FAHQ Annual Conference
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Our home health agency’s Star Rating was 2 with a Total Performance Score ranking in less than the 25th percentile for all quality measures. This put us at risk for up to a 5% penalty in 2025 reimbursement. The presentation will focus the steps taken to improve patient outcomes, star rating & industry ranking. It will include challenges, specific interventions, targeted quality measures, data collection/analysis & the final outcome.
NAHQ Competency Framework Domain(s): Performance and Process Improvement, Quality Review and Accountability
Wanda Henderson, RN, CPHQ, Compliance & Risk Program Manager, Alivia Care @ Home, Alivia Care Solutions, Inc., Summerfield, Florida
Wanda Henderson has been a registered nurse for over 35 years and holds a Bachelor of Arts in Healthcare Management from Lindenwood University, Saint Charles, Missouri. Wanda is a Certified Professional in Healthcare Quality (CPHQ) and has worked in compliance and performance improvement for home health agencies across the country for over 32 years. She currently provides oversight to the QAPI, Compliance and Risk Management programs for all home health and home care branches of Alivia Care @ Home in northeast and north central Florida.
Hospice care enhances end-of-life experiences for patients and families, yet many eligible individuals miss out on its benefits. This presentation explores a quality improvement initiative aimed at increasing General Inpatient Hospice (GIP) utilization. Participants will explore distinctions between hospice and palliative care, a structured process for identifying hospice eligibility, and the application of Lean Six Sigma tools to address missed referrals. By defining clear criteria and integrating them into mortality case reviews, the project uncovered systemic barriers, including a 43% missed referral rate. Despite improved timing of transitions, many patients still did not receive hospice services. This session offers actionable strategies to overcome barriers, deliver better end-of-life care, and foster a culture of data-driven improvement.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Health Data Analytics
Jodi Mullen, MS, RN-BC, CCRN, CCNS, ACCNS-P, FCCM, CPHQ, Senior Quality Improvement Specialist, UF Health Shands Hospital, Gainesville, Florida
Jodi Mullen has been a Senior Quality Improvement Specialist at UF Health Shands Hospital, in Gainesville, Florida for four years, where she collaborates with multidisciplinary teams to enhance patient safety, reduce hospital-acquired complications, and improve clinical outcomes. A seasoned healthcare professional, she holds a Master of Science as a Child/Adolescent Clinical Nurse Specialist from Wright State University, is a Lean Six Sigma Green Belt, and has earned numerous certifications, including a Certified Professional in Health Care Quality (CPHQ), and she is a Fellow of the American College of Critical Care Medicine (FCCM). With over 30 years of experience in pediatric and critical care nursing, Jodi has led award-winning quality initiatives, coauthored multiple peer-reviewed publications, and presented nationally on topics ranging from pediatric delirium to optimizing multidisciplinary communication. An advocate for excellence in healthcare, she serves on various committees, mentors healthcare teams, and contributes as a subject matter expert for professional nursing organizations.
Leanne Bonds, MSN, CPHQ, RN, Director of Quality and Patient Safety, UF Health Shands Hospital, Gainesville, Florida
Leanne Bonds has been a practicing quality specialist for approximately 10 years. She received her MSN at Cappella University. Prior to entering the quality arena, she practiced the majority of the time in critical care. Her experience includes work in Maryland, Vermont and Florida. She has been a critical care staff nurse, educator, assistant manager and manager. Leanne now serves as the Director of Quality and Patient Safety at an 1100- bed academic medical center, overseeing quality initiatives throughout the inpatient hospital. She now holds a green belt in Lean Six Sigma and is a Certified Professional in Healthcare Quality.
Richard Cartwright, ME, LSSBB, Senior Quality Improvement Specialist, UF Health Shands Hospital, Gainesville, Florida 
Richard Cartwright holds an M.S. in Industrial and Systems Engineering from Northern Illinois University and a Lean Six Sigma Black Belt certification. As Senior Quality Improvement Specialist at UF Health Shands Hospital, he has led projects enhancing patient care and efficiency, including reducing readmissions, developing predictive analytics for organ transplants, optimizing hospice enrollment, and improving clinic workflows. Richard has redesigned clinic layouts, created additional exam rooms, and led the Transplant team in implementing a data warehouse. In manufacturing, Richard developed a standard work model improving packaging output from 450K to over 1,000K units/month and built predictive models for packaging line speeds. A published researcher in BMJ Open Quality, Richard is also an active community member, musician, and youth softball coach.
3:30 PM – 4:30 PM
PROFESSIONAL DEVELOPMENT SESSION
Champions of Care: Elevating Quality through the Clinician Role at Muma Children’s Hospital
This presentation will introduce the new Quality Clinician role at Muma Children’s Hospital and how it has elevated quality in the children’s hospital. It emphasizes the importance of a dedicated quality structure with population-specific evaluations and goals. The discussion will include the current state of the role’s development, its future vision, and the anticipated impacts over time. Additionally, it will highlight the significance of collaboration and a holistic approach to quality improvement, demonstrating how these elements drive meaningful change and enhance patient outcomes.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Population Health and Care Transitions
Lyndsie Cangelosi, MSN, RN, RNC-NIC, C-ELBW, Quality Clinician, Muma Children’s Hospital, Tampa General Hospital, Tampa, Florida
Lyndsie Cangelosi holds a Bachelor of Science in Nursing from the University of South Florida and a Master’s in Nursing Education from the University of Central Florida. She is a certified Neonatal Intensive Care Nurse (RNC-NIC) and certified in the care of Extremely Low Birth Weight Infants (C-ELBW). Lyndsie has worked at Tampa General Hospital for a decade, contributing in roles such as bedside nurse, NICU nurse educator, and, most recently, as the Quality Clinician for Muma Children’s Hospital. Passionate about improving patient care, she collaborates with nursing and medical teams to identify opportunities for improvement and implement projects that enhance patient outcomes.
