowering the septic shock mortality index. By educating healthcare providers on accurate documentation, expected mortality rates became more aligned with clinical realities. This allowed for more precise coding and contributed to a more accurate mortality index. This project stood out for its strong multidisciplinary collaboration involving physicians, nurses, coders, data analysts, and leaders across Quality, Ambulatory Analytics, and Revenue Cycle. Unified efforts led to more accurate documentation and improved patient outcomes, showcasing the power of teamwork and innovation.
NAHQ Competency Framework Domain(s):
Jacqueline Young, MD, MBA, Internal Medicine and Patient Safety and Quality Assistant Member, Moffitt Cancer Center 
Jacqueline Young received her MD degree from the University of South Florida Morsani College of Medicine. She completed an Internal Medicine Residency and a Master of Business Administration degree at the University of South Florida. As a Physician Advisor, Jacqueline bridges clinical and administrative functions at Moffitt Cancer Center. Her responsibilities include ensuring accurate clinical documentation, managing the utilization of services, and supporting compliance with the regulations. Additionally, Jacqueline provides education to the medical staff on best practices and handles appeals for the denied claims, working proactively to prevent future denials. Through involvement in quality improvement projects, Jacqueline helps to align patient care with the organization’s goals, regulatory standards, and financial objectives, ultimately promoting efficient and effective healthcare delivery
Hardik Thakkar, MSPAS, PA-C
Artificial intelligence (AI) could greatly improve patient safety. Examples include the detection and prediction of sepsis, pressure ulcers, postpartum hemorrhage, adverse drug events, and patient decompensation. Yet if not designed, developed, implemented, and used appropriately, AI in clinical settings may contribute to patient harm. Recommendations for health care organizations and other stakeholders to consider as part of the AI safety program. This expert panel will discuss safe and effective AI implementation in clinical settings. considerations of the health care workforce, and existing technologies, policies, and processes.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Health Data Analytics; Patient Safety
MODERATOR: Cassandra Vonnes, DNP, GNP-BC, APRN, AOCNP, EBP-CH, GS-C, CPHQ, AGSF, FAHA, FAAN, Geriatric Clinical Consultant, Change AGEnt LLC
Cassandra Vonnes is a certified Gerontological and Advanced Oncology Nurse Practitioner and a Fellow of the American Heart Association, the American Geriatrics Society, and the American Academy of Nursing. She is the President-Elect of the Florida Association for Healthcare Quality and has been recognized as a Hartford Distinguished Educator in Geriatric Nursing. The Gerontological Advanced Practice Nurses Association awarded her the 2022 Excellence in Leadership Award, and she received the ONS Excellence in Care for the Older Adult with Cancer Award in 2019. Under her leadership, Moffitt Cancer Center was the first hospital in Florida and the first cancer center recognized by IHI as an Age-Friendly Health System Committed to Care Excellence.
PANELISTS:
Certification proves your expertise in your chosen field and supports career growth. It also enhances healthcare quality and safety by establishing professional standards. Join this panel of certified presenters to learn how certification benefits your professional development and your practice in healthcare quality and safety.
NAHQ Competency Framework Domain(s): Professional Engagement
MODERATOR: Kathryn Clinefelter, RN, MSN, MBA, CPHQ, FNAHQ, Senior Partner, Partners in Healthcare Quality, The Villages, Florida and Guthrie, Oklahoma
Kathryn Clinefelter has built a distinguished career in healthcare quality, with experience beginning in 1980 covering acute care, tertiary care, teaching hospitals, managed care, regulatory, and ambulatory settings. For over two decades, she has prepared candidates for the CPHQ certification exam, currently serving as a NAHQ-approved instructor for the NAHQ CPHQ Virtual Review Courses. In her current role as Senior Partner at Partners in Healthcare Quality, Kathy specializes in CPHQ preparation and foundational education for those entering the healthcare quality field. She holds the Certified Professional in Healthcare Quality (CPHQ) credential and is recognized as a Fellow of the National Association for Healthcare Quality (FNAHQ). Additionally, she is a Registered Nurse in Florida and earned her BSN (1972), MSN (1979), and MBA (1995) from the University of Florida, Gainesville. Ms. Clinefelter has been an active volunteer with the Florida Association for Healthcare Quality since 1984.
PANELISTS:
Listed alphabetically by primary presenter
Surgical oncology patients are at increased risk for venous thromboembolism (VTE) due to active malignancy, performance status, chemotherapy, and limited mobility. The goal was to reduce VTE rates among hospitalized surgical oncology patients. Literature review included VTE prophylaxis guidelines from the American Society of Clinical Oncology and studies across various cancer surgery types. Using AHRQ PSI-12 Peri-op VTE metric VTE rate was reduced by 74%. Interventions included implementing evidence-based guidelines, ensuring multidisciplinary ownership, and patient/family education.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety; Health Data Analytics
Trois Carter, MBA, BSN, RN, CCM, Clinical Quality Specialist, Orlando Health Cancer Institute
Trois Carter has more than 30 years of progressive nursing experience in oncology, care management, utilization management, and quality improvement. She earned her RN, BSN from Florida State University and began her nursing career as an oncology nurse at Tallahassee Memorial Regional Medical Center, in Tallahassee, FL, where she advanced to evening charge nurse and assisted in the development of oncology and sickle cell care pathways. After relocating to Orlando, Trois joined Orlando Regional Medical Center, Orlando Health’s flagship tertiary hospital and Central Florida’s only Level I trauma center. There, she provided direct oncology care and later managed the oncology inpatient nursing unit and the care management department. In these leadership roles, she led interdisciplinary initiatives and contributed to operational improvements, including assisting with the revamping of the Orlando Health Appeals team. Trois brings extensive expertise in utilization management and holds an MBA from Nova Southeastern University. She currently works exclusively in oncology, collaborating with multidisciplinary teams to implement care improvement and utilization-focused processes that have demonstrated positive outcomes in improving overall quality and patient safety. She has presented at state and national healthcare conferences.