Designing and executing a quality improvement project is challenging, with many potential pitfalls like selecting the wrong team or involving too many participants. Without a clear framework, goals can blur, making it difficult to gauge progress. A lack of a defined timeline can also cause initiatives to stall. This presentation provides a structured organizational approach to improvement and tools to effectively launch a project, increasing the likelihood of success. Examples of each step in the IHI framework will be given, which will then create a completed project charter.
Leanne Bonds, MSN, CPHQ, RN, Director of Quality and Patient Safety, UF Health Shands Hospital, Gainesville, Florida
Leanne Bonds has been a practicing quality specialist for approximately 10 years. She received her MSN at Cappella University. Prior to entering the quality arena, she practiced the majority of the time in critical care. Her experience includes work in Maryland, Vermont and Florida. She has been a critical care staff nurse, educator, assistant manager and manager. Leanne now serves as the Director of Quality and Patient Safety at an 1100- bed academic medical center, overseeing quality initiatives throughout the inpatient hospital. She now holds a green belt in Lean Six Sigma and is a Certified Professional in Healthcare Quality.
In 2020 Clinical Quality began by collaborating with other team members who better understood the metrics, reviewing the specifications and learning from the cases the team started to identify opportunities for improvement. The real change came when we created a forum to review these cases with multidisciplinary team members from across the health system. At times, it was purely documentation and collaborating with Coding and the Clinical Documentation Integrity team to educate providers. Over time, process improvements were implemented, such as evidence-based protocols for wound care and VTE chemoprophylaxis, pressure injury imaging, perioperative glucose management pathways, electronic health record documentation updates, and growing specialty teams such as wound care and vascular access. The Model for Improvement and PDSA cycles were key to the success of this team. All of which were measured for process and the specific quality metric outcome associated with the change.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement
Lauren Morata, DNP, APRN-CNS, CCRN, CCNS, CPHQ, Director, Quality and Process Improvement
Lauren Morata is an experienced critical care and trauma nurse with a passion for research and implementing evidence-based practices. She is currently the Director of Quality and Performance Improvement at Lakeland Regional Health where her goal is to improve patient outcomes and reduce harm. During her time in Clinical Quality, Dr. Morata and her team have led several successful multiprofessional process improvements, reducing hospital-acquired infections, patient safety indicators, and falls. Dr. Morata graduated with her BSN from the University of Central Florida, her MSN from the University of Cincinnati and her DNP from the University of Central Florida. She is involved in professional organizations both locally and nationally, including the National Associate for Healthcare Quality, Society of Critical Care Medicine, and the American Association of Critical-Care Nurses.
Jennifer Montero, PharmD, BCCCP, FCCM, Clinical Quality Pharmacy Specialist, Lakeland Regional Health, Lakeland, Florida
Jennifer Montero earned her Doctor of Pharmacy degree at Nova Southeastern University, West Palm Beach, FL. She completed her PGY1 Pharmacy Practice Residency at Lakeland Regional Health, where she also completed her PGY2 in Critical Care. Following her training, Dr. Montero began working at Lakeland Regional Health in 2011 as a Critical Care Pharmacy Specialist and is currently the Clinical Quality Pharmacy Specialist since 2020. Dr. Montero is a Board-Certified Critical Care Pharmacist (BCCCP) and a fellow of critical care medicine (FCCM). She is also a Clinical Assistant Professor at the University of Florida College of Pharmacy, Gainesville, FL and has had many Resident Preceptor positions at Lakeland Regional Health. Dr. Montero has held several leadership positions with the Florida Chapter of the Society of Critical Medicine to include Research Committee Chair, a three-year term as President and member of the Board of Directors and has participated in numerous research projects, publications and presentations.
Rebecca Burlin, BSN, RN, CCDS, Director, Clinical Documentation Integrity Department, Lakeland Regional Health, Lakeland, Florida
Rebecca Burlin is a spirited force in Clinical Documentation Integrity (CDI), blending over 27 years of hands-on experience in clinical and administrative realms with a knack for seamless workflow integration and team empowerment. Rebecca’s resourcefulness and expertise shine as she leads a 20+ person CDI team at Lakeland Regional Health, initiating impactful collaborations with departments from dietary to quality control, all aimed at enhancing patient care and documentation accuracy. Rebecca has a rich tapestry of experience across various healthcare environments, from her foundational days as a nurse in the emergency department and cardiac intensive care unit, to rapid-response coordinator to her work on the COVID-19 Response Team with the Cleveland Department of Public Health. Whether managing emergency departments or pioneering documentation integrity projects, Rebecca has proven to be a skilled problem-solver, active listener, and, above all, a compassionate advocate for both patients and her team. Certified as a Clinical Documentation Specialist, Rebecca continues her education and leadership in the CDI space, serving as a critical thinker and steadfast mentor, bringing lighthearted warmth and solid results to every project she takes on.
8:15 AM – 9:45 AM
HIGH RISK SESSION
Charting the Past, Forecasting the Future: Standardizing Suicide Prevention Protocols
UF Health Psychiatric Hospital (UFPH) identified inconsistent use of suicide risk assessment tools, leading to variability in care. The team focused on standardizing the use of the Columbia-Suicide Severity Rating Scale (C-SSRS) and Suicide Ideation (SI) Intensity Scale to enhance suicide prevention. Key interventions included literature reviews, data analysis of past inpatient suicide attempts, staff education, and mandatory documentation of C-SSRS in electronic records. Patients scoring high on SI Intensity scales triggered automatic suicide precautions or 1:1 observation. Outcomes showed a 5% rise in documentation compliance with suicide risk assessments, a 4% drop in patients placed on suicide precautions, and no significant change in 1:1 observation rates. Automation of precautions in admission orders improved processes but requires refinement. Next steps include full automation of precautions, auto-populating intake assessments into physicians’ records, standardizing intervention protocols, and increasing patient engagement through tailored programming.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Health Data Analytics; Patient Safety
Lana Watson, MBA, MHS, OTR/L, Senior Quality Improvement Specialist, UF Health Shands Hospital, Gainesville, Florida
Lana Watson holds a Bachelor and Master of Health Science in Occupational Therapy from the University of Florida—Go Gators!—and a Master of Business Administration with a focus on Healthcare Management from Western Governors University. With 20 years at UF Health, including 15 in operational leadership, she transitioned to quality improvement two years ago and has found it deeply rewarding. As a Senior Quality Improvement Specialist, Lana leads impactful projects in maternal health, behavioral health, social determinants of health, and hospital readmissions. Additionally, she has served for six years as a surveyor, collaborating with hospital programs across the country to enhance care for patients with brain injuries, spinal cord injuries, and stroke.
Ensuring Epidural Safety: Standardizing Best Practices to Prevent Misconnection Mishaps
The content of this lecture will cover the high-risk nature of the epidural placement procedure, including reported history of misconnection rates, and how using an organized approach with a validated framework can reveal opportunities for risk mitigation to reduce preventable harm.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Christina Rodriguez, MSN, RN, CPPS, CPHQ, NE-BC, LSSBB, Patient Safety Manager, Baptist Health South Florida, Miami, Florida
Christina Rodriguez has worked at Baptist Health South Florida for more than 15 years and holds a Master of Science in Nursing Administration and is also Lean Six Sigma certified. Christina is a Certified Professional in Health Care Quality (CPHQ), a Certified Professional in Patient Safety (CPPS), and is certified by ANCC as a Board-Certified Nurse Executive (NE-BC). She is 24 years into her nursing career, including both adult and pediatric clinical experience in cardiac intensive care, emergency department, and medical-surgical nursing. She also worked in Quality, PI, and Accreditation for 11 years prior to two years of Patient Safety, with a total of 9 years of leadership experience.
Implementation of a Quick Reaction Taskforce (QRT) to Decrease the Likelihood of the Re-occurrence of Serious Patient Harm Events
The implementation of a Quick Reaction Taskforce (QRT) review process at UF Health has significantly reduced the likelihood of serious patient harm events recurring. The initiative addresses the need for a systematic and proactive approach to ensure patient safety. QRT reviews are conducted within 24–48 hours of identifying serious harm events, involving multidisciplinary teams to identify failure points and implement corrective actions swiftly. Since its launch in October 2022, over 46 reviews have been completed, resulting in 27 out of 29 successful regulatory visits without deficiencies. Recognized as a best practice by a regulatory agency, this approach fosters collaboration, system-wide learning, and continuous improvement. The next phase aims to measure a 10% reduction in harm recurrence over six months, solidifying the process as a cornerstone of patient safety efforts. This presentation highlights the QRT process, its outcomes, and future objectives to enhance healthcare quality.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety; Quality Review and Accountability; Regulatory and Accreditation
Nisha Patel, MS, MHA, PMP, CPHQ, Director, Medical Staff Administration, UF Health Shands, Gainesville, Florida
Nisha Patel is a highly accomplished healthcare leader with over 25 years of experience driving quality, operational excellence, and patient safety. Currently serving as Director of Medical Staff Administration at UF Health Shands Hospital, her expertise spans leading multidisciplinary teams, implementing Lean Six Sigma strategies, and achieving system-wide cost savings while enhancing patient outcomes and regulatory compliance. Holding dual master’s degrees and certifications such as CPHQ and PMP, Nisha combines technical proficiency with a commitment to collaboration and excellence. A sought-after leader and mentor, she is dedicated to advancing quality in healthcare through data-driven strategies and team empowerment.
Brad Green, RN, MSN, Director of Clinical Risk Management, UF Health Shands Hospital, Gainesville, Florida
Brad Green holds a Masters of Nursing from Grand Canyon University. He has 34 years of nursing and leadership experience at UF Health including 22 years in cardiology and 12 years current experience in risk management. In his role as Director of Clinical Risk Management, Brad oversees patient safety at an 1100 bed academic medical center. His duties include, but are not limited to, oversight of a robust patient safety reporting system, facilitation of root cause analysis and Quick Reaction Taskforce (QRT) reviews, regulatory compliance and reporting, “Just Culture” training and education, liaison for UF Health enterprise risk management, and much more.
10:00 AM – 11:00 AM
Age Friendly Hospital Measure: A Roadmap for Centers for Medicare & Medicaid Services New Hospital Quality Reporting Program
The Centers for Medicare & Medicaid Services (CMS) has announced its FY2025 Inpatient Prospective Payment Systems final rule that includes a new Age Friendly Hospital Measure. Hospitals can take advantage of JAVA-supported initiatives to help meet this new measure.