The Emergency Departments (Main – Level One Trauma Center, Brandon, and Kennedy) at Tampa General Hospital face challenges in delivering high-quality and timely care amid rising patient volumes and limited resources. The goal was to improve patient experience by increasing top-box scores in the “Overall Rating of Care” domain. The project demonstrates that targeted communication strategies can significantly improve ED patient experience. Challenges included site-specific variability, staff turnover, resource constraints. a temporary pause in the workgroup. Lessons learned were to standardize interventions earlier, strengthen data feedback loops, maintain consistent workgroup engagement.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Quality Review and Accountability
Viktoria Filatova, BS Healthcare Management, LSSGB, MBA, Performance Improvement Specialist, Tampa General Hospital
Viktoria Filatova is a Performance Improvement Specialist 3 at TGH, where she supports high-impact quality and operational improvement initiatives with the organization. She partners with executive staff to analyze performance data, lead improvement efforts, and drive measurable improvements inpatient experience, safety, and efficiency. Viktoria holds a Bachelor of science in Healthcare Management from the University of South Florida and an MBA from Wester Governors University. She is Lean Six Sigma Green Belt certified and brings a strong background in data analytics, process improvement, and cross-functional collaboration.
With inpatient HCAHPS “Staff Responsiveness” scores consistently ranked below the 50th percentile, negatively impacting patient experience, CMS reimbursement, and Leapfrog Safety Grades and evidence in the literature linking responsiveness to patient satisfaction and outcomes, this project aimed to improve responsiveness through leadership-driven innovation and technology integration. The initiative demonstrated how nurse-led, data-driven innovation can transform patient experience. Challenges included initial resistance and adapting workflows to new technology. Future efforts would prioritize earlier stakeholder engagement and pilot testing. The project supported broader goals related to CMS ratings and Leapfrog Safety Grades, highlighting the critical role of nursing leadership in healthcare advancement.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Quality Review and Accountability; Performance and Process Improvement
Eva Mitra, MSN, RN, CPHQ, Manager Quality and Performance Improvement, West Kendall Baptist Hospital
Eva Mitra is a healthcare quality leader with a Master of Science in Nursing Informatics and over 13 years of experience in Quality and Performance Improvement. Currently the Quality and Performance Improvement Manager at West Kendall Baptist Hospital, she focuses on advancing operational excellence and improving patient safety and outcomes through data-driven strategies and process optimization. Eva is a Certified Professional in Healthcare Quality and a Lean Six sigma Green Belt, enabling her to apply evidence-based methodologies to enhance efficiency and quality across healthcare systems. Her strong clinical foundation, built on 20 years of experience in critical care nursing, provides a unique perspective bridging frontline care with organizational performance goals. Eva is passionate about continuous improvement and thrives on leveraging analytics, collaborative leadership, and innovative centered care to foster a culture of excellence.
Housing-insecure patients who visit an Emergency Department (ED) in the City of Chicago currently lack the ability to perform intake or update their housing assessments in the Coordinated Entry Housing System (CES) on a 24/7 basis. This limitation creates barriers to securing housing. Without stable housing, patients often turn to the ED for food, shelter, and medical care, irrespective of their background, history, or legal situation. To address the high frequency of ED visits among housing-insecure patients, we implemented in-person housing assessments directly from the ED. This initiative enables patients who previously could not reach a CES access center to receive assistance. The entire social work team in the ED collaborated across different shifts to connect with patients and coordinate with other partners who are either available for assistance or need updates.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Population Health and Care Transitions
Hannah H Rarick, LCSW, CCTP, Social Worker, Northwestern Memorial Hospital, Chicago
Hannah Rarick holds a Master of Science in Social Work from Columbia University in the City of New York and is currently enrolled in her second, a Master of Arts in Public Policy and Administration with a specialization in Global Policy from Northwestern University. Hannah is a Licensed Clinical Social Worker (LCSW) and is a Certified Clinical Trauma Professional (CCTP). She has worked at Northwestern Memorial Hospital for almost 5 years as a Social Worker, with four of those years overnight in the emergency department. Throughout her time at Northwestern, she has been a two-time Improvement Day Award Winner and recipient of Northwestern’s Star Award, in addition to the recognition she has received from staff and patients. Hannah has worked as a social worker for 10 years, including her work in community HIV health in the Peace Corps within Ukraine, as a project manager for care coordination programs in New York City at Project Renewal, and as an inpatient social worker at West Suburban Medical Community Hospital.
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