NAHQ Competency Framework Domain(s): Population Health and Care Transitions; Health Data Analytics; Patient Safety; Quality Review and Accountability
Cassandra Vonnes, DNP, GNP-BC, APRN, GS-C, AOCNP, EBP-C, CPHQ, AGSF, FAHA, Nurse Practitioner Certified in Geriatrics and Oncology, Tampa, Florida
Dr. Vonnes is a certified Gerontological and Advance Oncology Nurse Practitioner and Fellow of American Heart Association and American Geriatric Society. Her previous experiences include teaching at the USF College of Nursing for undergraduate and nurse practitioner students and was recognized as a Hartford Distinguished Educator Geriatric Nursing. She has worked as a nurse practitioner in internal medicine and cardiovascular medicine in both acute and outpatient settings. She serves on the national Nurse Leadership Board of AARP and on the Aging Policy Committee of the American Geriatric Society, who recognized Dr. Vonnes as a Fellow in 2023. Under Dr. Vonnes leadership Moffitt Cancer Center was the first hospital in Florida and first cancer center in the US to be recognized the Institute of Healthcare Improvement as Age Friendly Health System Committed to Care Excellence for the Older Adult. She has presented nationally and internationally on Fall and Injury prevention, delirium, and geriatric assessment. Dr. Vonnes hosts the podcast GAPNA CHAT that features leaders in Geriatric Health Care. The Gerontological Advanced Practice Nurses Association awarded her the Excellence in Leadership 2022 Award and the Oncology Nurses Society Excellence in Care for the Older Adult with Cancer Award in 2019.
11:00 AM – 12:00 AM
Engaging Patients and Families: Partnership for Safety, Patient Family Advisor Panel
Patients and caregivers play a central role in health care safety in the hospital, ambulatory care setting, and community. Since the publication of the patient safety report To Err Is Human in 1999, the role of patient and family caregivers within the safety of health care has grown in prominence. Patient Advisor participation will improve individual patient experiences regarding safety and quality.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Moderator: Cassandra Vonnes, DNP, GNP-BC, APRN, GS-C, AOCNP, EBP-C, CPHQ, AGSF, FAHA, Nurse Practitioner Certified in Geriatrics and Oncology, Tampa, Florida
1:00 PM – 2:30 PM
DATA, TOOLS AND TRICKS WORKSHOP SESSION
Mary Poppin’s Quality Bag of Tricks
As performance improvement and quality specialists, we have many tools at our disposal. We have data everywhere, but what does it tell us? What tools should we utilize to shed light onto our opportunities and illuminate them brightly. What corrective actions will become our spoon full of sugar to make a difference in the lives of those who we serve. We will briefly explore a project charter, diver diagram, Gantt chart, RACI, Visio workflows, FMEA, Poke Yoke and other tools. Hoping to show you enough to be dangerous and inquisitive. Maybe you will begin as ask the 5 whys. Join me in a journey into the bag of tips and tricks that dwell in that magical carpet bag. Supercalafragilisticexpialidocious and chimchiminy cherreee!
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Deborah F. Raposo, RN, BSN, LNC, BC-NI, CPHIMS, CPPS, LSSGB, Performance Improvement Supervisor, Tampa, Florida
Debbie Raposo holds a Bachelor of Science in Nursing from the Salve Regina University and is a Registered Nurse entering her 41st 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, to leadership, to informatics and analytics, to legal aspects, to information systems to patient safety, and to performance Improvement. 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 expectation, heal their bodies and minds, and to 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) by how they were presented, how they smelled and how they tasted. And now in her current position in transplant- her motto “We are human, to Err is Human but we must strive to create Zero Harm…One layer of the onion, one step of a thousand miles and one bite of an elephant at a time”.
Driving Quality through Data Analytics
The goal of the presentation is to share how to build a case for improvement through data analytics in healthcare setting. Join this session to understand the role of data analytics in improving patient care. It will examine key data analytics methodologies and tools used in healthcare and show how to evaluate the impact of data-driven decision-making on patient care.
NAHQ Competency Framework Domain(s): Data Analytics
Silvia Dilone, MSN RN, Director of Quality, Jackson Health System, Miami, Florida
Silvia Dilone is an accomplished healthcare leader with extensive expertise in quality improvement, patient safety, and data-driven decision-making. Silvia is currently serving as the Director of Quality at Jackson Health System, Silvia has a proven track record of driving operational excellence and improving patient outcomes. She has also successfully led the development of new healthcare facilities, including overseeing the quality, risk assessment, and operational processes of opening Jackson West Medical Center in Doral, Fl. With a strategic vision and deep leadership experience, Silvia is poised to influence healthcare at the highest levels. She holds a Master’s in Healthcare Systems Management from Loyola University New Orleans.
3:30 PM – 4:15 PM
Redefined Admission Classification Decreases Reportable Patient Safety Indicator Events
Patient safety indicators (PSIs) are essential metrics for identifying preventable complications, yet inconsistent admission classifications can lead to inflated reporting. This presentation demonstrates how a multidisciplinary team redefined admission criteria to decrease PSI rates for postoperative acute kidney injury requiring dialysis (PSI-10), respiratory failure (PSI-11), and sepsis (PSI-13). Using process mapping and quality improvement tools, the team shifted to patient-focused surgical scheduling and redefined elective, urgent, and emergent admission classifications. Outcome measures revealed significant reductions in reportable PSI rates: PSI-10 decreased by 71%, PSI-11 by 91%, and PSI-13 by 86%. Variation in PSI events was also halved. Participants gain practical knowledge on identifying key PSIs, implementing standardized admission classification processes, and applying quality improvement methodologies to effect meaningful change. Attendees leave equipped to drive improvements in their own organizations by applying these evidence-based practices.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety; Quality Review and Accountability
Jodi Mullen, MS, RN-BC, CCRN, CCNS, ACCNS-P, FCCM, CPHQ, Senior Quality Improvement Specialist, UF Health Shands Hospital, Gainesville, Florida
Jodi Mullen has been a Senior Quality Improvement Specialist at UF Health Shands Hospital, in Gainesville, Florida for four years, where she collaborates with multidisciplinary teams to enhance patient safety, reduce hospital-acquired complications, and improve clinical outcomes. A seasoned healthcare professional, she holds a Master of Science as a Child/Adolescent Clinical Nurse Specialist from Wright State University, is a Lean Six Sigma Green Belt, and has earned numerous certifications, including a Certified Professional in Health Care Quality (CPHQ), and she is a Fellow of the American College of Critical Care Medicine (FCCM). With over 30 years of experience in pediatric and critical care nursing, Jodi has led award-winning quality initiatives, coauthored multiple peer-reviewed publications, and presented nationally on topics ranging from pediatric delirium to optimizing multidisciplinary communication. An advocate for excellence in healthcare, she serves on various committees, mentors healthcare teams, and contributes as a subject matter expert for professional nursing organizations.
Leanne Bonds, MSN, CPHQ, RN, Director of Quality and Patient Safety, UF Health Shands Hospital, Gainesville, Florida
Leanne Bonds has been a practicing quality specialist for approximately 10 years. She received her MSN at Cappella University. Prior to entering the quality arena, she practiced the majority of the time in critical care. Her experience includes work in Maryland, Vermont and Florida. She has been a critical care staff nurse, educator, assistant manager and manager. Leanne now serves as the Director of Quality and Patient Safety at an 1100- bed academic medical center, overseeing quality initiatives throughout the inpatient hospital. She now holds a green belt in Lean Six Sigma and is a Certified Professional in Healthcare Quality.
Richard Cartwright, ME, LSSBB , Senior Process Improvement Specialist, UF Health Shands, Gainesville, Florida
Richard Cartwright holds an M.S. in Industrial and Systems Engineering from Northern Illinois University and a Lean Six Sigma Black Belt certification. As Senior Quality Improvement Specialist at UF Health Shands Hospital, he has led projects enhancing patient care and efficiency, including reducing readmissions, developing predictive analytics for organ transplants, optimizing hospice enrollment, and improving clinic workflows. Richard has redesigned clinic layouts, created additional exam rooms, and led the Transplant team in implementing a data warehouse. In manufacturing, Richard developed a standard work model improving packaging output from 450K to over 1,000K units/month and built predictive models for packaging line speeds. A published researcher in BMJ Open Quality, Richard is also an active community member, musician, and youth softball coach.
4:15 PM – 5:00 PM
Small Hospital, Big Ripple. How Innovative Change at a Community Hospital Can Make Waves for an Organization
Dr. Phillips Hospital recognized a need for stroke alert process improvement due to a steady incline in our door to decision times. We will review how we used the PDSA model to identify that change was needed to improve the quality of care provided to this patient population. After thorough review of the literature and our personal process failures, a “pitstop” approach in combination with use of telemedicine was implemented. We have seen sustained improvement over one year with a 56% reduction in decision times. We will discuss how success at our small hospital gained popularity amongst other sister hospitals within our organization, ultimately leading them to all adopt our new process. This systemic change has led to an overall 35% reduction in decision times across 5 campuses since implementation, saving brain tissue when every minute matters.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Population Health and Care Transitions; Health Data Analytics
Kimberly Neumann, MSN, RN, CEN, CPHQ, Program Manager of Nursing and Special Projects, Orlando Health, Orlando, Florida
Kimberly Neumann holds a Masters of Science in Nursing with an emphasis in Healthcare Quality and Patient Safety from Grand Canyon University. Kimberly is both a Certified Emergency Nurse (CEN) as well as a Certified Professional in Healthcare Quality (CPHQ), giving her a unique skill set to make impactful change in the emergency department setting. She has worked for Orlando Health for 14 years within the emergency and quality departments, playing a pivotal role in the development of the Dr. Phillips Hospital Stroke Program. Her collaborative and strategic approach has significantly improved the corporate stroke program, leading to the standardization and alignment of stroke care across the system.
8:15 AM – 10:45 AM
INFECTION PREVENTION SESSION
Line of Defense: Reducing CLABSI and Enhancing Outcomes in Pediatric & Neonatal Patients
This presentation highlights strategies to reduce CLABSI and improve outcomes in Pediatric and Neonatal Care. By focusing on problem identification, process review, and the implementation and sustainment of change, this approach is adaptable across all healthcare settings and patient populations. Establishing a healthcare system with robust processes that support continuous improvement is essential. In this project, quality control tracking and a detailed review of historical data were pivotal in achieving a significant reduction in CLABSI rates and transitioning into a successful sustainment phase.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Lyndsie Cangelosi, Quality Clinician for Muma Children’s Hospital, Tampa General Hospital, Tampa, Florida
Lyndsie Cangelosi holds a Bachelor of Science in Nursing from the University of South Florida and a Master’s in Nursing Education from the University of Central Florida. She is a certified Neonatal Intensive Care Nurse (RNC-NIC) and certified in the care of Extremely Low Birth Weight Infants (C-ELBW). Lyndsie has worked at Tampa General Hospital for a decade, contributing in roles such as bedside nurse, NICU nurse educator, and, most recently, as the Quality Clinician for Muma Children’s Hospital. Passionate about improving patient care, she collaborates with nursing and medical teams to identify opportunities for improvement and implement projects that enhance patient outcomes.
Leveraging the Magnet Model to Transform Quality Care
Central Line-Associated Blood Stream Infections (CLABSI) are a contributor to harm, leading to extended lengths of stay, increased morbidity and mortality rates and increased healthcare costs. Solutions for Patient Safety (SPS) notes CLABSI to be the largest contributor to harm across the SPS network. We identified an opportunity to drive local CLABSI rates towards zero. We challenged the pediatric intensive care unit (PICU) to decrease CLABSI rates from 1.7 to 1.29 (2024 annual goal). The Institute for Healthcare Improvement (IHI) Model of Improvement was applied, in partnership with the Quality and Safety department and PICU team, at the hospital CLABSI taskforce and local unit-level Professional Governance. By leveraging the ANCC Magnet Model, the PICU team and taskforce were empowered and supported to make impactful changes at the bedside with the flexibility to make unit-specific changes, when indicated. The PDSA cycles led to a reduction in CLABSI in the PICU, reaching 1-year+ CLABSI free.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Nicole Grahl, BSN, RN, CCRN, CPN, PICU Nurse Manager, Nemours Children’s Hospital, Orlando, Florida
Nicole Grahl is a nurse manager in the Pediatric Intensive Care unit at Nemours Children’s Hospital in Orlando, FL. She has over 7 years’ experience in nursing leadership and has a passion for developing and mentoring nurses. She started her career in adult critical care and then found her true passion when she transitioned to pediatric intensive care. In her time at Nemours, Nicole has participated in several quality improvement projects and is always striving to make the PICU a better place for patients, families, and nurses.
Evan Johnson, MPH, CPPS, Quality Improvement Specialist, Nemours Children’s Hospital, Orlando, Florida
Evan Johnson holds a Master of Public Health in Health Policy and Systems Management from the Louisiana State University Health Sciences Center in New Orleans. Evan is a Certified Professional in Patient Safety (CPPS) and certified Tableau Desktop Specialist. He has worked at Nemours Children’s Hospital for about two years as a Quality Improvement Specialist. In this role Evan serves as a quality improvement mentor for departments and taskforces designed to improve the health of pediatric patients. Evan has seven years of healthcare experience.
Pressing Reset on Hand Hygiene to Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia
Cleveland Clinic Weston Hospital was experiencing an increase in Methicillin Resistant Staphylococcus Aureus (MRSA) Bacteremia cases. The MRSA bacteremia cases were further investigated, and hand hygiene non-compliance was identified as a possible cause. A review of the hand hygiene surveillance data revealed that there was a 55% data variance, indicating that hand hygiene compliance was lower than what was recorded. A quality improvement project team was formed to complete an A3 project to explore gaps in the hand hygiene surveillance program and barriers in conducting hand hygiene. Countermeasures were implemented to optimize the surveillance program to ensure accurate data is captured and effectively utilized to improve hand hygiene compliance. In result, MRSA bacteremia cases were reduced by 80% and data variances in the surveillance program decreased from 55% to 10%. These results indicated that there is a correlation between improved hand hygiene and reduction in MRSA bacteremia cases and that the surveillance program is now capturing accurate hand hygiene data.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Sanam Baig, MSN, RN, CCRN, CPHQ, Senior Safety, Quality, and Patient Experience Specialist, Cleveland Clinic Weston Hospital, Weston, Florida
Sanam Baig holds a Bachelor of Science in Nursing from Florida International University and a Master of Science in Nursing from Florida Atlantic University. Sanam has acquired certification as a Critical Care Registered Nurse (CCRN) and is a Certified Professional in Healthcare Quality (CPHQ). Sanam has worked at Cleveland Clinic Weston Hospital for 9 years. During her tenure, Sanam has held roles in the critical care department as a bedside Registered Nurse, Assistant Nurse Manager, and Nurse Manager. Sanam has been in the role of a Senior Safety, Quality, and Patient Experience Specialist for the past 4 years. Sanam has influenced several policies and procedures based on evidenced based practice within her health system. Additionally, Sanam has led and participated in various performance improvement projects in collaboration with interdisciplinary teams to improve quality and patient safety. Sanam has connected teams and led with innovative thinking to problem solve and enhance patient care.
The Intersection of Infection Prevention and the Environment of Care
Infection prevention regulations have a tremendous impact on accreditation outcomes as they are often the drivers for adverse decisions or conditional level findings which cost the organization time and money. This presentation will provide an overview of the new infection prevention standards and how they intersect with the environment of care and higher risk areas. We will provide practical survey tips and mitigation using data from 2024 and our experience as national consultants. Finally, a practical discussion of the increasing importance of conducting a risk assessment will be reviewed.
NAHQ Competency Framework Domain(s): Patient Safety; Regulatory and Accreditation
Marianne Sevcik, RN, MSN, Healthcare Advisor, Partnership Consulting International, LLC, St Petersburg, Florida
Marianne Sevcik’s clinical foundation began over 30 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.
Jenny Manderino, RN, MSN
More speaker information will be posted when available.
11:00 AM – 12:30 PM
Change Management at the TGH-USF People Development Institute
The Change Management at the TGH-USF People Development Institute workshop is an engaging and interactive session designed to equip healthcare professionals and leaders with the skills needed to navigate and implement organizational change effectively. This workshop explores why change often leads to resistance and introduces the TGH Model of Organizational Change, guiding participants through planning, execution, and institutionalization of change initiatives.
NAHQ Competency Framework Domain(s): Performance and Process Improvement
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, Tampa, 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 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.
12:30 AM – 1:30 PM
Lunch together as conference ends. Drawing for FREE 2026 Conference registration!
Listed alphabetically by primary presenter
Reducing the Organizations Reported Mortality Index Through Documentation and Coding Accuracy
Accurate coding and comprehensive clinical documentation are critical to reducing an organization’s mortality index and accurately reflecting patient outcomes. This project examines how leveraging the Vizient Risk Model can enhance organizational performance by improving risk adjustment and ensuring precise mortality data representation. By aligning coding practices with clinical realities and optimizing documentation processes, healthcare organizations can better capture the complexity of patient care, reduce discrepancies, and identify actionable areas for improvement. Key strategies include staff training on coding accuracy, implementation of quality checks, and the integration of advanced analytics using the Vizient platform. Findings demonstrate a measurable reduction in the observed-to-expected (O/E) mortality ratio, highlighting the impact of accurate risk stratification and its role in driving quality improvement initiatives. This presentation outlines practical interventions, challenges, and outcomes, offering a road-map for organizations to align documentation practices with performance metrics to improve both patient care and reporting accuracy.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety; Quality Review and Accountability
Reurita Deam, MSN MBA RN, Senior Quality Data Analyst, Moffitt Cancer Center, Tampa, Florida
Reurita Deam holds a Masters of Science in Nursing/Informatics and Masters in Business Administration degree. Reurita is a Registered Nurse, Six Sigma Green Belt Certified and Project Management – Lean Process Certified. She has worked for more than 8 years as Sr. Quality Data Analyst and was Quality and Patient Safety Specialist at Moffitt Cancer Center. Reurita has worked in healthcare for more than 25 years, her experiences also include patient care in Emergency Department, Nursing Leadership, Infection Prevention, Risk Management and Quality Management.
Maximizing Appropriate Use of High-Flow Nasal Cannula in Bronchiolitis Patients
A quality improvement project spanned from October 2023 through June 2024 to help promote a best practice bronchiolitis clinical pathway for patients receiving a respiratory score of mild that are then placed on High Flow Nasal Cannula (HFNC) in the emergency department setting. Although the clinical pathway offers guidance on how to effectively score patients based on three respiratory score categories, there was little awareness and trust about the pathway overall. A cause-and-effect diagram was implemented on this project to better understand both barriers and opportunities. The application of a key driver diagram informed the team to prioritize clinical leadership engagement about the pathway via widespread sharing. In addition, a one-page flier with monthly run chart data was shared on a periodic basis to detail the project and its intent to emergency department providers.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Population Health and Care Transitions
Evan Johnson, MPH, CPPS
Evan Johnson holds a Master of Public Health in Health Policy and Systems Management from the Louisiana State University Health Science Center in New Orleans. Evan is a Certified Professional in Patient Safety (CPPS) and certified Tableau Desktop Specialist. He has worked at Nemours Children’s Hospital for about two years as a Quality Improvement Specialist. In this role Evan serves as a quality improvement mentor for departments and taskforces designed to improve the health of pediatric patients. Evan has seven years of healthcare experience.
Journey to a System-Wide Quality Structure
Tampa General Hospital (TGH) addressed the challenge of siloed quality outcomes by creating a unified quality framework spanning hospital and ambulatory settings. Through the formation of an Ambulatory Quality Committee, TGH integrated ambulatory care into its system-wide quality improvement structure. Using Lean Six Sigma and Project Management methodologies, the initiative established a cohesive, data-driven approach to quality. This unified framework now enables consistent and measurable improvements across all care settings, transforming TGH into a seamlessly integrated system and enhancing patient outcomes throughout both hospital and ambulatory environments.
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement
Sabrina Nunez, MBA, CPHQ, Performance Improvement Specialist, Tampa General Hospital, Tampa, Florida
Sabrina Nunez is a seasoned professional with over 10 years of experience in healthcare quality and performance improvement. She holds an MBA from Florida Atlantic University, earned in 2020, and is a Certified Professional in Healthcare Quality (CPHQ). Sabrina is also trained in Lean Six Sigma methodologies and is currently pursuing her Project Management Professional (PMP) certification to further enhance her expertise. Her commitment to excellence and continuous improvement has made her a valuable asset in driving impactful change in the healthcare industry.
Combating C.Difficile: Promoting Awareness, Prevention, and Patient Safety
This presentation outlines a hospital-wide campaign aimed at reducing hospital-onset Clostridium Difficile (C. diff) infections through targeted education for physicians and nurses. The initiative focused on three critical areas: identifying risk factors for C. diff, implementing evidence based treatment protocols, and adhering to proper testing guidelines. By equipping healthcare providers with the knowledge and tools to recognize and manage C. diff effectively, the campaign sought to improve clinical decision making and enhance patient safety. Through a combination of educational sessions, clear communication strategies, and ongoing performance feedback, we achieved a reduction in our hospital onset C. diff infections. This presentation will share the campaigns goals, methods, and outcomes, highlighting key challenges and successes to provide actionable insights for other organization aiming to strengthen their infection prevention efforts. 
NAHQ Competency Framework Domain(s): Patient Safety
Victoria Rhett, MPH, CPH, Infection Preventionist, Halifax Health Medical Center, Daytona Beach, Florida
Victoria holds a Bachelors in Biology and a Masters in Public Health from the University of South Florida and is certified in Public Health. During her MPH program, she interned in the Infection Control Department at Halifax Health Medical Center, where she developed a comprehensive hand hygiene manual and participated in the implementation of diversion blood culture kits. She now serves as an Infection Preventionist at Halifax Health, focusing on patient safety and infection prevention initiatives.
RESEARCH – Predictors of Tract Hemorrhage after External Ventricular Drain Placement: A Single-Center Retrospective Study
External ventricular drains (EVDs) relieve intracranial pressure by draining cerebrospinal fluid in patients with serious neurological conditions and is one of the most common neurosurgical procedures. EVD placement can result in significant complications, such as hemorrhage, infection, and misplacement. New techniques and technologies have been developed in an attempt to reduce these complications; and despite these advancements, they continue to be a significant problem. This study aimed to identify predictors of EVD tract hemorrhage and to compare post-EVD hemorrhage rates between computer-assisted navigation and freehand technique EVD placement. This research study identifies best practice elements to help triage at-risk patients and reduce adverse outcomes of the procedure
NAHQ Competency Framework Domain(s): Quality Leadership and Integration; Performance and Process Improvement; Patient Safety
Linda Scribner, BA, CPHQ, HACP, LSSGB, Director, Quality Services, Methodist Dallas Medical Center, Dallas, Texas
As Director of Quality Services at Methodist Dallas Medical Center, Linda’s role includes quality, risk, infection prevention, guest services and in-house interpretation services along with program management of Comprehensive Stroke and Trauma Services. She earned her bachelor’s degree at the University of Florida in Gainesville. Past professional experience includes acute care quality improvement and medical staff quality in community and teaching hospital settings. She has co-authored two articles in the Journal of Healthcare Management and the Journal of Healthcare Quality. Linda served in board leadership for both Florida and Texas healthcare quality associations, as well as on the NAHQ Board in several positions including President in 2010 and as chair of the Healthcare Quality Certification Commission (HQCC) for the CPHQ credential.
QUALITY IMPROVEMENT – Optimizing Sepsis Management: Leveraging the Safety Learning System (SLS) Case Review Process in Internal Medicine Residency to Decrease Sepsis Mortality Rates
Sepsis has the highest rate of mortality within all patient populations and has a primary impact on overall mortality. The Aim of this improvement was to to decrease the risk adjusted sepsis mortality rate from 1.00 to 0.80 or lower in two years among the adult inpatient admissions (18 years and older) diagnosed with severe sepsis with septic shock or severe sepsis without septic shock at present on admission (POA ), by utilizing the Safety Learning System (SLS) sepsis case review process with PGY 2 internal medicine residents through identifying Opportunities for Improvement (OFIs) and applying shared learning from the collaborative to clinical practice.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Linda Scribner, BA, CPHQ, HACP, LSSGB, Director, Quality Services, Methodist Dallas Medical Center, Dallas, Texas
As Director of Quality Services at Methodist Dallas Medical Center, Linda’s role includes quality, risk, infection prevention, guest services and in-house interpretation services along with program management of Comprehensive Stroke and Trauma Services. She earned her bachelor’s degree at the University of Florida in Gainesville. Past professional experience includes acute care quality improvement and medical staff quality in community and teaching hospital settings. She has co-authored two articles in the Journal of Healthcare Management and the Journal of Healthcare Quality. Linda served in board leadership for both Florida and Texas healthcare quality associations, as well as on the NAHQ Board in several positions including President in 2010 and as chair of the Healthcare Quality Certification Commission (HQCC) for the CPHQ credential.
QUALITY IMPROVEMENT – Road to Tenecteplase, Decreasing Door to Needle Times at Methodist Dallas Medical Center
This is an improvement project testing transition to bedside mixing combined with the ease of administration of Tenecteplase, to reduce door to needle time (DTN) for acute ischemic stroke (AIS) requiring fibrinolytics. Alteplase has been the fibrinolytic
of choice in acute ischemic stroke (AIS) management for years. Recent literature supports tenecteplase (TNK, 0.25 mg/kg) as a reasonable, noninferior alternative fibrinolytic compared to alteplase.1, 2 • Because of tenecteplase’s ease of administration (5 second IV push) compared to alteplase (bolus followed by 1 hour infusion), there is the proposed benefit of possible shorter door to needle (DTN) times. • At Methodist Dallas Medical Center (MDMC), our inpatient pharmacy has traditionally prepared and hand delivered alteplase . Our hypothesis is with the transition to bedside mixing combined with the ease of administration of tenecteplase, we can reduce DTN for our AIS requiring fibrinolytics.
NAHQ Competency Framework Domain(s): Performance and Process Improvement; Patient Safety
Linda Scribner, BA, CPHQ, HACP, LSSGB, Director, Quality Services, Methodist Dallas Medical Center, Dallas, Texas
As Director of Quality Services at Methodist Dallas Medical Center, Linda’s role includes quality, risk, infection prevention, guest services and in-house interpretation services along with program management of Comprehensive Stroke and Trauma Services. She earned her bachelor’s degree at the University of Florida in Gainesville. Past professional experience includes acute care quality improvement and medical staff quality in community and teaching hospital settings. She has co-authored two articles in the Journal of Healthcare Management and the Journal of Healthcare Quality. Linda served in board leadership for both Florida and Texas healthcare quality associations, as well as on the NAHQ Board in several positions including President in 2010 and as chair of the Healthcare Quality Certification Commission (HQCC) for the CPHQ credential.
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